Legal Implications of a Broken Engagement in Georgia by lqr10527

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									                                      Medical futility, moral distress and continuing to care




ICNE YALE #19




                Medical futility, moral distress and continuing to care




                          Karen Trotochaud, RN, MN, MA
                              Senior Program Associate
                         Emory University Center for Ethics
                          1462 Clifton Road NE. Suite 302
                               Atlanta, Georgia 30322
                               404-727-2796 (phone)
                                 404-727-7399 (fax)
                                 ktrotoc@emory.edu




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                                             Medical futility, moral distress and continuing to care




Abstract

Health care providers often face clinical situations where they believe a particular treatment is

futile because it will not meet their defined goals of treatment but patients/families that hold

differing values and goals disagree with the futility of the treatment. Despite intense debate about

the definition and acceptable management of medically futile treatment, one critical question

remains. How does the provider continue to provide competent, caring and compassionate care

to a patient when the provider believes aggressive therapy provides no benefit and the family

thinks otherwise? Through openly engaging moral distress and by pursuing a process of moral

reckoning, providers can learn to analyze the basis for the moral dilemma, understand the

reasons for their own moral distress, accept the legitimacy of the patient/family goals, identify

how they can continue to provide compassionate care in the face of their own disagreement, and

maintain a sense of moral integrity.



Keywords: ethics, futility, moral distress, moral integrity




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Case Study

With limited financial resources Shanna gave birth to Maria prematurely at 24 weeks gestation

and weighing only 550 grams (1 pound, 3 ounces). Maria developed severe Respiratory Distress

Syndrome requiring long term ventilator support. A cranial ultrasound revealed bilateral Grade

Four intraventricular hemorrhages (IVH) with progressive hydrocephalus. Her prognosis was

extremely grim.



With early signs of liver failure, the team met with Shanna explaining each of Maria’s problems

in detail. They did not think Maria would survive and, if she did survive, she would likely be

severely impaired, unable to walk, talk, or interact with others on any meaningful level. Shanna

was extremely upset, but she loved Maria and continued to hope the doctors were wrong. Maria

failed to show any improvement and began to show signs of kidney failure, so the doctors again

met with Shanna. They told Shanna that Maria was dying and it was very unlikely they could do

anything to stop this. If Maria’s heart were to stop, they did not recommend resuscitation.

Reluctantly, Shanna agreed to the Do Not Resuscitate (DNR) order. In addition, the doctors

believed that the ventilator was only prolonging her dying process. By removing the ventilator,

Maria could be made more comfortable as she died naturally. This discussion upset Shanna

greatly. She understood what they were telling her. Maria was not going to live; she would never




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go home; she would never grow up to run, jump, and play. But she also understood that if the

doctor’s removed the ventilator, Maria would die immediately. Even if Maria had almost no

chance of survival, any chance she might have would be eliminated if she was taken off the

ventilator. Shanna told the doctor’s she would not play God by agreeing to stop the ventilator

and end Maria’s life. She understood what they were saying but she believed it would be wrong

for her to agree to this. Multiple discussions with Shanna did not change her mind.



The decision was made: Maria would be maintained on the ventilator and made as comfortable

as possible until she died. Standing at Maria’s bedside and sitting with Shanna in each of these

conferences were doctors, nurses, social workers, and other providers who cared for Maria’s

health and about Shanna’s needs. They did not agree with Shanna’s decision to maintain Maria

on the ventilator, but that was the decision. They were to continue to care for Maria on the

ventilator even though they believed maintaining ventilator support was medically futile.



Introduction

Scenarios similar to this one are regularly played out in neonatal and adult intensive care units in

hospitals everywhere challenging the professional and personal moral integrity of doctors, nurses

and other healthcare providers. While the ethical issues inherent in these cases are widely




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debated and opinions continue to be argued, healthcare providers routinely face an important

question. How does one continue to provide competent, caring and compassionate care to a

patient when the healthcare provider believes that aggressive therapy provides no benefit and the

family thinks otherwise?



Three dimensions of this question require closer scrutiny. First, how does one understand the

disagreement regarding the treatment plan? The healthcare team described this as a request for

futile treatment. Is this in fact what is going on or is it something else? Second, what are the

internal responses experienced by the providers when faced with this dilemma? An important

factor impacting how the team responds is the emotional impact of this request. How are we to

understand their response? And third, how can providers integrate their understanding of the

request and their own emotional response in such a way as to maintain a sense of moral integrity

while continuing to provide treatment with which they do not agree? With this paper I will break

down these three dimensions. I will propose that it is through active engagement with these

dimensions that we can continue to provide treatments with which we do not agree and still

maintain a sense of moral integrity.



Requests for futile treatment or disagreement with the goals of treatment?




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The first dimension of this question relates to how we understand Shanna’s request for continued

ventilation of Maria. The providers described continued ventilation as medically futile treatment

and as such they believed it to be medically inappropriate. Because this was their belief, they

supported overriding Shanna’s request to maintain Maria on the ventilator preferring withdrawal

of the ventilator and allowing natural death.



In the past thirty years hundreds of articles and books have been written about the concept of

medical futility or requests for medically futile treatment. The one clear consensus that can be

drawn from all of these writings is that there is no clear consensus on what medical futility is or

how it should be managed. Reviewing some of the arguments about medical futility can help us

to understand how this concept may apply in the case of Shanna and Maria.



In an articulate analysis of over 50 articles on futility Helft, Siegler and Lantos1 describe four

categories of discussions presented in the literature. Early articles focused on defining futility,

assuming that clearly futile treatments fail to support an ethical obligation that they should be

provided. Quantitative definitions attempted to define futility based on the lack of a statistical

chance of success but other arguments challenged all definitions that offered anything greater

than a 0% chance of success, a case that is extremely infrequent. Qualitative definitions




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articulated specific treatments under defined circumstances that were believed to be futile. As

with quantitative definitions, legitimate arguments against each of these definitions were

offered.2 In the end attempts to define futility failed to achieve consensus supporting clear

definition and thus a consistent, agreed consensus that these requests need not be honored could

not be reached.



Several empirical studies attempted to describe how to scientifically determine futile treatment.

Physician’s reported predictions of the likelihood of survival with further treatment but the

results were too variable to support a reliable basis for determining futility founded on physician

predictions.3 Even established scoring systems, like APACHE III (Acute Physiology and

Chronic Health Evaluation), while well suited to describe the likelihood of survival of patient

populations, were not specific enough to support their use with individual patients.4 Attempts to

establish empirical thresholds for when treatment could be judged as futile proved equally

unsuccessful.



A third category of discussion focused on who has the right to decide whether a treatment is

futile. These discussions examined arguments supporting patients’ autonomy versus arguments

defending physicians’ autonomy. In the end these arguments concluded that rights exist on both




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sides forming “a complex network of relational obligations, which can be negotiated in one way

under certain circumstances and in another way when the situation changes.”1



The final category of discussion addressed the development of processes for addressing difficult

situations of conflicting opinions. These discussions have been most compelling generating a

great deal of interest. Support has been generated for the creation of policies that outline a

conflict resolution process.5,6 Follow up studies appeared to indicate some value in this process

approach to the futility question.7 However, recent push back from families, communities, and

providers following implementation of these policies in some institutions has argued that there is

a lack of consensus for this approach.8 There may be reason to support the use of a process

approach in these conflicts but the use of a terminal step that supports provider withdrawal of

treatment against the clear wishes of the patient/family continues to be a point of contention for

many providers and patients/families.



In addition to these four categories of discussions, underlying themes in most of these

discussions have included questions related to the legal and financial implications of using

futility as a justification for decisions to stop treatments against the request of patients/families.

History has not supported the effectiveness of using futility as a legal justification to stop




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treatment as U.S. courts have generally failed to address either a clear description of what

constitutes medically futile treatment or the appropriateness of futility as a defense for

withholding/withdrawing treatment.1 Real concerns about the cost of healthcare have fueled

discussions about the value of continuing to pay for futile treatments. But discussions that use

futility as a defense for stopping treatment when it is believed that the treatment is too costly are

more accurately described as arguments for rationing. Although issues of the cost of treatment

are extremely important, it is argued that futility is a weak or even inappropriate justification for

rationing of medical care.1, 9



Perhaps the most compelling moral understanding of what is going on when providers face

requests for treatment they believe to be futile is offered by Lantos.9 He states that analysis of the

futility question requires discussion of two primary components: 1) the goals of treatment

requested and 2) the likelihood of reaching the goals with the proposed treatment. He argues that

the first component, the goals of treatment, properly belongs to the patient/family. Goals are

clearly value oriented and, as such, belong to the patient/family, particularly the life and death

goals typically involved in futility questions. The second component, the likelihood of success,

properly belongs to the medical professional. As an empiric question medicine is the one entity

that can answer these questions. Despite this seemingly clear division of moral responsibility for




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the two components of the futility question, difficulty in addressing questions that arise in

individual clinical cases remains because both components must be taken into consideration

whenever futility is a question and both are filled with significant uncertainties.9



Though lack of consensus exists within the discussions about medical futility, one thing is clear.

Clinical cases where patients/families request treatments that providers believe to be futile

continue to occur and, more importantly, they are not likely to decrease. The reality is that as

healthcare providers we will be asked to provide treatments with which we do not agree because

we believe them to be futile. Even if we work within an institution with an established futility

policy, there will be at the very least a period of time when we will need to continue the

treatment plan until final resolution occurs. We cannot stop caring for patients just because we

disagree with the treatment plan. “The judgment that further treatment would be futile is not a

conclusion – a signal that care should cease.”1



Analyzing the case described relative to the question of medical futility helps to understand

Shanna’s request to continue ventilation for Maria. With respect to the goals of treatment, the

healthcare team understood Shanna’s goals for Maria’s treatment: not to cause Maria’s death by

removing the ventilator. She believed that God would determine when Maria should die and that




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neither Shanna nor the doctors should remove the ventilator resulting in Maria’s death. The

providers’ goals were different. Because they did not believe they had any curative treatment

options and that Maria was in the process of dying, the providers believed a more appropriate

goal for Maria was a peaceful, natural death. With Maria dying from her underlying pathology,

for them removal of the ventilator would not be the cause of her death. There was a clear

difference in goals of treatment. Arguments can be made for both goals, but there is no clear

ethical basis for prioritizing one goal over the other. While neither goal is unethical, neither is

one goal more ethical than the other.



Addressing the question of the likelihood that ventilator support would keep Maria alive, the

physicians admitted that at least for the immediate time period, it was likely to be successful.

And thus, to meet Shanna’s goal of treatment, the proposed treatment was not futile. Neither

Shanna nor the medical team disagreed with the likelihood of success for this treatment to

address this limited goal. They did disagree about what was an appropriate goal. Since it is

generally accepted that families as surrogate decision-makers for children have the moral right to

establish goals for treatment, it can be argued that there is a moral obligation to continue to

maintain ventilation for Maria even though there is disagreement about the appropriateness of




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the goal of treatment. Certainly, the providers can try to change Shanna’s mind about the goal

and try to convince her that the goal of a peaceful, natural death is more appropriate.



Moral distress as a response to requests for medically futile treatment

When asked to provide treatment they believe to be medically futile, it is not enough for

providers to understand simply the nature of the dilemma they face. They must also understand

their own response to the request especially when they do not agree with the treatment plan. In

most of these cases providers’ response is one of moral distress.



Moral distress has been reported when providers are faced with the requirement that they

participate in treatments they believe to be inappropriate or futile. Intensive care nurses identified

ethical conflict/moral distress when faced with life-prolonging aggressive therapies where they

questioned the balance of harm versus good10 and when placed in situations of having to provide

what they described as “overly aggressive medical treatments” that conflict with their own

values.11 Critical care nurses specifically surveyed about their response to situations they

perceive as futile or non-beneficial to their patients reported a high degree of moral distress that

was significantly related to emotional exhaustion.12 Even palliative care nurses reported

perceiving inappropriateness of medical treatment as a frequent and important source of moral




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difficulty.13 Nurses writing about distressing clinical experiences most frequently described these

conflicts as involving aggressive care denying palliative care.14 Common emotional responses to

these cases were feelings of being demoralized, powerless, frustrated, angry, distressed, or guilty

for failing patients.



Less frequently other providers have reported moral distress when faced with the need to provide

treatment believed to be futile. For example, intensive care physicians pressured to continue

what they believed to be unwarranted aggressive treatment reported feelings of moral distress.15

Another study including physicians identified three key sources of distress: patient suffering,

distressed family members and prognostic uncertainty, and the breakdown in relationship with

family members.16 Two additional reasons explaining clinician feelings included: distress at the

lack of trust on the part of the family who are not willing to follow recommendations and

feelings of distaste and repugnance that arises when providers are asked to provide treatments

they would not want for themselves or their families.17 Respiratory care practitioners reported the

highest moral distress related to treatments not in the patient’s best interest which included

disagreement with surrogate decision makers and providing futile care.18




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This concept of moral distress was initially described by Jameton.19 He describes moral and

ethical problems as including three different types. First, moral uncertainty exists when one is

unsure what the moral problem is or which moral principle or value applies,. Second, when two

or more clear moral principles apply to a situation, each supporting mutually inconsistent courses

of action, a moral dilemma is present. Third, moral distress occurs when one knows the right

action to take but pursuit of this course of action is nearly impossible due to institutional

constraints. Wilkerson describes moral distress as “the psychological disequilibrium and

negative feeling state experienced when a person makes a moral decision but does not follow

through by performing the moral behavior indicated by that decision.”20



Jameton identifies two forms of moral distress: initial distress and reactive distress.20 Initial

moral distress includes feelings of frustration, anger, and anxiety that occur when one is faced

with obstacles and conflict with others about values. Reactive moral distress arises when one

does not act upon the initial moral distress. Avoidance of reactive distress requires that one

actively respond to the initial distress.



Moral distress exhibited by the providers in this case was initial moral distress. Providers

believed the appropriate goal of treatment for Maria was a peaceful, natural death. The primary




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value supporting this goal was respect for persons during the dying process and a belief that it

was harmful to Maria to extend her dying process any longer. Shanna’s belief system was

strongly supported sanctity of life. She believed Maria was alive at the present time and removal

of the endotracheal tube and the ventilator would result in her death. This act would violate

support for the sanctity of life and thus would be wrong. Although Shanna did not want Maria to

suffer, she more strongly opposed any positive action that would result in her death. These two

value systems support opposing treatment goals and in this case are in direct conflict with each

other. What action can be taken when distress arises because of a conflict in values between the

family and the provider as in the case of Shanna and Maria?



Facing a situation that causes one to be in moral distress, it is incumbent upon the individual to

take specific steps to address their own distress. Purtillo21 suggests a six step process for the

analysis and resolution of ethical problems in clinical settings: 1) gathering information, 2)

identifying the ethical problem, 3) analyzing the problem, 4) exploring the options, 5)

implementing the action, and 6) evaluating the process outcome. A clear requirement of this

process is to address the specific ethical problems at hand. Consideration of the moral

obligations on the part of both family and provider must be closely examined including the

recognition of the place that personal values play in these decisions. Clearly identifying,




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discussing, and analyzing the ethical aspects of these cases are critical steps to addressing

provider moral distress.



Writing on moral distress Rushton22 proposes a four A’s model to rise above moral distress

identified as ask, affirm, assess, and act. This systematic approach identifies action steps that can

be implemented to develop an ethical practice environment. One critical action step requires that

the nurse affirm her professional obligation to respect the dignity and worth of every individual.

Rushton challenges us to look beyond just the negative feelings that may result in cases of moral

distress. She emphasizes that one can use the experience of moral distress as “an opportunity to

reappraise one’s ethical values and commitments, adopt a stance of respect for contrary views,

and engage in practices that foster growth and critical reflection. While distress has the potential

to erode self-esteem, it is also an opportunity for growth and compassionate action.”22



Hamric23 reinforces the need for identification of values in conflict as an essential component of

everyday ethical situations faced by nurses. She encourages nurses to be explicit about their

personal values and to explore how these values affect their perceptions of what is the right

action in a particular situation. It is not enough just to explore one’s own values, nurses should




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learn to question whose values are in conflict and to identify their relationships to the patient and

the situation.



Writing about palliative care nursing Georges and Grydonck13 support a concept of engagement.

Providers who take on an attitude of disengagement can develop negative feelings and

professional disillusionment following their inability to resolve these moral problems. By

supporting nurses’ efforts to develop skills for adequately addressing moral problems and for

reflecting on critical cases, nurses can enhance their sensitivity to the consequences of their

actions and can be encouraged to appropriately consider moral aspects of cases.



Dismissing feelings of moral distress when providers are required to provide treatments they

believe to be futile can lead to frustration and emotional exhaustion. In many cases it is not

possible to change the treatment plan. So how can moral distress in these cases best be

addressed?



I would like to propose a process of engaging moral distress. Begin by recognizing the feelings

that providers are experiencing as that of moral distress resulting from the decision to provide

such treatment. Be alert to feelings and behaviors that indicate the presence of moral distress,




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like anger, frustration, and anxiety. Openly discuss these feelings, affirming the existence of the

very real responses to these requests. Once moral distress is openly affirmed, the basis for the

distress can be broken down by clearly identifying the values held by the providers, the values

held by the patient/family, and the differences between the two. Analyze the ethical argument for

each perspective and the basis for the moral standing of each. Being able to recognize the ethical

justification for differing values and varying points of views is the first step to being able to

understand and accept other’s beliefs while still retaining one’s own beliefs. It is not necessary

for providers to change their own values to be in agreement with patients’/families’ values in

order for them to accept the others’ values as justified.



In the case of Shanna and Maria, the providers held a lengthy conference with Shanna. They

carefully listened as she clearly articulated her goals for Maria’s treatment. The providers stated

their goals explaining at length why they supported those goals. It was an opportunity for both

sides to listen to the other. In a post-conference meeting, the providers were able to verbalize

their distress over a decision to continue to ventilate Maria. Even though they did not agree with

Shanna’s goals they were able to accept her right to have those goals and their moral obligation

to continue to provide treatment. Although they were not able to totally eliminate all moral




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                                              Medical futility, moral distress and continuing to care




distress, by engaging their moral distress they were able to move beyond their emotional

response to the decision to continue ventilator support for Maria based on Shanna’s goals.



Continuing to care with moral integrity in the face of disagreement

The last dimension of these difficult clinical situations is the integration of the provider’s

understandings into actions in such a way as to maintain moral integrity. Moral integrity refers to

a sense of wholeness or oneness between our values and beliefs and our actions, “a certain

conception of our self as being a consistent whole.”24 But moral integrity requires more than

simply responding to a belief we have about a particular clinical situation; it is more than just

acting on a gut feeling. Moral integrity requires the presence of three distinct aspects: 1) critical

thinking about the situation, 2) the presence of coherence with our values orientation, and 3) a

commitment to act in a principled way.24 Important to the development of moral integrity is

reflection on different values and thoughtful discussion about these values in relationship with

others. In this respect moral integrity is a process, not a fixed point. Equally as important,

gaining and maintaining moral integrity is “a relational process in which we need to reflect

within ourselves and have a dialogue with others to do the work that allows us to settle on our

principles and values, and to be able to justify them to others.”24




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In the process of developing and maintaining moral integrity, sometimes moral compromise may

be appropriate. It can be argued that moral compromise does not necessarily undermine moral

integrity and in some cases may even be morally required. This conclusion requires an

understanding of the concept of moral pluralism, or the belief that there are a plurality of norms

and values that relate to moral judgments and that there is no one principle that can be used to

determine a single answer when these norms and values are in conflict.25 Under these

circumstances people can hold belief in values that do not relate back to higher order values.

When values are incompatible with each other and cannot all be fully realized and if there exists

no way to determine some order of priority, resolving a conflict in priority is impossible. In such

cases, when individuals acknowledge there is no sufficient argumentative grounding to prioritize

their position over an opposing view that is supported by plausible arguments, then moral

compromise can be considered to be appropriate.25



Learning to cope with moral distress has been identified as a critical element in the process of

preserving moral integrity. In an analysis of moral development of new graduate nurses, Kelly26

describes the process new nurses go through as they learn to recognize, face, and deal with

situations that create moral distress as a redefinition of self and identity. She identifies one

outcome of this struggle as preservation of moral integrity.26




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Using the concept of moral reckoning, Nathanial27 offers a three-stage process where nurses can

critically and emotionally reflect on their motivations, choices, actions and consequences as they

relate to troubling patient care situations. The first stage, a stage of ease, exists when nurses feel

on the whole rewarded and fulfilled with their work. At some point nurses face situations that

interrupt this stage of ease causing turmoil because core beliefs and other claims come into

conflict. Being faced with providing treatments believed to be futile is an example of such a

situational bind. The nurse experiences strong emotional responses to this situational bind

including intolerable internal conflict or a state of moral distress.



At this point the nurse moves into the second stage, a stage of resolution, where she is faced with

two choices: making a stand or giving up. Neither option denotes a right or a wrong response. In

addition, these options are not mutually exclusive, with nurses sometimes making different

choices over time and depending upon circumstances and understandings.



The third stage is a stage of reflection where the nurse remembers and reflects as she reckons her

actions. Activities of this stage include remembering, telling the story, examining the conflicts,

and living with the consequences. By understanding this process of moral reckoning and




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supporting movement through these stages, providers can successfully preserve their own moral

integrity when they are faced with clinical situations where they believe treatments are futile.



Using the process of moral reckoning in discussion of this clinical case illustrates how providers

can reach a point of being able to provide continuing ventilation for Maria even though they

believe this treatment to be futile. The initial clinical course for Maria represents the stage of

ease. During this time both providers and Shanna agreed on the goals of treatment for Maria. As

Maria failed to progress as expected, these goals became unrealistic. The situational bind in this

case occurred when the providers no longer felt they were able to maintain Maria’s life, even

with aggressive treatments, and that she would ultimately die. At that point the providers

changed their goal of treatment to one focused on support for a peaceful, natural death. They

believed the best way to accomplish this goal was to withdraw Maria from the ventilator and

make her comfortable until she died.



However, Shanna did not agree with this goal or this plan of treatment. She wished to keep

Maria on the ventilator and alive. Although she realized that hope for recovery was likely

unrealistic, she was not able to give up hope altogether. At this point a situational bind existed.




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                                            Medical futility, moral distress and continuing to care




The goal the providers held and the goal Shanna held were in conflict with no clear way to

prioritize one goal over the other.



Facing this decision the providers moved into the stage of resolution. Through a process of open

discussion about the futility question, the providers heard Shanna’s values and wishes for Maria

and they discussed their own values and beliefs about what they thought was best for Maria.

Ultimately, respecting Shanna’s moral right as mother to set goals for Maria’s treatment, the

providers agreed to continue to ventilate Maria and to be supportive of Shanna’s values. This

decision, however, did not change the providers’ belief that a peaceful, natural death was a more

appropriate goal for Maria. Even though they agreed to the treatment plan, they continued to

believe it was futile since it would not achieve what they believed was a more appropriate goal.

Having agreed to support Shanna’s values in this case does not exclude the option of continuing

to help Shanna to understand the providers’ values and goals. Some providers were reluctant to

just “give up” and continued to discuss the value of a peaceful, natural death with Shanna.

However, she never altered her values. The providers accepted the decision to continue

ventilation refocusing care on assuring that Maria was as comfortable as possible.




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Having accepted the treatment plan the providers maintained Maria on the ventilator until she

died. They changed the focus of their care planning to one of a palliative care, addressing pain

and symptom relief, decreasing unnecessary tests, not adding new treatments, and supporting

Maria in her dying process. They also addressed how they could support Shanna as she

continued to mother her dying infant. After about two weeks Maria developed bradycardia.

Knowing that the end was imminent, Shanna agreed to the removal of the ventilator. Within a

couple of hours Maria died peacefully in her mother’s arms.



The final stage of reflection required that the providers reckon their actions and the outcomes of

the case. The providers concluded that Maria did not significantly suffer in her final two weeks

of life having been provided appropriate pain medication and sedation. No new procedures were

added and only limited diagnostic testing was done. She was provided with compassionate and

caring treatment by all of her providers. Most providers believed that continuing ventilation was

futile treatment but they were able to accept that Shanna had the moral right to her values and

goals. In this way they were able to maintain their own moral integrity while continuing to

provide care even when they did not agree with the treatment plan.




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Conclusion

The dilemma of medical futility often results in clinical cases where providers believe that a

particular treatment is futile because it will not meet their defined goals of treatment but

patients/families holding different values and goals disagree with the futility of the treatment. In

these life and death cases for a multitude of reasons the patient/family goals are the ones that are

honored and the provider-defined futile treatments are continued. These cases require that

providers face situations where they must participate in a treatment plan focused toward a goal

with which they do not agree, often time resulting in significant feelings of moral distress.

Through openly engaging this moral distress and by pursuing a process of moral reckoning,

providers can learn to analyze the basis for this moral dilemma, understand the reasons of their

moral distress, accept the legitimacy of the patient/family goals, identify how they can continue

to provide compassionate care in the face of their own disagreement, and maintain a sense of

moral integrity.




1 Helft PR, Siegler M, Lantos J. The rise and fall of the futility movement. New England Journal
  of Medicine 2000; 343(4): 293-296.
2 Schneiderman LJ, Jecker NS, Jonsen AR. Medical futility: its meaning and ethical
  implications. Annals of Internal Medicine 1990; 112: 949-954.
3 McCrary SV, Swanson JW, Younger SJ, Perkins HS, Winslade WJ. Physicians’ quantitative
  assessments of medical futility. Journal of Clinical Ethics 1994; 5: 100-105.
4 Ridley, SA. Uncertainty and scoring system. Anaesthesia 2002; 57l: 761-767.




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5 Halevy A, Brody BA. A multi-institutional collaborative policy on medical futility. JAMA
  1996; 276:571-574.
6 The Council on Ethical and Judicial Affairs, American Medical Association. Medical futility in
  end-of-life care: Report of the Council on Ethical and Judicial Affairs. JAMA 1999; 281:937-
  941.
7 Fine RL, Mayo TM. Resolution of futility by due process: Early experience with the Texas
  Advance Directives Act. Annals of Internal Medicine 2003; 138: 743-746.
8 Truog RD. Tackling medical futility in Texas. New England Journal of Medicine 2007; 357: 1-
  3.
9 Lantos J. When parents request seemingly futile treatment for their children. The Mount Sinai
  Journal of Medicine 2006; 73 (3): 587-589.
10 Redman BK, Fry ST. Nurses’ ethical conflicts: What is really known about them? Nursing
  Ethics 2000; 7(4): 363-366
11 Gutierrez KM. Critical care nurses' perceptions of and responses to moral distress.
  Dimensions in Critical Care Nursing 2005; 24(5):229-41
12 Meltzer LS, Huckabay LM. Critical care nurses' perceptions of futile care and its effect on
  burnout. American Journal of Critical Care 2004; 13(3):202-8.
13 Georges JJ, Grypdonck M. Moral problems experienced by nurses when caring for terminally
  ill people: A literature review. Nursing Ethics 2002; 9(2): 155-178.
14 Ferrell BR. Understanding the moral distress of nurses witnessing medically futile care.
  Oncology Nursing Forum 2006; 33(5):922-30.
15 Hamric AB, Blackhall LJ. Nurse-physician perspectives on the care of dying patients in
  intensive care units: collaboration, moral distress, and ethical climate. Critical Care Medicine
  2007; 35(2):422-9.
16 Workman S, McKeever P, Harvey W, Singer PA. Intensive care nurses’ and physicians’
  experiences with demands for treatment: Some implications for clinical practice. Journal of
  Critical Care 2003; 18(1): 17-24.
17 Curtis JR, Burt RA. Why are critical care clinicians so powerfully distressed by family
  demands for futile care? Journal of Critical Care 2003; 18(1): 22-24.
18 Schwenzer KJ, Wang L. Assessing moral distress in respiratory care practitioners. Critical
  Care Medicine 2006; 34(12): 2967-73
19 Jameton A. Nursing Practice: The Ethics Issues. New Jersey; Prentice-Hall, Inc., 1983.
20 Jameton A. Dilemmas of moral distress: moral responsibility and nursing practice.
  AWHONN’s Clinical Issues 1995; 4(4): 542-551.




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21 Purtillo RB. Ethical Dimensions in the Health Professions. 4th Ed. Philadelphia: Elsevier
  Saunders, 2005.
22 Rushton CH. Defining and addressing moral distress: Tools for critical care nursing leaders.
  AACN Advanced Critical Care 2006; 17(2); 161-168.
23 Hamric AB. Moral distress in everyday ethics. Nursing Outlook 2000; 48(5): 199-201.
24 Hardingham LB. Integrity and moral residue: Nurses as participants in a moral community.
  Nursing Philosophy 2004; 5: 127-134.
25 Van Willigenburg T. Moral compromises, moral integrity and the indeterminacy of value
  rankings. Ethical Theory and Moral Practices 2000; 3: 385-404.
26 Kelly B. Preserving moral integrity: a follow-up study with new graduate nurses. Journal of
  Advanced Nursing 1998; 28(5): 1134-1145.
27 Nathanial AK. Moral reckoning in nursing. Western Journal of Nursing Research 2006; 28:
  419-438.




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