Upcoming Education

Tuesday, March 2912:15 p.m. – 1:45 p.m.

Register at washington.providence.org/events/phc/professional-education/clinical-ethics/

Ethics Grand Rounds Care Across Cultures:

Communicating About Serious Illness

Moral Distress or Moral Courage?Andrea Chatburn, DO, MAMedical Director for Ethics, PHCFebruary 18, 2016

Learning Objectives

• Differentiate between an ethical dilemma & moral distress

• Recognize common causes of moral distress

• Discuss strategies to reduce moral distress

Nothing to disclose

THANK YOU

Upcoming Education

Tuesday, March 2912:15 p.m. – 1:45 p.m.

Register at washington.providence.org/events/phc/

professional-education/clinical-ethics/

Ethics Grand Rounds Care Across Cultures:

Communicating About Serious Illness

Vision Together, we answer the call of every person we serve: Know me, care for me, ease my way.®

Mission As people of Providence, we reveal God’s love for all, especially the poor and vulnerable, through our compassionate service.

High Reliability

• Improves organizational effectiveness• Improves organizational efficiency• Improves customer satisfaction• Improves compliance• Improves organizational culture• Improves documentation

Solidarity“We are one human family whatever our national,

racial, ethnic, economic, and ideological differences.

We are our brothers’ and sisters’ keepers, wherever they may be.

Loving our neighbor has global dimensions

in a shrinking world.”US Conference of Catholic Bishops

What is Moral Distress?

“inability of a moral agent to act according to their core values and perceived obligations due to internal and external constraints”

Jameton 1984

Moral Distress

Moral Uncertainty

Moral Dilemma

DISCOMFORT

Discomfort

• Frustration• Avoidance• Anger• Guilt• Confusion• Sadness• Physical Symptoms

Institutional Obstacles

• Lack of time• Lack of administrative support• Lack of continuity*• Poor Communication*• Inadequate resources, staffing• Hierarchical culture• Institutional policy• Legal limits

Signs of Moral Distress

• “It’s not my job to speak up”• “No one will listen anyway”• “Why are we doing this?”• “I feel like I’m causing suffering”• Withdrawing/ Moral apathy

Source Events

• Aggressive, prolonged, non-beneficial pattern of interventions

• Mistrust among care team members• Difficult patient encounters• Repeated events• Caring for an abused patient when

family at the bedside is potential abuser

Against the Grain

• Violates core values• Honoring patient choices that you would not

choose for yourself

• Challenges Personhood- view of oneself as a moral person and professional

• Shaped by multiple contexts

Diverse Communities

Moral Residue

Moral Residue:•Intensity lingers•“Crescendo effect”•Validation: People in the same event may experience moral distress very differently

Effects of Moral Distress

• Systemic poor communication• Inadequate collaboration• Perceived powerlessness• Limited time to address concerns• Intensity of emotion lingers

Organizational Impact

• Miscommunication• Increased near-misses, safety events• Avoidance of crucial conversations• Low satisfaction• High turnover (25%)

Moral Courage

Must we be courageous?

“Courage should not be necessary for any health care professional to

ask a question or make a suggestion

regarding a patient’s care.”

Ann Hamric, John Arras, & Margaret Mohrmann

Decreasing Moral Distress

• Open dialogue• Seeking common ground• Mutual respect across disciplines• Collaborative problem solving• Collegial atmosphere• Targeted education around root causes

High Reliability Culture

• Speak up about near-misses• Create a culture where speaking up is

acceptable• Validate coworker concerns• Voice concerns about unhealthy power

dynamics• Self Care

Strategies to Address Distress

• Early, frequent and consistent communication with patients and families

• Name the ethical dimensions of care• Build team solidarity• Seek skilled facilitators• Debrief distressing citations

It’s all about relationships

• Self care• Effects of nourishing vs. toxic

community• Interprofessional education in heath

professions can help learners build ethically healthy teams

Core Values & Virtues

• Identifying the values in conflict• Reflection on own personal values• Reflection on application of values to

the situation

Tools- Personal

• Engaged curiosity• Self-Care

Tools- Team based

• Interdisciplinary team huddle• Conflict resolution & mediation• Ethics Consultation• Spiritual Care Consultation• Palliative Care Consultation

CISM: Critical Incident Stress Managment

• How: Dial the Operator

A critical incident is any event that creates a very strong emotional reaction.

Anyone, anytime, any reason

CISM: Critical Incident Stress Managment

• Traumatic patient death or near-death• Internal or external disaster• Cumulative stressful events• Personally stressful event• Unresolved ethical/moral distress

Respecting Choices• Next facilitator training March 30th • Expanding at the end of March

– Cancer Care Northwest– Spokane Valley – Northpoint campus

Respecting Choices• Started 1st cohort ONE year ago• 7 Clinic locations• Integrated locations:

– VNA– Adult Day Health– St. Joseph Care Center– St. Joseph in Chewelah

Tools

Next Schwartz Rounds: – Holy Family Hospital

• Friday March 11 @ Noon• HEC 1, 4, 5

– Sacred Heart Medical Center Fri April 1st

• “One mark of moral progress in a community or society…[is] the extent to which measures are taken to reduce the incidence of moral distress in members of that community. Just as respect and tolerance are marks of a moral community, so is a seriousness about this often devastating phenomenon.”-Bill Bartholome 1998

Bibliography• Epstein * Hamric. Moral distress, moral residue, and the crescendo effect. Journal

of Clinical Ethics, 20(4), 330-342.• Hamric, Ann. A Case Study of Moral Distress. Journal of Hospice & Palliative

Nursing. 2014; 16, no. 8: 457-463.• Hamric, Ann. Moral Distress in Everyday Ethics. Nursing Outlook 2000; 48:199-

201.• Hamric, Arras, and Mohrmann. Must we be Courageous? Hastings Center Report

45 no. 3 (2015):33-40.• Savel and Munro. Moral Distress, Moral Courage. American Journal of Critical

Care. 2015; 24 no. 4; 276-• Ulrich, et al. Moral Distress: A Growing Problem in the Health Professions?

Hastings Center Report. 40, no.1 (2010):20-22.• Whitehead, et al. Moral Distress Among Healthcare Professionals: Report of an

Institution-Wide Survey. Journal of Nursing Scholarship. 2015; 47:2,117-125.• http://www.centerfortransforminghealthcare.org/hro_portal_main.aspx

Upcoming Education

Tuesday, March 2912:15 p.m. – 1:45 p.m.

Register at washington.providence.org/events/phc/professional-education/clinical-ethics/

Ethics Grand Rounds Care Across Cultures:

Communicating About Serious Illness