A summary of the existing literature related to moral distress (MD) and the paediatric intensive care unit (PICU) reveals a high-tech, high-pressure environment in which effective teamwork can be compromised by MD arising from different situations related to: consent for treatment, futile care, end-of-life decision making, formal decision-making structures, training and experience by discipline, individual values and attitudes, and power and authority issues. Attempts to resolve MD in PICUs have included the use of administrative tools such as shift worksheets, the implementation of continuing education, and encouragement to report. The literature does not yet show these approaches to be effective in the resolution of MD. The need to acknowledge MD among PICU teams is discussed and an argument made that, to facilitate understanding among team members, practice stories need to be shared.
End-of-life decisions, including limitation of life prolonging treatment, may be emotionally, ethically and legally challenging. Euthanasia and physician-assisted suicide (PAS) are illegal in Norway. A study from 2000 indicated that these practices occur infrequently in Norway.
In 2012, a postal questionnaire addressing experience with limitation of life-prolonging treatment for non-medical reasons was sent to a representative sample of 1792 members of the Norwegian Medical Association (7.7% of the total active doctor population of 22,500). The recipients were also asked whether they, during the last 12 months, had participated in euthanasia, PAS or the hastening of death of non-competent patients.
Seventy-one per?cent of the doctors responded. Forty-four per?cent of the respondents reported that they had terminated treatment at the family's request not knowing the patient's own wish, doctors below 50 and anaesthesiologists more often. Anaesthesiologists more often reported to have terminated life-prolonging treatment because of resource considerations. Six doctors reported having hastened the death of a patient the last 12 months, one by euthanasia, one by PAS and four had hastened death without patient request. Male doctors and doctors below 50 more frequently reported having hastened the death of a patient.
Forgoing life-prolonging treatment at the request of the family may be more frequent in Norway that the law permits. A very small minority of doctors has hastened the death of a patient, and most cases involved non-competent patients. Male doctors below 50 seem to have a more liberal end-of-life practice.
Samuel Golubchuk was unwittingly at the center of a medical controversy with important ethical ramifications. Mr. Golubchuk, an 84-year-old patient whose precise neurological level of function was open to debate, was being artificially ventilated and fed by a gastrostomy tube prior to his death. According to all reports he was neither brain dead nor in a vegetative state. The physicians directly responsible for his care had requested that they be allowed to remove the patient from life support against the wishes of the patient's family. Concurrently the Manitoba College of Physicians and Surgeons released a statement which states that the final decision to withdraw life support lies with the physician. In our opinion the statement is ethically problematic for a number of reasons. 1. It is an affront to the guiding principles of Western medical ethics: patient autonomy and human freedom. 2. The position of Samuel Golubchuk's physicians and the new statement lack cultural sensitivity towards other traditions. 3. In modern society there exists an erosion of a basic attitude towards the value of life. 4. The ability of physicians to predict life expectancy in terminally ill patients has been shown repeatedly to be quite limited.
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Clinicians frequently encounter and grapple with complex ethical issues and perplexing moral dilemmas in critical care settings. Intensive care unit (ICU) clinicians often experience moral distress in situations in which the ethically right course of action is intuitively known, but cannot be acted on. Most challenging cases pertain to end-of-life issues. Researchers have shown that moral distress and moral residue are common among critical care nurses. It is, therefore, essential that all ICU clinicians (and nurses, in particular) have an ongoing opportunity to work safely through these ethical dilemmas and conflicts. In this article, we describe the medical surgical intensive care unit (MSICU) experience with its monthly ethics initiative and explore the next steps to enhance its use through maximizing attendance and value to MSICU clinicians. To optimize attendance of staff a small group discussion among critical care clinicians (n = 8) was conducted asking about their perceptions of the debriefing sessions and their suggestions on how to promote their use. Process changes were implemented based on the group's suggestions. The process changes resulted in increased awareness of the benefits, increased frequency of sessions and demonstrated utility. Lessons learned from the MSICU experience will inform the development of education curricula to help critical care nurses with challenging end-of-life situations.
To withhold and withdraw treatment are important and difficult decisions made in the intensive care unit (ICU). The aim of this study was to investigate the incidence of withholding or withdrawing treatment, characteristics of the patients, and how these decision processes were handled and documented in a general ICU from 2007 to 2009 in a university hospital in Norway.
Patient characteristics and outcomes of treatment were prospectively registered. We retrospectively reviewed the medical records for information on limitations in treatment.
In total, 1287 patients were admitted to the ICU. The ICU mortality was 208 (16%), and the hospital mortality was 341 (26%). In total, 301 patients (23%) had treatment withheld or withdrawn. Medical and unscheduled surgical patients with limitations in treatment had higher Simplified Acute Physiology Score II (P?