Suspending Our Agenda: Considering What Will Serve When Confronting Ethical Challenges

Tom Franklin was admitted to the surgical intensive care unit (ICU) 8 weeks ago after resection of necrotic bowel due to superior mesenteric artery occlusion. On postoperative day 3 he suffered a cardiac arrest and was resuscitated. Mr Franklin’s course since then has been complicated by acute respiratory distress syndrome, stroke, renal failure, and multiple episodes of septic shock. He has a sacral decubitus requiring twice-daily dressing changes, during which he grimaces while his blood pressure and oxygen saturation drop. His decision-making capacity has been intermittent. Throughout Mr Franklin’s surgical ICU stay, his care team addressed each acute event and complication with additional treatment interventions. His wife, Mrs Franklin, has power of attorney for health care and has come to view these treatments, including cardiopulmonary resuscitation, as necessary for her husband’s survival. The clinical team is concerned that they are participating in a course that is incrementally adding burden with unclear benefit. Lisa Waller is the attending physician in the surgical ICU this week. She cared for Mr Franklin last month and now wants to have another family meeting to discuss resuscitation preferences and goals of care. She is certain that she can convince the family to shift the focus from aggressive treatment to a palliative approach and to agree to a do not resuscitate (DNR) order. The critical care nurse caring for Mr Franklin states, “I’m not sure what good it will do; we’ve had this conversation many times and it always turns out the same.” Despite Dr Waller’s efforts to redirect the conversation, she is unsuccessful in convincing Mrs Franklin to shift the goals for her husband’s treatment. The team leaves the meeting expressing despair that nothing seems to get through to Mrs Franklin—that she is in denial. As a last resort, they request an ethics consult with the goal “to get the DNR order.”Scenarios such as this are common in critical care and can provoke anger, frustration, and, in some cases, moral distress.1 A common refrain begins to emerge as we lament our helplessness during rounds and handoffs and in reports.2 Patients or their surrogates begin to withdraw, become angry, or intensify their resistance to the team’s recommendations. The team’s ongoing insistence about limiting treatments such as resuscitation is commonly interpreted by the family as a lack of commitment or engagement in their loved one’s care. Often trust is broken on both sides of the equation, and this can create the conditions for communication failures, deepening conflict, and lack of understanding.3,4 The result is a widening gap between patient goals and clinician recommendations in addition to stalled progress in providing integrity-preserving care.The repetition of these scenarios creates patterns of communication, decision-making, collaboration, and conflict resolution within the critical care team as well as individual patterns of responses including emotions, narratives that are created to explain the situation, and activation of fears, among other responses. These systemic patterns, fueled by internal and external financial pressures, regulations, legal concerns, and organizational priorities, create context for both our individual and team responses. Systemic pressures to increase throughput and efficiency make it difficult for us, as critical care clinicians, to fulfill our ethical obligations to provide person-centered care and to be responsible stewards of our own integrity and well-being.5 We find it difficult to get to know our patients because of these constraints and therefore repeatedly lapse into monotonous or robotic patterns that are not beneficial and may cause harm to our patients, their families, or ourselves. For instance, the medical futility rationale for establishing a DNR order is more likely to be invoked for patients who are older, admitted from a skilled nursing facility, or being cared for in a medical ICU.6 Surfacing these assumptions requires attention that may be in short supply as a result of external and internal constraints. As critical care clinicians, we believe that ethical conflict and moral suffering are nonnegotiable “parts of the job,” which leads to feelings of powerlessness, victimization, and resignation. This belief is reinforced when repeated attempts to address the issues do not yield what we perceive to be satisfactory results. We routinely overlook the daily examples of integrity-preserving decisions, respectful communication, and compassionate action in both our team members and ourselves. In so doing, we fail to appreciate our contributions and take for granted the effort, wisdom, and skill that manifest daily in clinical practice. Our organizations count on us to go “above and beyond” to ensure that patient care is delivered safely and respectfully without meaningfully acknowledging our routine, and at times extraordinary, contributions. When moral sensitivity and conscience engagement are eroded, it is more likely that clinicians will adopt a we/they reaction that fosters blaming each other, patients or their surrogates, and the health care system for the conditions in which we practice. At the core of our health care organizations are the processes, structures, and designs that can either foster or erode clinician integrity or well-being. When work environments are unhealthy, ethical practice can be impeded, which leads to increasing distress that has been described as “death by a thousand cuts.”7 Systems that compound the dissonance between professional and organizational values and the actions taken on behalf of patients add to further erosion in relationships and a we/they mentality. One alternative is for stakeholders to identify and align shared values, which can produce results that shift detrimental patterns. This requires all stakeholders to take responsibility for both the process and the results ultimately produced. This is not to suggest that clinicians are solely responsible for addressing the situations that create moral suffering and distress but rather that processes and tools that restore integrity, meaning, and well-being are simultaneously needed.8These recalcitrant clinical encounters accumulate and deplete us because they require expenditure of enormous amounts of energy to fight what is in front of us. Despite our best efforts, we cannotConsider what would happen if we shift our perspective/mind-set instead of striving for a particular outcome: we could pause and consider, “What will actually serve in this situation?”9 How is this different from the usual modus operandi? What are the patterns that keep us stuck in this repeating cycle?When we focus our energy on finding a solution to the present problem or symptom, we can overlook the bigger context of the situation, root factors, and possibilities for change. In the case of Mr Franklin, the focus of the clinical team is on getting a particular outcome, a DNR order. By restricting their attention, the team overlooks the root causes of the current stalemate. What is the context of Mr Franklin’s life? How does his wife understand her role as a surrogate decision-maker? What is at stake for the clinicians involved in his care? What factors in the organization have contributed to the pattern of communication and decision-making that is evident in this case? A broader topography is needed, one that reveals intrapersonal and relational patterns, organizational structures and systems, and societal context and forces. We need a process to recognize this landscape, understand its contribution to the present adversity, and inquire how to shift it to create more beneficial outcomes for patients, families, and clinicians.10,11 Rather than continuing to ask why this family member resists our efforts to change her mind, we might begin our mapping process by wondering why this DNR order is the focus of our team’s resources. Why are we stuck?Applying the “4 Rs” is an approach to release the grip of these complex and recalcitrant issues by focusing on the interplay among patients, families, clinicians, and teams. Figure 1 outlines the 4 R elements. The very real and significant health care system issues are beyond the scope of this column. However, the process described here could also be used by leadership teams, in partnership with front-line staff, to address organizational patterns that contribute to these recalcitrant situations and reveal novel opportunities to shift dysfunctional organizational patterns.Naming fundamental ethical values, intentions, and commitments can reveal gaps in understanding, patterns of conflict, confusion, or disagreement. Exploring what is at stake from an ethical perspective, and the consequences to patients, families, colleagues, and ourselves, is an important starting point. In a case such as Mr Franklin’s, we tend to articulate concerns about the just allocation of scarce critical care resources. However, another clinician might consider conscientious refusal as an expression of his duty not to harm, whereas another colleague may express frustration at her inability to provide benefit to the patient. A sense of moral responsibility for another team’s actions or inactions can weigh a team down and undermine communication, decision-making, and collaboration. Pausing to calm reactivity, focus attention, and connect to our professional values, ethical commitments, and responsibilities allows us to recognize patterns and habitual responses within others, the broader system, and ourselves.A process that cultivates self-awareness, self-regulation, and compassion is vital for creating a foundation that fosters this kind of awareness and insight.12 Deliberately reclaiming our attention from myriad distractions— pagers, alarms, past and future uncompleted items in bottomless in-boxes—and reconnecting to our core intentions as professionals and as human beings focuses our attention on what matters most.9 The process of cultivating mindfulness involves bringing attention to what is happening in the body, mind, and emotions in the moment; repeating this practice creates new neural pathways that are available during periods of stability and, more importantly, when challenges arise. Halifax9 described a process aimed at creating the conditions for compassion to arise that builds on a foundation of mindfulness. The elements, illustrated in the mnemonic GRACE, include 1) gathering our attention, 2) recalling our intention, 3) attuning to self then others, 4) considering what will serve, and 5) enacting ethically and ending the encounter.9 The process has been described in detail elsewhere.9With a stable ethical grounding, we can begin to systematically identify and respond to patterns that contribute to conflict, dissonance, or uncertainty. This begins byInstead of focusing on Mrs Franklin’s persistent request for aggressive treatment, there are several opportunities to explore: first, how are those of us involved in Mr Franklin’s care showing up to the patient encounters? Are our nervous systems stuck on hyperalert or are we harried, distracted, or just going through the motions? Are we fully present or distanced in our encounters with patients, families, or colleagues? Additional questions we might consider include the following8:Repeating the same phrases—“they don’t get it,” “nothing will change,” “why are we doing this”—signals an unrecognized or unresolved issue to be addressed.2 Oftentimes, these refrains are predictably accompanied by emotional responses such as becoming angry and frustrated; avoiding patients, families, or colleagues; and numbly going through the motions.13 These patterns manifest not only in us as individual clinicians but also within and among teams. Examples include making dismissive responses to questions about goals of care and leaving unaddressed conversations for the next team. If Mr Franklin had gone into cardiac arrest, the nurse practitioner on the surgical team may have advocated for a family meeting but have been dismissed and told, “We’re not there yet.” Alternately, he may have received such a response so often regarding past patients that he did not even raise the question on Mr Franklin’s behalf. He may have hoped that the next change in ICU attendings would bring someone whose greater influence could achieve what he felt helpless to do himself. Recognizing patterns of thinking, speaking, and silence related to cases of moral adversity or distress allows us to break out of our autopilot responses. For example, the care team could that each with Mr Franklin’s family a pattern could that individual clinicians and involved in cases such as this come to helplessness as their and family members perceive their contributions as and they this as The more what these patterns of communication and decision-making up the of and the patterns a foundation to and they are or more we recognize the patterns that have the current conflict, we need to pause to release of our approach that have not and the values which we might For instance, what would happen if we to our grip on the of getting the DNR we might ask include the these questions begins a process of what the clinical and actions and about what they might need to The distress that when clinicians perceive that their actions are more harm than benefit a pattern of anger, and feelings are and an to rather than These feelings unresolved moral repeated to or an commitment to a outcome, such as getting a DNR that possibilities for another to instance, Mr Franklin’s nurse about the next family meeting in of a past meeting will be the one about that in the same last his wife was just Mrs Franklin, just on If we recognize the pattern of past into the with the that Mr Franklin is not the patient but a with a family with particular and the is and new might Recognizing that important is our view of this is the of being to to release Recognizing the to the with a different patient and it from Mr Franklin’s case does not the moral In addressing the moral requires attention and a commitment to do Mr Franklin’s case with a shift that allows us to the the of our attention and compassion and creates the conditions for new possibilities to as clinicians, that we do not have the or to and are about what will happen if we to be to the the or our own and The systemic pressure for throughput or can create a of a that there is or emotional to address these complex This belief a pattern of conversations there is a or someone the in critical care leads us to our On the other solely on clinical may other or of For critical care to address values and goals often from a need for additional or an organizational the of is not that these are and that our are often not is to what may take the of a and recalling why we have to serve as critical care and what we to bring about in our practice. In the case of Mr Franklin, may go of the that if we and with more in for a DNR we will be in Mrs Franklin’s may also go of Mrs Franklin to the of her husband’s when she is not to do The process of may reveal that we are significant amounts of energy to bring about an in a conflict that is by systemic patterns that have not been or When we are to and release what there is for new awareness and what will serve being to a new by go of what and the with This process involves into and considering all the of One to is the of how team members harm and benefit in cases such as Mr This often from a of the as they would to be would to and so they for a change in the of as Mr Franklin’s team is our own values and preferences is and we our own treatment preferences to A more alternative may be to shift to the as they would to be which patient and the could to providing but with moral and emotional for Franklin’s team may that his request to Mr Franklin’s to how that of his for even the of that he would to how that of his by of The the belief that one is only bringing harm and the that one is to benefit the one has a duty to about core ethical values and commitments clinicians to and release their and the new and opportunities may the that we might clinicians to and understand the of This involves being and about who the being cared for are beyond their their and what matters to and as Patients or their surrogates have or values, intentions, and that their as do does not clinical or but rather the very best while to what we we with such as emotions, with and can clinicians in attuning to the of the and to take the and what may be that has not been so may not be to change the for Mr Franklin, but it may be to create the conditions for Mrs Franklin to her by the of her husband’s as a of her to her commitment to her and their rather than as a conflict with the clinical team. 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