Doing the right thing

February 6, 2009 -- Today the New York Times ran a remarkably astute "Doctor and Patient" piece in which Pauline W. Chen, M.D., explained the problem of "moral distress," when nurses and physicians feel that they cannot do what is right for patients because of the "competing demands" of the health system that surrounds them. The most remarkable part is that Chen relies mainly on the experiences of nurses trying to protect patients in settings in which physicians and others have more power. Chen describes one of her "closest friends, a brilliant and articulate" nurse who still feels she must resort to indirect statements to express her concerns about the care plans of physicians. Chen even consults a nurse expert on moral distress in I.C.U. settings, referring to her as "Dr. Hamric" (!). The expert, Ann Hamric, urges all concerned to recognize and discuss moral distress, because "[n]o one is going to stay otherwise." We thank Dr. Chen and the Times.

Chen's column, "When Doctors and Nurses Can't Do the Right Thing," begins by noting that a physician and ethics consultant recently told her that moral distress is a growing problem at her hospital. Health professionals "feel trapped" by "the competing demands of administrators, insurance companies, lawyers, patients' families and even one another," and "are forced to compromise on what they believe is right for patients."

As an example, Chen discusses her work over the years with "one of my closest friends, a brilliant and articulate nurse whom I'll call Mary." Chen saw that "Mary's assessments of different clinical situations were nearly always correct," but that "she would often resort to enigmatic and noncommittal statements when expressing her opinions to doctors and supervisors." Chen describes a time when she was a surgical resident and had a transplant patient with a badly infected abdominal hernia repair who had been living in the ICU for a month--"what was left of" his abdominal wall was "a beehive of festering bacterial pockets." Over several days Mary took Chen and other members of the surgical team aside and asked, "How much can a person take?" Shockingly, no one on the surgical team seemed to care what Mary thought. So Mary resorted to what we would have to call passive aggression, though Chen does not. In response to a physician's request that she get the patient ready for another operation, Mary would respond with statements like, "What do you want me to do?", or "Say that again?", or "O - kay." Eventually Mary simply grew silent and perfunctory. Chen asked what was wrong. Mary's reply:

If I say something, I get into trouble. Doctors think I am out of line, and I get warnings from my superiors about being unprofessional. But if I don't say anything, I'm afraid that the patient might suffer. What can I do?

Many nurses will recognize the frustrating experience of feeling disabled by power relations from advocating for a patient in great need of their help, and nursing managers who seem to have little sense of what a "professional" actually does enforcing a code of silence by citing "professionalism," a reflection of the dysfunctional tradition of submissiveness that has long threatened nurses and their patients. And the nurse's response--masking her real meaning with indirect language and hints in an apparent effort not to disrupt physicians' sense of their ownership of clinical settings--is also sadly familiar. Of course, a nurse trying to protect a terminal patient from painful and unnecessary interventions by physicians was also the subject of Margaret Edson's powerful 1999 play "Wit" and Mike Nichols' 2001 film adaptation.

Chen says that "moral distress" was "first described in 1984 in a book on nursing ethics"--an astonishing statement for anyone (much less a physician) to make in a major publication, since nursing ideas are often recognized only when physicians later notice the same thing, whereupon the research or advance is presented as a physician discovery. Chen explains that research has shown that nurses and others suffering from moral distress often withdraw from colleagues and patients, and that one study found 15% of nurses left jobs because of it. Chen writes that physicians themselves are now feeling increasingly "trapped" by competing demands of patients, insurers, and administrators. She cites a University of Virginia study that found that while I.C.U. physicians tend to be less frustrated than I.C.U. nurses, "they can also suffer from intense moral distress." Chen describes her own "profoundly disheartening" experiences haggling for insurance approvals, struggling with increasing patient loads, and handling "estranged relatives who swoop into the hospital during the last days of life and demand aggressive treatment."

Looking for analysis and ideas to reduce moral distress, Chen turns to nurse Ann B. Hamric, "the lead author of the study on I.C.U. physicians and nurses." She quotes "Dr. Hamric" at length:

There are many different reasons why a clinician may feel that he or she is not able to do the ethically appropriate thing. A lot of the reasons for moral distress come from the environments where we work. Are we working as respectful partners or are we afraid? Doctors feel that the risk managers or the lawyers are telling them what they can and cannot do for patients, and that affects physicians.

Chen notes that she discussed with Hamric "the implications of moral distress for the current nursing shortage and the impending primary care shortage." Chen ends the piece with Hamric's observations on how to improve the work environment:   

Part of what we have to do is to start recognizing moral distress and deliberately talking about it in health care settings. Otherwise, we will fail to recognize the damage to the integrity of the provider. We can't expect people to work in this kind of highly intense, emotional, intimate space and then expect them to tolerate threats to their professional integrity. No one's going to stay otherwise. It's just too heartbreaking.

Here Chen has done what Mary's colleagues did not do for the transplant patient in the ICU:   listened to the ideas of highly skilled nurses and made at least some effort to put those ideas into practice, in this case by presenting them to a large, influential audience. Chen also makes a point of presenting the individual nurses she discusses as "brilliant," or as clinical or research experts who might earn the honorific "Dr." It seems to us that next steps for health professionals include treating all colleagues with the respect they deserve and need to do their jobs. And everyone can try to work toward systems in which all health workers are able to provide the care patients need, even if that means reforming systems and re-allocating resources. Of course, it's not always easy to do the right thing.

See Pauline W. Chen's "Doctor and Patient" article: "When Doctors and Nurses Can't Do the Right Thing," in the February 6, 2009 issue of The New York Times.

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