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


In the results of this national survey, we observed remarkable similarities in clinicians' rankings of the most frequent and most disturbing ethical situations. We note with concern that the most frequent situations were also rated the most disturbing, which provides insight into why moral distress and burnout can become a serious issue among critical care clinicians.[2,6] Nurses and physicians identified demands for inappropriate treatment as the most disturbing circumstance, which corroborates findings from other studies.[29,30] Despite recommendations from multiple societies on how to respond to requests for inappropriate treatment,[31] clinicians continue to find these situations challenging.

Three important insights about moral obligations emerged from this study. First, clinicians consistently rated physicians' obligations higher than nurses' and teams' obligations. This finding suggests that physicians' roles and responsibilities are fairly well defined and more universally understood. By contrast, clinicians' perceptions about nurses' roles in these situations varied considerably. Nurses rated their own moral obligations higher than physicians rated nurses' obligations. For example, nurses believed they have a moral obligation to participate in team discussions about treatments, code status, and goals of care. This viewpoint is supported by current nursing practice standards from the American Nurses Association[32] and the American Association of Critical-Care Nurses.[33] Physicians, however, rated these obligations for nurses lower than nurses did.

One way of understanding moral obligations is to view them as instances of role-specific morality, as cited in professional codes of ethics.[34] The specific content of one's moral obligations depends on one's role and professional goals. Although nursing and medicine aim in general to promote patients' health and well-being, each profession enacts its own responsibilities to achieve that end. These responsibilities are distinct even if the aims of both professions at times coincide (eg, to relieve suffering). Understanding moral obligations as arising from role-specific ethical codes of conduct may help explain how the physicians in our study viewed their moral obligations as distinct from nurses' or the health care team's obligations. It may also explain how nurses perceived their entwined obligations and why the moral obligations of health care teams are not well understood. Finally, understanding obligations as specific to one's role may explain why disagreement was evident regarding entwined responsibilities (eg, discussing prognosis with patient and family), especially given our finding that, among survey participants, end-of-life discussions tend to occur late in the patient's hospitalization.

Role ambiguity may lead to gaps in care. In a study about interprofessional collaboration at the end of patients' lives, role confusion emerged as a main barrier to having end-of-life conversations with patients and their families.[35] Researchers found that health care professionals often expected others to initiate these discussions or believed it was outside the scope of their professional responsibilities. In our study, both nurses and physicians rated nurses' moral obligation to "Discuss code status with patients and families" relatively low, which is inconsistent with the American Nurses Association position statement on code status: "Nurses must advocate for and play an active role in initiating discussions about DNR [do not resuscitate] with patients, families, and members of the health care team."[32] (p1) The resulting information gap can leave seriously ill patients and their families even more vulnerable.[15,35] Because nurses generally spend more time with patients and families than do other health care providers, they have the opportunity to collect valuable information about the patient and family that could assist with complex decision-making during critical illness. Opportunities to share this information can improve teamwork, care quality, and patient safety.[22,33,36–38]

Second, embedded and often divergent expectations about teamwork surfaced in this study. Human expectations manifest in everyday life as people assign meaning to their experiences.[28] For example, when confronted with an ethically difficult situation, patients, their families, and clinicians generally use past experiences, education, and professional and personal values to construct meaning and form expectations, which they carry into interactions with each other.[28] As different frames interact, the potential for mismatched expectations arises, especially if these expectations are unclear or unspoken.[39] An expectation "mismatch" often leads to confusion and sometimes to expectation conflict.[39] (p72) In a study that involved interviewing participants about collaborative practice, participants suggested that team difficulties often emerge from inadequate understanding of or appreciation for the professional responsibilities of other team members.[40] The authors concluded that "without mutual understanding [of roles], meaningful communication and relationships, including those with patients, can be more difficult to develop."[40] (p44) Clarifying and attending to different frames of meaning and the resulting expectations could improve services for patients and families and enhance teamwork among multidisciplinary teams.

"Despite practice standards, nurses' roles and responsibilities in ethically complex situations were not universally understood, which can result in role ambiguity and gaps in care."

The current view of shared decision-making models in which physicians and patients are the primary actors in discussion and decision-making about treatment[41] might reinforce the primacy of physicians' roles and moral obligations, and this could lead to expectation conflicts among health care team members. The trend of increasing care complexity raises the question of whether physicians should be considered "captain of the ship."[42] (p309) Our results indicate that clear communication about role expectations, coordination, and accountability could improve teamwork, which is essential to high-quality critical care.

Finally, different perceptions about trust in health care teams surfaced in this study. Physicians rated level of trust significantly higher than nurses did. This finding is consistent with other studies that showed more satisfaction with teamwork and ethical environment among physicians than among nurses.[43,44] Narrative comments in our survey suggested that some nurses perceive risk when raising ethical concerns to the health care team, which is also consistent with findings of other studies.[20,45–47] It is interesting that in our study, younger age was associated with more favorable team communication. Creating collaborative mind-sets and developing teamwork practices during health care education are key elements for trust and team performance. Team members who trust one another are more likely to share information, interact productively, and engage in other processes that enhance team performance, such as team situation awareness.[10,19,48,49]

One limitation of this study is the relatively small convenience sample, which does not represent the overall population of critical care clinicians. The use of a novel instrument to measure perceptions about moral obligations also limits our findings.