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Conversations about challenging end-of-life cases: ethics debriefing in the medical surgical intensive care unit.

In the intensive care unit (ICU), severe illness is always accompanied by vulnerability where clinicians, particularly nurses, see patients and family members endure critical illness, fear, and tragic loss. The majority of the cases that are considered challenging by ICU clinicians pertain to complex end-of-life issues and dilemmas. The experience of caring for severely ill patients often provides a highly stressful and anxiety-provoking situation for which many nurses are ill equipped to effectively cope. Ethics debriefing provides an opportunity for ICU clinicians, especially nurses, to decompress and process their feelings toward ethical dilemmas and conflicts. In this article, the authors describe the MSICU experience with a monthly ethics initiative and explore the next steps to enhance its use through maximizing attendance and value to MSICU clinicians. The following vignette is an account nurses may have encountered in ICU.

Mrs. B., an 80-year-old woman, was in the ICU for a year. She was dependent on mechanical ventilation and intermittent hemodialysis. Mrs. B. became unable to make treatment decisions. Her advance care directive stated she did not wish to be kept on life support for a prolonged period in the event that her medical condition became irreversible. The ICU team met with Mrs. B.'s family on multiple occasions to review the patient's expressed wishes, current medical condition, and likely outcome, including death. Her family decided to keep her on life support. Eventually, Mrs. B. suffered two cardiac arrests and died during the second one. As one of the nurses who tried to resuscitate her, Mina helped disconnect the various tubes and lines, and provided post-mortem care. The process was very technical. Most post-mortem scenarios in the ICU are similar to this. Because of the fast pace of the event, little time was left for contemplation. At the end of the day, Mina reflected on this, and other similar situations with which she had been involved. She lamented, "There are not a lot of good deaths in the ICU" With regard to Mrs. B.'s death, Mina noticed that some of her colleagues expressed a feeling of relief while others simply shrugged their shoulders.

Boyle and Carter (1998) suggest that high levels of death anxiety among those working in health care may negatively influence their attitudes and behaviours toward the dying patient and her/his family, thus creating obstacles in striving to provide quality care for those living in the face of death. Many nurses in the ICU feel abandoned in the experience of looking after the dying and deceased (Solomon et al., 1993). In a study comparing nurses with physicians, the former experienced more moral distress, perceived their ethical environment as more negative, and were less satisfied with the quality of care provided on their units than the latter (Hamric & Blackhall, 2007). All too often, nurses express how ill equipped they feel in their role as comforter, supporter and bearer of bad news to the patient's family (Costello, 1995). Relating to the vignette, we can change the culture in critical care settings so that the provision of palliative or supportive care is integrated into existing ICU practice. One way of attaining this is through ethics debriefing sessions where ICU clinicians have an opportunity to critically work through pressing ethical concerns or dilemmas, explore perceptions and process their feelings. As such, ethics debriefing sessions offer an opportunity for interprofessional collaboration to cope with moral distress and compassion fatigue. Hamric and Blackhall (2007) propose that improving the ethical climate in ICUs through explicit discussions of moral distress, recognition of differences in nurse/physician values, and improving collaboration may mitigate frustration and anxiety. Debriefings, in general, have the potential to enhance communication between health professionals, educate about the process of withdrawing or withholding treatment, and improve patient care and reduce burden on nurses (Halcomba, Dalyb, Jackson, & Davidson, 2004).

Moral distress is experienced in situations in which the ethically right course of action is intuitively known by health care professionals, but cannot be acted on for a variety of reasons (Canadian Nurses Association, 2003). Researchers show that moral distress is predominant among critical care nurses (Elpern, Covert, & Kleinpell, 2005). On the other hand, compassion fatigue is commonly associated with the emotional or psychological cost of caring for others who are clearly suffering (Figley, 1995). It has been described as secondary traumatic stress (Stamm, 1995; 1997), or vicarious trauma (McCann & Pearlman, 1990). It is naturally related to the term "compassion" which is defined as a "feeling of deep sympathy and sorrow for another who is stricken by suffering or misfortune, accompanied by a strong desire to alleviate the pain or remove its cause" (Webster, 1989, p. 229).

End-of-life discussions, moral distress and compassion fatigue

Clinicians frequently encounter and grapple with complex ethical issues and perplexing moral dilemmas in critical care settings. A common disconcerting issue occurs when ICU clinicians and substitute decision-makers disagree over the benefit and value of the continuation of "aggressive" medical interventions. Feeling that they are incapable of advocating for their most vulnerable patients, clinicians may experience tremendous anguish and torment, which can lead to compassion fatigue and moral distress.

The effect of nurses' attitudes and behaviours on both their personal and professional lives, caused by their empathetic engagement with their patients' experiences, lead to moral distress (Corley, 2002) and compassion fatigue (Clark & Gioro 1998). Known causes of moral distress include the failure to respect a patient's known prior expressed capable wishes, failure to protect patients from harms, the treatment of patients as objects, and the prolongation of the dying process (Badger & O'Connor, 2006; Corley, 2002).

Researchers associate moral distress in critical care nursing with challenging end-of-life issues. In a study of surgical intensive care unit nurses (n = 12), Gutierrez (2005) reported 11 out of 12 participants described "overly aggressive treatments" (p. 232). Elpern et al. (2005) reported that medical surgical intensive care nurses (MSICU) (n = 28) rated highest levels of moral distress in situations when aggressive care is provided to patients not expected to benefit from that care. McClendon and Buckner (2007) found that the two highest-ranked situations of moral distress for intensive and coronary care units (n = 9) were following the family's wishes to continue aggressive life-sustaining support even though it was not in the best interests of the patient, and initiating extensive life-saving actions only to prolong death. These findings are consistent with the experiences of nurses involved in the above scenario, as many of the attending physicians were very hesitant to challenge the substitute decision-maker's refusal to honour the patient's prior expressed wishes (as required by legislation) through appropriate legal mechanisms, such as the Consent and Capacity Board of Ontario.

McGibbon, Peter and Gallop (2010) posit that there are three conceptualizations of nurses' stress: occupational distress, moral distress, and vicarious traumatization. Vicarious traumatization or compassion fatigue is the cumulative transformative effect on the helper of working with survivors of traumatic life events (Bloom, 2003). In an attempt to ameliorate the feelings of anxiety, nurses may employ negative or unhealthy coping strategies such as avoidance and evasive treatment of dying patients (Clark & Gioro, 1998). This can be an obstacle in the provision of quality care for dying patients and in the support provided to grieving families. In the case of Mrs. B., the nurses went about the process of post-mortem care like automatons--it is simply part of the job! Nurses may express mixed emotions towards a patient's death, for example, with Mrs. B. some felt relieved, some did not care, and others felt that the whole situation just reinforced dissatisfaction with end-of-life care.

Benefits of ethics debriefing

Ethics debriefing sessions provide a safe and respectful forum where ICU team members are able to share varying perspectives and feelings around issues and dilemmas they may be grappling with (irrespective of the source), validate and support one another, and provide a sense of solidarity and interconnectedness. These sessions also help caregivers to navigate through complex moral, professional and legal issues, clarify complex concepts and issues and develop a strategy to address these concerns in a timely manner. When ethical dilemmas occur, the American College of Critical Care Medicine Task Force recommends that the interprofessional team be kept fully informed of treatment goals and care plans so that the messages conveyed to the substitute decision-maker/family are clear, coherent and consistent, thereby reducing any tension or friction among team members and between the care team and substitute decision-maker/family (Davidson et al., 2007). In addition, the task force recommends that a mechanism is created whereby all staff members may request a debriefing to voice concerns with the treatment plan, decompress, vent feelings, or grieve (Davidson et al., 2007).

The MSICU experience

Similar to others' efforts in implementing evidence-based practice, we encountered challenges in implementing ethics debriefing sessions in the MSICU. Rycroft-Malone (2004) proposed that successful implementation of evidence-based practice is dependent on the nature of research evidence being used, the quality of context, and the type of facilitation to enable the change process. As reflected in the nature of evidence presented by the American College of Critical Care

Medicine Task Force, there are few studies that support the reception of ethics debriefing sessions in critical care settings. Despite this, our MSICU has a strong unit-based organizational support, and interprofessional collaboration to facilitate ethics debriefing sessions.

Ethics debriefing was first introduced in our MSICU in 2008. The initial debriefing sessions were not consistently well attended, not held on a regular basis and, consequently, were not readily integrated and sustained in the MSICU. Our bioethicist leading the sessions revisited the need to revitalize ethics debriefing sessions with the clinical leader manager (CLM) in 2009. In turn, the CLM approached the clinical nurse specialist (CNS) to assist with organizing the sessions each month.

With interprofessional collaboration among the nurse leaders and the bioethicist, a more organized and systematic approach to ethics debriefing was initiated in MSICU in February 2009. The MSICU provides debriefing sessions every second Tuesday of the month. Debriefing sessions are coordinated by the CNS. Trained personnel, including the bioethicist, social workers, and chaplain co-facilitate the sessions. Occasionally, the MSICU medical director joins the round table discussion. While interprofessional ethics debriefing sessions are scheduled regularly and considered beneficial by ICU clinicians, particularly nurses, attendance at these opportunities to decompress and process emotions was not optimal.

Despite the changes to formalize the process, the 2009 MSICU debriefs after critical incidents were well attended, but attendance at regular monthly sessions was low. In order to optimize attendance of staff, particularly the nurses, the facilitators and CNS conducted a small group discussion (that is, a quasi-focus group) among interprofessional team members (n = 8), of which five participants were nurses, in order to solicit feedback and input in December 2009. Participants in the group were asked about their perceptions and experiences of the sessions. They were also asked about their suggestions on how to promote greater attendance.

The following changes were implemented in 2010 as a result of the discussion:

1. Meeting location and proximity to ICU. Ethics debriefing sessions had been held in one of the conference rooms outside of the MSICU. The nurses in the small group discussion suggested that some nurses felt quite anxious leaving their patients in the middle of their shift, particularly when the unit was busy and patient assignment coverage may become an issue. The nurses recommended that the sessions be relocated to the nurses' lounge on the unit to make it easier for nurses and other care professionals to come in and out of the session more readily when their assigned patient's status changed, and could be called back to the bedside.

2. Advertisement of sessions. Sessions are advertised well in advance using multimodal methods. The ethics debriefing session is included in the monthly unit calendar emailed to MSICU staff at the beginning of each month, as well as posted in the bathrooms. Posters are placed in common areas such as the easel (located at the nursing station), washrooms, and the nurses' lounge. The design of reminder posters is changed every month to capture the care team's attention. Email reminders are circulated two days before the sessions, and this is followed by verbal reminders early in the morning on the day of ethics debriefing sessions. One of the facilitators also circulates around the unit to remind and encourage team members to attend the session just before its commencement.

3. Incentives to attend. Snacks are provided to promote staff attendance. This also serves to convey the message that the staff members are appreciated, and that the sessions are a valued resource. Sessions are held at flexible times to also include night staff.

4. Topics and themes. Team members are provided with opportunities to share a challenging topic/theme/case for discussion, in addition to processing the emotional component of their experiences. The sessions have an open agenda, and the entire ethics debriefing session is devoted exclusively to what participants feel pressing, relevant or emotionally challenging.


As part of the changes made in organizing ethics debriefing sessions, the CNS also started tracking attendance and participation at these sessions. Comparing the number of team members attending the sessions in 2009 with 2010 (Figure 1), out of which [greater than or equal to] 25% are nurses, and from anecdotal accounts from team members, the following positive results were noted:

Increased awareness. Anecdotally, the MSICU team members have expressed their increased awareness of the value and benefits of ethics debriefing. The improved awareness allows more proactive, collective and consistent planning, preparation and implementation of optimal holistic care of family and support for families. It also promotes staff's well-being and welfare, and fosters a safer, healthier and enhanced ethical culture.

Increased frequency of sessions. The 2010 MSICU debriefing sessions graph (Figure 1) shows the attendance at the regular monthly debriefing sessions. Team members have also been asking for sessions when they identify a need to debrief, rather than wait until a major critical incident occurs. Hence, frequency of debriefing sessions has increased (nine sessions in seven months in 2010 versus seven sessions in seven months in 2009). We also observed a slight increase in the number of attendees in the debriefing sessions, from six to 17 attendees in 2009 to eight to 21 attendees in 2010.

Demonstrated utility. Ethics debriefing sessions have been effective in collectively exploring alternatives and strategies to address concerns prior to family meetings and to try to reach a team consensus on care plans for patients and families with complex needs. It, therefore, respectfully draws from the expertise and competencies of interprofessional team members. The sessions facilitated the team to arrive at consistent messages to patients and families. This is augmented by the incorporation of the strategies and approaches in the patients' care plans. The care plan documentations are displayed prominently in the chart for team members' reference. This is particularly important for providing consistent messages and care delivery processes in a unit with approximately 200 staff. Azoulay and colleagues (2009) described that the absence of decision-making processes associated with end-of-life care was independently associated with conflicts among team members, and suggested that communication around end-of-life care is a target for improvement. We posit that ethics debriefing is a valuable strategy to meet this need.

Alignment with corporate initiatives. In 2009, our institution launched its three-year Best Practice Spotlight Organization (BPSO) candidacy journey. BPSO is a designation awarded by the Registered Nurses' Association of Ontario (RNAO) on successful implementation, evaluation and knowledge translation of established nursing best practice guidelines (BPG). MSICU decided to implement, evaluate and sustain two BPGs: establishing therapeutic relationships and professionalism in nursing. We found that ethics debriefing sessions provide opportunities to embed concepts about cross-disciplinary ideas of professionalism and establishing therapeutic relationships by injecting BPG concepts relevant to topics discussed.

Alignment with accreditation standards. Meaningful and consistent family-centred, patient-focused care through an interprofessional delivery process is supported by ethics debriefing sessions. The health and well-being of caregivers is enhanced and issues relating to moral distress and compassion fatigue are mitigated through effective and timely ethics debriefing sessions as reported anecdotally by the majority of participants.

Provide educational opportunities. On team members' requests, lunch-and-learn sessions are held to provide feedback about discussions on challenging cases. Following ethics debriefing sessions after critical incidents, the CNS organized lunch-and-learn sessions facilitated by our bioethicist and medical director. These sessions allow team members to ask more questions pertaining to practice issues related to the critical incidents. It is important to note that the most frequent issues discussed at all sessions invariably pertain to end-of-life situations and the multiple complex ethical dimensions, including their lasting impact on staff.

Next steps

We are enthused by the positive results from the changes made to the process of providing regular ethics debriefing sessions in the MSICU. However, since our experience is mostly anecdotal, we plan to implement an outcome measure or tool to systematically evaluate team members' attitudes and perceptions of ethics debrief sessions. Since the MSICU team also expressed the need for a follow-up on technical (rather than the emotional) issues raised in ethics debriefing discussions, we also plan to assess the feasibility of a systematic mechanism to inform the team about the outcomes of ethics debriefing sessions. Technical care planning details, the result of (ideally) consensus decision-making, are different and are naturally shared with other care team members. It is important to note that perceptions and emotions shared at all ethics debriefing sessions are kept confidential and/or are anonymized unless there is collective agreement to share these outside the group.

The lessons learned from our experience of establishing scheduled ethics round table discussions will also help inform the development of education curricula for MSICU nurses. Although efforts are being made to improve education, critical care nurses still lack knowledge about providing end-of-life care and have variable opportunities for continuing education to improve end-of-life care (Hansen, Goodell, DeHaven, & Smith, 2009). Critical care nurses also have a great deal to learn about dealing and coping with complex end-of-life situations to prevent moral distress and compassion fatigue. Given that some nurses expressed a common coping strategy, "not thinking about" the challenges they faced during end-of-life care and how they perceive such avoidance as "normal behaviour" so that they can "move on to look after their next patient," it simply reinforces the need for more ongoing education and support. Arguably, it is conceivable that many critical care nurses not only lack knowledge about palliative care in general, but also lack knowledge about the process of effectively caring for themselves. Frequent education sessions on end-of-life care, death and dying, and the importance of reflective practice and feedback should be provided to decrease the caregivers' feelings of isolation, moral angst, and despondence, and increase his/her knowledge base and personal and professional fulfillment and satisfaction. This could only serve to enhance holistic patient care and support to the worried family. Open discussion about end of life during ethics debriefing session would inevitably lead to consistent ethical practice and a safer, healthier, more respectful and therapeutic work environment.


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By Cecilia Santiago, MN, RN, CNCC(C), and Steve Abdool, PhD, MA, BA, RN

Cecilia Santiago, MN, RN, CNCC(C), Clinical Nurse Specialist, Critical Care Department, St. Michael's Hospital, Toronto, Ontario, Adjunct Clinical Faculty, Lawence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario.

Steve Abdool, PhD, MA, BA, RN, Bioethicist, Critical Care Department, St. Michael's Hospital, Toronto, Ontario, Faculty, University of Toronto Joint Centre for Bioethics, Toronto, Ontario.

Address for correspondence: Cecilia Santiago, MN, RN, CNCC(C), St. Michaels Hospital, 30 Bond Street, Room 4013 Bond Wing, Toronto, Ontario, Canada M5B 1W8. E-mail; Office telephone (416) 864-6060 ext. 4152; Fax (416) 864 5041.
Figure 1: Top: Number of attendees--2009 MSICU monthly debriefing
sessions. Bottom: Feb.-Oct. 2010: Nine debriefing sessions held
in seven months, number of attendees per session

2009 MSICU Monthly debriefing sessions


June      15
July      17
August     7
Sept.      7
Oct.       8
Nov.       6
Dec.       7

2009 MSICU Monthly debriefing sessions


9 Feb.     17
13 Apr.     9
4 May      20
11 May      8
15 Jun.     8
13 Jul.    21
17 Aug.    21
31 Aug.    18
12 Oct.     8

Note: Table made from bar graph.
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Date:Dec 22, 2011
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