Courtenay R. Bruce

A qualitative study exploring moral distress in the ICU team: the importance of unit functionality and intrateam dynamics

Objective:Our study objectives were to determine the key sources of moral distress in diverse critical care professionals and how they manage it in the context of team-based models. Design:Qualitative case study methodology using three recently resolved clinical cases. Setting:A medical and surgical adult ICU in a 900-bed academic, tertiary Houston hospital. Subjects:Twenty-nine ICU team members of diverse professional backgrounds interviewed between March 2013 and July 2013. Interventions:None. Measurements and Main Results:All members of the ICU team reported experiencing moral distress. Intrateam discordance served as a key source of distress for all healthcare disciplines. Interviewees identified two situations where intrateam discordance creates moral distress: 1) situations involving initiation or maintenance of nonbeneficial life-sustaining treatments and 2) situations involving a lack of full disclosure about interventions. Healthcare professionals engaged in a variety of management techniques, which can be grouped according to maladaptive behaviors (pas-de-deux, “fighting,” and withdrawing) and constructive behaviors (venting, mentoring networks, and building team cohesion). Maladaptive behaviors were more common in the surgical ICU. Constructive behaviors were more prevalent in the medical ICU and typically used by nurses and ancillary staff members. Physicians report becoming detached as morally distressing cases unfold, whereas nurses report becoming more emotionally invested. Conclusions:This study identified the ways in which moral distress manifests across critical care disciplines in different ICU environments. Our results have potential implications for patient care. First, when clinicians alter the content of their goals-of-care conversations with patients or families to accommodate intrateam discordance (as part of the “pas-de-deux”), subsequent decisions regarding medical care may be compromised. Second, when different team members respond differently to the same case—with nurses becoming more emotionally invested and physicians becoming more withdrawn—communication gaps are likely to occur at critical moral distress junctures. Finally, our findings suggest that physicians and any healthcare professionals in surgical units might be susceptible to unmitigated moral distress because they report less engagement in constructive behaviors to recalibrate their distress.

Ventricular assist devices: a review of psychosocial risk factors and their impact on outcomes.

BACKGROUND Psychosocial contraindications for ventricular assist devices (VADs) remain particularly nebulous and are driven by institution-specific practices. Our multi-institutional, multidisciplinary workgroup conducted a review with the goal of addressing the following research question: How are preoperative psychosocial domains predictive of or associated with postoperative VAD-related outcomes? Answers to this question could contribute to the development of treatment-specific (contra) indications for patients under consideration for mechanical devices. METHODS AND RESULTS We identified 5 studies that examined psychosocial factors and their relationship to postoperative VAD-related outcomes. Our results suggest that 3 psychosocial variables are possibly associated with VAD-related outcomes: depression, functional status, and self-care. Of the few studies that exist, the generalizability of findings is constrained by a lack of methodologic rigor, inconsistent terminology, and a lack of conceptual clarity. CONCLUSIONS This review should serve as a call for research. Efforts to minimize psychosocial risk before device placement can only be successful insofar as VAD programs can clearly identify who is at risk for suboptimal outcomes.

An Embedded Model for Ethics Consultation: Characteristics, Outcomes, and Challenges

Background: Little has been written about models for clinical ethics consultation. By “model” we mean the way in which the engagement between the clinical ethics consultant, hospital staff, and other stakeholders is structured, with a key variable being the degree of integration with stakeholders within the institution or segments of the institution. We describe an innovative model of clinical ethics consultation, which we term “embedded ethics,” involving embedding clinical ethics consultants within clinical specialties and subspecialties based on institutional needs and areas of clinical ethicists’ expertise. Methods: The overarching methodology for this article is a case study, reporting our experience with an intervention that we evaluated using mixed methods. Results: Our results underscore the positive impact that an embedded ethics intervention can have on consultation volume and intensity, as well as clinical staff perceptions of an ethics consultation service (ECS). Conclusions: Our experience with the embedded ethics model supports several intuitions about the benefits of adopting such a model for increasing awareness (and use) of the ECS as a resource for clinicians, patients, and families and of improving clinicians’ satisfaction.

Clarification of the intent of ventricular assist devices before patient consent

Moazami and Feldman recently proposed a single indication for mechanical circulatory support (MCS). This indication, ‘‘end-stage heart failure refractory to medical therapy,’’ similar to the tripartite nomenclature (‘‘destination therapy,’’ ‘‘bridge to transplant,’’ and ‘‘bridge to recovery’’) by the Centers for Medicare and Medicaid Services (CMS), is clinically and ethically incomplete. In this article, we describe how the CMS tripartite nomenclature unintentionally increases the risk of ethical problems characterized by misalignments in expectations and goals among heart failure teams, patients, and surrogates, and thus increases the risk of an inadequate informed consent process forMCS. Similar toMoazami and Feldman, we assert that the current tripartite nomenclature is problematic because of its emphasis on intended use. However, in providing only the single indication of MCS, the proposal by Moazami and Feldman does not address the nature of MCS, its shortand long-term goals, or outcomes. As a result, their proposal does not fully address the ethical problems with the CMS nomenclature. We address this ethical challenge with an ethically justified, clinically practical framework for describing ventricular assist device (VAD) implantation. Although this framework is particularly relevant for VADs, it is likely equally applicable for most other types of MCS devices. As clinical ethicists at 3 high-volume VAD programs, we often participate in informed consent processes with VAD candidates to elucidate patients’ and surrogates’ understanding and expectations of the device, trajectories, and outcomes, and to document advance care planning preferences before device implantation. We also conduct ethics consultations for VAD patients who already have the device implanted, typically for the purpose of mediating conflicts between surrogates or between surrogates and health care professionals about device deactivation and withdrawal of

Practical Guidance for Charting Ethics Consultations

It is generally accepted that appropriate documentation of activities and recommendations of ethics consultants in patients’ medical records is critical. Despite this acceptance, the bioethics literature is largely devoid of guidance on key elements of an ethics chart note, the degree of specificity that it should contain, and its stylistic tenor. We aim to provide guidance for a variety of persons engaged in clinical ethics consultation: new and seasoned ethics committee members who are new to ethics consultation, students and trainees in clinical ethics, and those who have significant experience with ethics consultation so that they can reflect on their practice. Toward the goal of promoting quality charting practices in ethics consultations, we propose recommendations on a broad array of questions concerning clinical ethics consultation chart notes, including whether and when to write a chart note, and practical considerations for the tenor, purpose, and content of a chart note. Our broader aim is to promote discussion about good charting practices in clinical ethics, with the hope of contributing to clear standards of excellence in clinical ethics consultation.

Challenges in Deactivating a Total Artificial Heart for a Patient With Capacity

The use of mechanical circulatory support (MCS) devices has increased sixfold since 2006. Although there is an established legal and ethical consensus that patients have the right to withdraw and withhold life-sustaining interventions when burdens exceed benefits, this consensus arose prior to the widespread use of MCS technology and is not uniformly accepted in these cases. There are unique ethical and clinical considerations regarding MCS deactivation. Our center recently encountered the challenge of an awake and functionally improving patient with a total artificial heart (TAH) who requested its deactivation. We present a narrative description of this case with discussion of the following questions: (1) Is it ethically permissible to deactivate this particular device, the TAH? (2) Are there any particular factors in this case that are ethical contraindications to proceeding with deactivation? (3) What are the specific processes necessary to ensure a compassionate and respectful deactivation? (4) What proactive practices could have been implemented to lessen the intensity of this cases challenges? We close with a list of recommendations for managing similar cases.

Barriers and Facilitators to Initiating and Completing Time-Limited Trials in Critical Care.

Objectives:A time-limited trial is an agreement between clinicians and patients or surrogate decision makers to use medical therapies over a defined period of time to see if the patient improves or deteriorates according to agreed-upon clinical milestones. Although time-limited trials are broadly advocated, there is little empirical evidence of the benefits and risks of time-limited trials, when they are initiated, when and why they succeed or fail, and what facilitates completion of them. Our study objectives were to 1) identify the purposes for which clinicians use time-limited trials and 2) identify barriers and facilitators to initiating and completing time-limited trials. Design:Semistructured interviews: We analyzed interviews using qualitative description with constant comparative techniques. Setting:Nine hundred-bed, academic, tertiary hospital in Houston, Texas. Interviewees were from open medical, surgical, neurosurgical, and cardiovascular ICUs. Subjects:Thirty healthcare professionals were interviewed (nine surgeons, 16 intensivists, three nurse practitioners, and two “other” clinicians). Interventions:None. Measurements and Main Results:Interviewees reported initiating time-limited trials for three different purposes: to prepare surrogates and clinicians for discussion and possible shifts toward comfort-care only therapies, build consensus, and refine prognostic information. The main barriers to initiating time-limited trials involve clinicians’ or surrogate decision makers’ disagreement on setting a time limit. Barriers to completing time-limited trials include 1) requesting more time; 2) communication breakdowns because of rotating call schedules; and 3) changes in clinical course. Finally, facilitators to completing time-limited trials include 1) having defined goals about what could be achieved during an ICU stay, either framed in narrow, numeric terms or broad goals focusing on achievable activities of daily living; 2) applying time-limited trials in certain types of cases; and 3) taking ownership to ensure completion of the trial. Conclusions:An understanding of barriers and facilitators to initiating and completing time-limited trials is an essential first step toward appropriate utilization of time-limited trials in the ICUs, as well as developing educational or communication interventions with clinicians to facilitate time-limited trial use. We provide practical suggestions on patient populations in whom time-limited trials may be successful, the setting, and clinicians likely to benefit from educational interventions, allowing clinicians to have a fuller sense of when and how to use time-limited trials.

Content Analysis of Social Media Related to Left Ventricular Assist Devices

Background—Social media have the potential to offer important benefits for patient education, support, and shared decision making. Despite the proliferation of social media use during the past decade, little is known about the scope and quality of available information, or the purposes that social media sites serve for patient decisional and support needs. Methods and Results—We conducted a mixed method study, including content analysis of social media and principal components analysis analysis of data sites discussing left ventricular assist device treatment for heart failure. This study explored aspects of interactivity, user-friendliness, appeal, medium, purpose, audience, and accuracy of information. Higher levels of interactivity (eg, posting comments) seem to enhance the appeal and usability of available information but also introduce greater potential for inaccuracy and inconsistency. The current lack of oversight into the content and quality of available information constitute a challenge for the reliable use of social media as forums for information-seeking and social network–based support. Conclusions—We conclude that social media outlets constitute a promising source of informational and psychosocial support for patients, caregivers, and candidates, and if used in conjunction with patient-provider dialog, can contribute to informed decision making by facilitating reflection and discussion of personal concerns, values, and informational needs.

Flawed Assumptions: Ethical Problems with Proposed Presumed Consent Legislation

At present, there is a House bill in the Texas Legislature that would shift Texas from an opt-in organ donation model – a model requiring explicit consent for organ donation from the donor or donors family – to an opt-out, or presumed consent, model. Under this new bill, the state would assume that a person agreed to organ donation unless the donor registered an objection. If passed, this law would be the first-of-its-kind in the United States, and it represents the direct inverse of the nations current opt-in model as outlined by the Uniform Anatomical Gift Act (although the bill does not violate federal law). (1) Recently, lawmakers in other states such as Delaware and New York have proposed similar bills. Proponents’ intentions are clear: to increase the number of available organs. They argue that data from other countries suggest that a shift from opt-in to opt-out could increase organ procurement. (2) This article is protected by copyright. All rights reserved.

An ethical appraisal of financial incentives for organ donation

Legally, the purchase or sale of human organs is not allowed, according to the National Organ Transplant Act (NOTA) and the Uniform Anatomical Gift Act. At present, the only form of compensation that is legally permissible includes reimbursement for living donors’ expenses associated with ‘‘travel, housing, and lost wages.’’ The purpose of these payments is to mitigate financial loss living donors might incur as a result of the donation process, rather than provide financial incentive or encouragement to donate. Although NOTA permits reimbursements for living donors, most donors do not actually receive reimbursements, because insurance companies typically cover only the evaluation process, surgery, and postoperative care. Deceased donors and their families do not receive any form of compensation. In this commentary, we will synthesize existing conceptual arguments in favor of and against financial incentives, with an eye toward living donation. Many of the arguments are applicable to either the living or deceased donation context. We will conclude with recommendations, with the goal of advancing dialogue and systematic information-gathering to further develop this issue.