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


Participant Characteristics

A total of 435 critical care clinicians completed the questionnaire: 40 physicians (9%); 70 nurse leaders (16%), including nurse executives, administrators, and clinical nurse specialists; and 325 clinical nurses (75%), including nurse practitioners. Nurse leaders were older and had more years in clinical practice than the clinical nurses and physicians (P < .001). The physicians were more likely to be men (P < .001).

Perceptions About Ethical Situations

We noted few differences in the top-3 rankings of "most frequent" and "most disturbing" ethical situations. "Treatment decisions at the end of life" was the most frequent situation encountered. The 3 most disturbing ethical issues identified in this survey centered on decision-making. Comments provided details that verified the quantitative findings. Several participants indicated that end-of-life discussions occur too late, as providers tend to avoid or delay addressing these issues. Patients' or surrogates' adamancy about treatments considered by clinicians to be nonbeneficial or even harmful contributed to clinicians' moral distress. Finally, several participants indicated that families are sometimes allowed to make decisions that violate patients' previously written or expressed wishes.

"A survey was used to collect data from members of the American Association of Critical-Care Nurses and the Society for Critical Care Medicine."

Perceptions About Moral Responsibility

Physicians, nurse leaders, and clinical nurses did not differ significantly in their ratings of physicians' moral responsibilities (Table 1). Results indicated rating differences for the nurse groups. Nurse leaders and clinical nurses rated the nurse group higher for certain actions, whereas physicians rated nurses' moral responsibilities lower (Table 2). Actions that significantly differed included (1) informing the patient, the surrogate, or both about the benefits and limitations of treatment options (P = .005); (2) addressing or mediating ethical conflicts (P = .01); and (3) assessing patients' cultural and religious values while discussing patients' treatment preferences (P = .02). A post hoc Tukey test revealed that physicians' and nurses' (leader and bedside) ratings were significantly different, but the ratings of the 2 nurse groups were not. Ratings for the responsibilities of the health care team differed among the clinician groups (Table 3).

Evidence of Entwined Obligations

Narrative comments characterized moral obligations as interdependent. For example, nurses indicated that they depended on physicians to have early, honest conversations with patients about prognosis and treatment outcomes so nurses could realize their own moral obligations to address suffering and provide support to grieving patients and families. A nurse stated, "Physicians tend to be unwilling to be blunt and open about a patient's prognosis. It is difficult for nurses to support families through the decision-making and grieving process[es] if they [families] are not given realistic information by the physicians." In many narratives, clinicians described difficulty meeting their obligation to implement patients' preferences when pressured by patients' families to implement a different plan.

Perceptions About Teamwork: Trust, Communication, and Organizational Support

Physicians were more likely than nurse leaders and clinical nurses to agree that a high level of trust existed between nurses and physicians (91% vs 73% and 67%; P = .02). Physicians also were more satisfied with communication between nurses and physicians than were nurses, though this difference was not statistically significant (P = .07). Nurse leaders were more similar to physicians than to clinical nurses in their perceptions of organizational resources and leadership (Table 4).

Clinicians' age and years of clinical practice were strongly correlated with clinicians' perceptions of communication between nurses and physicians. In logistic regression analyses, age was the only significant predictor of favorable communication between nurses and physicians—that is, younger clinicians were more likely to agree that nurses and physicians could rely on one another to communicate openly about ethical concerns (odds ratio, 0.97; 95% CI, 0.95–0.99).

In their final comments, 66% of clinicians described teamwork in ethically difficult situations. Most (63.7%) described teamwork struggles. For example, a nurse reported that

"few ICU [intensive care unit] clinicians have formal training in a systematic approach to ethical decision-making, and are not fluent in the vocabulary of ethics. These training shortcomings contribute to defensiveness and subsequent conflict between clinicians. Additionally, there is no shared paradigm [in our unit] for WHO, HOW, and WHEN to engage the patient/family in ethical decision-making. This lack of consensus often leads to conflict, particularly if nurses initiate a conversation [eg, seeking to elicit goals for end-of-life care] at a time that physicians do not feel is appropriate."

The main variables that contributed to teamwork struggles include poor or inadequate communication, hierarchical power (which prevented shared decision-making), and team or family conflict. A nurse indicated that "we see many times the lack of open communication and documentation of what is discussed with family members." Many teamwork struggles involved conversations "too little and too late" during end-of-life situations.

Evidence of Embedded Expectations

After clustering expectations that were embedded in 137 narrations, we created 3 statements to illustrate the most common themes. First, many nurses expected physicians to have honest, proactive conversations about a patient's condition and prognosis, appropriate treatments, potential outcomes (including unfavorable ones), and code status. Physicians provided fewer comments, but they reflected an expectation that physicians were primarily responsible for deciding when and how to initiate treatment discussions with patients and families. Second, several nurses believed that they should speak up during ethically difficult situations and that health care organizations need to support and educate nurses for a more active role. Finally, nurses expected health care team members to communicate freely and frequently about goals of care and to work consistently and collaboratively toward consensus.

"Clinical nurses, nurse leaders, and physicians rated physicians' moral obligations similarly, whereas physicians rated nurses' moral obligations lower than nurses rated their own responsibilities."