A National Survey on Moral Obligations in Critical Care

Carol L. Pavlish, PhD, RN; Katherine Brown-Saltzman, MA, RN; Joseph A. Raho, PhD; Belinda Chen, MPH


Am J Crit Care. 2019;28(3):183-192. 

In This Article

Abstract and Introduction


Background: Critical care clinicians routinely encounter ethically complex situations. Ethical conflicts sometimes arise from different perspectives regarding goals of care and moral obligations. These conflicts contribute to providers' moral distress and burnout and can erode trust between patients, families, and clinicians.

Objectives: To explore the most disturbing and most frequent types of ethically complex situations; compare clinicians' perceptions of their own, each other's, and shared moral obligations for providing quality care in these situations; and examine perceptions of communication and teamwork.

Methods: A national, web-based survey was made available to members of the American Association of Critical-Care Nurses and the Society for Critical Care Medicine. The survey included rank order, rating, and open-ended questions.

Results: Nurses and physicians ranked similarly the most frequent and disturbing ethical situations encountered during critical care practice. Nurses and physicians rated similarly physicians' moral obligations, but their ratings of nurses' moral obligations differed, with physicians giving lower ratings. Physicians also were more likely than nurses to report higher levels of trust (90.6% vs 66.8%) and more satisfaction with team communication (81.3% vs 66.9%). Narrative comments revealed embedded, entwined, and sometimes divergent expectations about moral obligations, which interfered with effective teamwork during ethically complex situations.

Conclusions: Teamwork in critical care would benefit from acknowledgment of and clear communication about role-specific, interdependent, and shared moral obligations. Opportunities for routine, team-based dialogue about ethical aspects of care and moral obligations could reduce role ambiguity and ethical conflicts.


Critical care clinicians who frequently encounter ethically complex situations in clinical practice may disengage or develop moral distress, burnout, or both.[1–5] Four critical care organizations issued a call to action that identified ethical conflicts as a precursor to moral distress and burnout syndrome, which are particularly common among critical care clinicians.[6] Ethical conflicts arise from intractable disagreements about treatment[7–12] or "when patients, surrogates, or clinicians perceive their goals related to care and outcomes are being thwarted by the incompatible goals of others."[13] (p342)

Harmful consequences can result for patients, families, and clinicians.[6,14–16] Patients and families who must confront critical decisions with little preparation can experience uncertainty, fear, anxiety, guilt, skepticism, anger, and moral distress—none of which is conducive to understanding and shared decision-making.[9,14] Patient and family satisfaction and trust in care providers decrease as ethical conflicts escalate.[11,15] Ethical conflicts and clinicians' moral distress also affect teamwork.[6,8,10,17] Information sharing and trust are particularly affected.[18–20] Compromised communication and teamwork are associated with more medical errors and higher patient mortality and morbidity.[6,21–23]

"Ethical conflicts decrease patient and family trust in providers and affect communication among members of the health care team."

The Joint Commission noted that all health system components must interact effectively and be proactive in providing safe, high-quality patient care.[24] However, studies to investigate teamwork factors that contribute to ethical conflicts are sorely lacking.[25,26] To address this gap, we conducted focus groups with nurses and physicians to explore their teamwork experiences during ethically complex situations. We found that although nurses and physicians are aware of their own moral responsibilities, both generally lack awareness about each other's obligations and only occasionally consider their shared moral responsibilities, such as being patient-centered and family-focused. We also found that clinicians rarely discuss with each other the ethical aspects of everyday clinical care. Many clinicians expressed lingering regret about not doing enough in ethically complex situations, which suggests unrealized moral obligations. Therefore, we designed a survey study to explore clinicians' perceptions about ethically difficult situations and discipline-specific and shared moral responsibilities in clinical practice.