8
Journal of Advanced Nursing, 1993, 18, 2008-2014 Intensive care: situations of ethical difficulty Anna Soderberg RNT Doctoral Student and Astnd Norberg RN PhD Professor, Department of Advanced Nursing, Umea University, Umea, Sweden Accepted for publicabon 23 March 1993 SODERBERG A & NORBERG A (1993) Journal of Advanced Nursmg 18, 2008-2014 Intensive care: situations of ethical difficulty Twenty enrolled nurses (ENs), 20 registered nurses (RNs) and 20 physicians v\rorking in intensive care m northern Sweden narrated 255 stones about their expenence of bemg m ethically difficult care situations The ENs' stones mainly concemed problems relating to relationship ethics, the stones narrated by the physicians mainly concemed problems relating to action ethics, w^hile the RNs' stones gave equal attention to both kinds of problems The most common theme of both the RNs' and the physicians' stones was that of too much treatment An obvious similanty between the ENs, RNs and physicians was that they saw themselves as equally lacking m influence m ethically difficult care situations The only apparent difference between the three groups, however, was that the ENs brought up relationship problems more often than the others Thus, the differences between the RNs and the physicians were fewer than usually reported in the hterature This might be related to the speaalization of intensive care INTRODUCTION as from a relationship ethics perspective, how people , ^ f . , , , , . . . , relate to each other m vanous situations (Lmdseth 1992) Canng for cntically ill patients in an mtensive care urut . . , , , , , , iir , ,, , 1 rr u n 1 li .1 /• j j Moral development has been descnbed trom the action means that difficult ethical problems must be faced and , r ,^ ^ n v i 1 ,. ., „ f , 1 . , .1 . . ethics perspective ot Kohlberg (1981) as an increased dealt with Deasions of vital unportance to the patient , , i i i i £., ,iLt ..lTi LL ability to reason m accordance with abstract and een- otten have to be taken instantly Previous research has , , , , i , , , . , , ,, , eral ethical prmaples m a context-independent way descnbed ethical problems mamly concemmg organ ,,, , , ,,. , , , J . , „ ^ ii,,,^,,^! Vitz (1990) reasoned mainly from a relationship ethics donation (e g Omery & Caswell 1988), how pn- j i , i i i i , , , j , J .1 r , perspective and descnbed moral development as an onties should be made m the provision of care (eg "^ "^ , , . . '^ /- 1 u c u I I ,r,o,-. T.t . I ,r.o,,\ 11 mcreasmg ability to use narrative thmkmg m a context- Gerlach-Engborg et al 1989, Munoz et al 1989), as well J i as withholdmg and withdrawmg treatment (e g Berggren , ^ , , ,„„., ^ , . „ , ,,,„„» Another way of statmg the difference between vanous et al 1991, Gilmour & Rosenberg 1989) u i. tu i. J a v L u L LU 1.1. rv L u 1 J (• . <i approaches to ethics is to differentiate between the ethics Questions can be asked from an adion ethics perspec- ^. , 1 , / ^ , , c LU L <-LL LL L 11 of justice and the ethics of care (Ford & Lowery 1986) tive, 1 e focusing on the choice of the nght action, as well _ , 111 Puka (1991) said that the two perspectives presuppose r- J i c-j-L r, ^ 1C1.J ir^ . . ,xj J., each other, you must care m order to be fair and m order Correspondence Anna SoOerherg Dodoral Student Department of Advanced Nursmg, Umea University, Box 1442 S-09124 Umea Stceden tO Care yOU mUSt be fair 2008

Intensive care: situations of ethical difficulty

Embed Size (px)

Citation preview

Page 1: Intensive care: situations of ethical difficulty

Journal of Advanced Nursing, 1993, 18, 2008-2014

Intensive care: situations of ethicaldifficulty

Anna Soderberg RNTDoctoral Student

and Astnd Norberg RN PhDProfessor, Department of Advanced Nursing, Umea University, Umea, Sweden

Accepted for publicabon 23 March 1993

SODERBERG A & NORBERG A (1993) Journal of Advanced Nursmg 18 ,2008-2014Intensive care: situations of ethical difficultyTwenty enrolled nurses (ENs), 20 registered nurses (RNs) and 20 physiciansv\rorking in intensive care m northern Sweden narrated 255 stones about theirexpenence of bemg m ethically difficult care situations The ENs' stonesmainly concemed problems relating to relationship ethics, the stones narratedby the physicians mainly concemed problems relating to action ethics, w^hilethe RNs' stones gave equal attention to both kinds of problems The mostcommon theme of both the RNs' and the physicians' stones was that of toomuch treatment An obvious similanty between the ENs, RNs and physicianswas that they saw themselves as equally lacking m influence m ethicallydifficult care situations The only apparent difference between the threegroups, however, was that the ENs brought up relationship problems moreoften than the others Thus, the differences between the RNs and thephysicians were fewer than usually reported in the hterature This might berelated to the speaalization of intensive care

INTRODUCTION as from a relationship ethics perspective, how people, ^ f . , , , , . . . , relate to each other m vanous situations (Lmdseth 1992)Canng for cntically ill patients in an mtensive care urut . . , , , , , , i i r ,

,, , 1 rr u n 1 l i . 1 /• j j Moral development has been descnbed trom the actionmeans that difficult ethical problems must be faced and , r ,^ ^ n v i1 ,. ., „ f , 1 . , .1 . . ethics perspective ot Kohlberg (1981) as an increased

dealt with Deasions of vital unportance to the patient , , i i i i£ . , , i L t . . l T i LL ability to reason m accordance with abstract and een-

otten have to be taken instantly Previous research has , , , , i •, , , . , , , , , eral ethical prmaples m a context-independent way

descnbed ethical problems mamly concemmg organ , , , , , , , . , , ,J . , „ „ ^ i i , , , ^ , , ^ ! Vitz (1990) reasoned mainly from a relationship ethicsdonation (e g Omery & Caswell 1988), how pn- j i , i i i i

, , , j , J .1 r , perspective and descnbed moral development as anonties should be made m the provision of care (eg "̂ "̂ , , . . '^/- 1 u c u I I ,r,o,-. T.t . I ,r.o,,\ 11 mcreasmg ability to use narrative thmkmg m a context-Gerlach-Engborg et al 1989, Munoz et al 1989), as well J ias withholdmg and withdrawmg treatment (e g Berggren , ^, , ,„„., ^ , . „ , ,,,„„» Another way of statmg the difference between vanous

et al 1991, Gilmour & Rosenberg 1989) u i. tu i. J a v L u L LU 1.1.rv L u 1 J (• . <i approaches to ethics is to differentiate between the ethicsQuestions can be asked from an adion ethics perspec- .̂ , 1 , / ^ , ,

c LU L <-LL LL L 11 of justice and the ethics of care (Ford & Lowery 1986)tive, 1 e focusing on the choice of the nght action, as well _ , 1 1 1

Puka (1991) said that the two perspectives presupposer- J i c-j-L r, ̂ 1C1.J ir^ . . ,xj J., each other, you must care m order to be fair and m orderCorrespondence Anna SoOerherg Dodoral Student Department of Advanced Nursmg,Umea University, Box 1442 S-09124 Umea Stceden tO Care yOU mUSt be fair2008

Page 2: Intensive care: situations of ethical difficulty

Ethical difficulties m intensive care

THE STUDY

This study presupposes that the analysis of the stonesabout people in ethically difificult care situations revealboth action ethics as well as relationship ethics perspec-tives and that the relationship between action ethics andrelationship ethics perspectives is complex People canrefled on their choice of action, on the effect of theiractions, on their relationships and on the effect of theirrelationships to other people

The rationale behind the use of a narrative approach(Maclntyre 1985, Sarbm 1986) is that human experienceIS always understood withm a whole, which gives it itsmeaiung This whole constitutes a story, we tell our storyand we are also told as a story When we narratesomething, the lived story is the startmg point of the toldstory Narrating an expenence means giving meaning tothe expenence A story demonstrates the complex inter-play between cognitive, emotional and conative elements(Locke 1983, Tappan 1990) and is believed to disclosesome 'tacit' knowledge (Vitz 1990) and provide newmsights

It IS difificult to study ethical reasoning m practice Ourvalues are part of our 'taken for granted' common sense,woven mto our culture Narratmg situations can make usaware of the values that guide our thinking and actingThus narratives about ethically difficult care situationsmay disclose differences of perceptions, feelmgs, reason-mg and actions

Walker et al (1991) found that registered nurses (RNs)and physicians m general medical service identified dif-ferent kmds of ethical problems when caring for the samepatients The RNs, for example, identified more problemsrelated to patients' and families' wishes, while physiciansperceived problems related to quality of life and eco-nomic factors When Uden et al (1992) interviewed RNsand physicians m medical and oncological care in north-em Norway, they found that these two groups narratedtheir expenence of bemg in ethically difificult care epi-sodes differently RNs stressed care and reasoned inaccordance with relationship ethics, while physiciansstressed justice and reasoned in accordance with actionethics The RNs disclosed a lot of moral outrage (cf PikeI99I) which was said to relate to their problems mcommunicating v«ith the physiaans

Ethical reasorung among enrolled nurses (ENs) hasbeen addressed in a study of several categones ofcaregivers m dementia care (eg Norberg et al 1987)but the ENs were not descnbed separately No studyhas been found focusmg on ethical reasonmg amongENs

The aun of this study was to lUummate ENs', RNs' andphysicians' expenence of bemg m ethically difficult caresituations by comparmg their stones

METHOD

Setting

This study was performed m northem Sweden, wheremost hospitals are public and patients pay a fixed dailyrate irrespective of the type of medical treatment or levelof care The personnel in intensive care units consist ofENs with 2 years of training at upper secondary school,RNs with 3 years of college training, and physiaans withabout 7 years of university trammg and 4 to 5 years ofspecialist trainmg work The chief physician (anaesthetist)IS legally responsible for medical care as well as nursmgcare The everyday nursmg is run by a ward sister AnEN works with pradical nursmg tasks, takmg care of oneor two patients while an RN is responsible for one to fourpatients and also for one to four ENs

Subjects

To find out if the expenence of ethically difficult caresituations varies depending on level of expertise, genderand professional role, a sample of ENs, RNs and phys-icians was selected from mtensive care uiuts at sixdifferent hospitals The rationale behmd the selection ofmterviewees from the three professional groups was thefact that previous research has shown that professionalson different levels of expertise (Corley & Selig 1992) andof different gender (Ford & Lowery 1986) narrate careepisodes m different ways

After the study had been approved by the EthicsCommittee at the Medical Faculty, Umea University, themedical head of each dime was asked to select a lessexpenenced person from each professional group, men aswell as women All but one RN agreed to participatem the study She was replaced by another nurse Fiveof each category—less expenenced/more expenencedfemale and male ENs (M = 20), RNS ( « = 2 O ) and phys-icians (K = 20)—were mterviewed from October 1991 toSeptember 1992 Their charactenstics are shown m TableI

Interviews

A tape-recorded transcnbed personal mterview was per-formed The interviewees were asked to narrate anethically problematic care episode that they had expen-enced at the ward, le a situation where they felt

2009

Page 3: Intensive care: situations of ethical difficulty

A Soderberg and A Norberg

Table 1 Charactenstics ofmterviewees («=60)

LE less expenenced ME, moreexpenenced

IntervieweesMean ageRangeYears m intensive careRange

ENs

LE

10

18

22-362

02-8

ME

1038

28-59102-25

RNs

LE

1028

21-332

04-5

ME

10

41

31-51135-22

Physiaans

LE

10

36

28-481

01-5

ME

10

46

40-59165-27

imcertam about what was the good and/or nght thmg todo Only additional narrative questions were asked (e gWhen? What next? Who? How did you feel?) to danfythe circumstances descnbed m the stones (cf Mishler1986)

All mterviewees related more than one care episodeAll m all there were 255 stones, 92 stones narrated byENs, 80 stones narrated by RNs and 83 narrated byphysicians (Table 2) When the narrative had ended themterviewee was asked about his or her reflections on theepisode that she/he had narrated The mterviews lastedfrom 20 to 70 mmutes (mode = 30)

Interpretation of interviews

A phenomenological-hermeneutic analysis mspired bythe philosophy of Ricoeur (1976, 1984, Brown et al 1989)was performed Each mterview was regarded as a textThe stones about the mterviewees' bemg m an ethicallydifficult care situation were extracted and analysed msteps, first, a naive readmg of each mterview wasperformed m order to acquire a sense of the wholeSecond, a structural analysis with narrative categoneswas made In accordance with this approach used m thestudy, the third step should be to mterpret each mterviewseen as a whole agam, takmg the naive readmg and thestructural analysis mto account This step will be per-formed later on Because of the great number of stones

Table 2 Number of narrated stones

ENs RNs Physiaans

Number ofcare episodesTotal 255

LE

4692

ME

46

LE

4080

ME

40

LE

3583

ME

48

LE, less expenenced, ME, more expenotced

(n=225) it was decided to make an overview of thenarrative structure of the stones before more detailedanalyses will be performed In this paper this overview ispresented Summanes of typical stones illustrate thematenal

Structural analysis

Mam plot

The plot of a narrative arrjmges the vanous events mto awhole (Polkmghome 1988) Therefore, the mam contentof each story was charactenzed and it was stated whetherthe action asped or the relationship asped dommatedThe plot dommatmg a story was labelled 'main plot' Inorder to make the mam plot explicit the followmgquestions were asked during the analysis What choice ofaction does the story represent? (adion ethics) Whatdoes the story tell about the relationships between theactors? (relationship ethics)

OutcomeIn order to define the outcome of the story the followmgquestion was asked How does the story end? The resultswere then classified from the interviewees' pomt of viewmto positive, negative or neutral outcomes

FINDINGS

Mam plot

Fifty-four per cent of the stones dealt mainly withrelationship problems, while 46% mamly concemed thechoice of action When the three professional groupswere compared, without takmg gender and level ofexpertise mto account, the foUowmg pattem emerged(Figure 1) Relationship problems were seen to be themam plot of the ENs' stones, relationship problems andproblems to find the nght action were brought up mequal proportions by the RNs The physiaans mostlybrought up problems relatmg to the choice of action The

2010

Page 4: Intensive care: situations of ethical difficulty

Ethical difficulties m intensive care

60

40

20

Choice of action Relationship

Figure 1 Differences between the professional groups concem-mg relationship problems or the choice of action graph ofdistnbution of categones m percentages • , EN, 0 , RN, • ) ,physician

content of the mam plots of the stones differed m thethree professional groups Six types of mam plots werefound, namely, relationship to patients, to the patients'families and to other professionals (relationship problems)and withdrawmg treatment, withholdmg treatment andtoo much treatment (problems concemmg the choice ofaction)

When the main plots of the stones of the three groupsmvestigated were compared, the followmg pattememerged (Figure 2) Too much treatment was the mostcommon problem for the physiaans and RNs In addition,these two groups of professioneds often brought upnearly the same aspect of the problem, the physiaans

40 r

A B C 0Figure 2 The number of ENs', RNs' and physicians' stoneswith different mam plots • , EN, 0 , RN, D, physiaan A,withhold treatment, B, withdraw treatment, C, too muchtreatment, D, relation professions, E, relation patients' families,F, relaticm patients

related situations where they had not had enough influ-ence to convmce the physiaans of the 'mother clinic', ofthe need to withdraw or withhold certam medical treat-ment The RNs narrated care episodes where they hadbeen ashamed of the care provided, but where they hadnot had enough courage or influence to change thmgs theway they wanted, especially vts-a-vis the physician

A physiaan narrated.

This episode concemed a woman with some sort of cancer,the outcome of which was known to be very poor She hadbeen given a very aggressive anticancer treatment She hadnearly no trombocytes and developed ARDS (adult respir-atory distress syndrome) She was placed m a respiratorbecause the mtemist was of the opinion that the ARDS wasa side-effect of the anticancer treatment and as soon as thathad been overcome she would recover Her lungs became somelashc, though, that the respirator did not manage to pressoxygen mto them The internist wanted to start an ECLA-treatment (to extract carbon dioxide and to supply the bloodoutside the body with oxygen) There have been no reportsin medical literature about anyone suffenng from this type ofillness survivmg such treatment Besides, the patient wouldbleed to death when the cannulae was mserted mto hervascular It was impossible for me to convmce the mtemistto withhold the ECLA-treatment and let her die m peace andwith dignity with her family around her A lot of specialistswere called for and nearly all resources available at thehospital were mvolved The pahent died as soon as thesurgeon started to operate The surgeon was shocked and sowere all the other people mvolved Have human bemgs nonght to die m peace? Do we allow technical saence toprovide absurd medical treatment? The next mommg I wentto the head of this dmic and asked him frankly. Has ananaesthetist no nght to decide about the treatment of apatient? He answered 'Actually no, we are a servicemstitution'

An RN narrated,

A man with leukaemia had been given several anh-cancertreatments but his cancer had not been cured One night hesuddenly became worse and I thought he was dymg How-ever, mstead of acceptmg this and let him die with dignity, avery aggressive anticancer treatment was administered Themtravenous catheter suddenly stopped funchonmg, so wetned to msert a new one but failed We pncked him all overand he was grunting and groarung all the time, because hedreaded those tubes more than anything else All of us knewthat, but now the physicians ignored it and we contmuedthis treatment until he died I felt so sorry for him havmg todie like that and I felt so ashamed about the care providedbecause it violated his mtegnty

Mostly, the mam plot of the ENs' stones concemed therelationship with patients' families Families can visit their

2011

Page 5: Intensive care: situations of ethical difficulty

A Soderberg and A Norberg

loved ones whenever they like Sittmg in the wardtogether vnth the patient most of the day, womed andemotionally affected, it is often a difficult situation tohandle for the ENs Problems concemmg the relation-ships between patients, patients' families and profession-als, as well as problems concemmg information, deasionmakmg and treatment, become evident m the relationshipbetween ENs and patients' families, the ENs sometimesfeel like scapegoats and are made responsible for adionsthey can neither understand nor mfluence

An EN narrated.

Team-work among professionals helps me emotionally mdifficult situations ENs depend on other professionals be-cause we are not m a posihon to make deasions on ourown I realized that once, when I was carmg for a badlymjured little child Canng for children m this unit is usuallyvery mce Everyone comes mto the ward to babble with thebaby and talk to its parents But this time everythmg wasdifferent, because the parents had caused the mjury bybattering the baby It was a traumatic expienence for me Icould not talk to the parents without resentment and I couldnot piossibly understand how anyone could do such adreadful thmg to their own child The RN in charge that daywas new and completely unknown to me and so was thephysiaan They hardly entered the room at all, so I knewvery little about what went on or what had been planned forthe child I found myself nght m the middle of it m themiddle of the trymg situation, but I felt like an outsider Icould hardly manage the situation by myself I felt sovulnerable and lonely and missed the co-operation withother professionals

Stones about the relationship to patients mduded avanety of episodes, from moments of sorrow whensomeone, for example, had to tell a patient. Tour familydied m that car acadent' or "You are tetraplegic', tomoments of happiness, as when an unconscious patientcame to The relationship to patients also concemedother issues for mstance, how to face patients' suffenng,how to mterpret the wishes of unconsaous patients, andhow to prevent moral outrage and repression

Outcome of the stones

Sixty-seven per cent of the 255 stones had a negativeoutcome, (65% for the RNs', 69% for the physiaans' and67% for the ENs' stones) Four per cent of the stones hadpositive outcomes and 60% were negative all through,while 7% started m a positive way and ended negativelyand 23% started negatively and ended positively Theremammg 6% of the stones were neutral

An example of a typical story with a positive outcomenarrated by an EN follows

A 'long-stay' patient was taken down as a 'no CPR' (nocardiopulmonary resuscitation) after several months of in-tensive care without success I felt that the 'no CPR' wasn'tnght m his particular case He wasn't very old and he hadbeen very fit before the operation when the complicationsstarted One day his heart actually stopped and 1 realizedthat I couldn't just stand there witnessmg his dymg, domgnothing So I pressed the alarm and started to try to bnnghim back to life Other professionals amved and conhnuedmy job successfully When everythmg was over I gotfnghtened and asked myself, 'What have I done? Was thisthe nght thmg to do?' Then the ward sister came andsupported me by assurmg me that I had done very well Thephysician grumbled though. This was a "no CPR-pahent"

' but nothmg more was said about it Some months laterthe patient was discharged and could return to his home HeIS now domg very well and I'm so pleased' I thmk we needbetter co-operahon between all groups of professionalsbefore deasions about the level of treatment of cntically illpatients can be made

An example of a typical story with a negative outcomenarrated by an RN follows

A woman amved at the hospital with a pam m her chestWe suspected myocardial infarction so she was observeddunng the night, but ECG did not show the pattem typicalfor this kmd of illness, nor did her blood tests I felt that thiswas no cardiac failure iTie next moming the anaesthetistamved askmg the mtemist angnly, 'Why hasn't the pahentbeen given Achlyse?' The mtemist felt ashamed and, aftersome argumg, the angry and upset mterrust prescnbedAchlyse I reacted, but I said nothmg After the admiruster-mg of drugs the patient suffered senous complicahons' Thiswas no myocardial infarction, but an injury m the vertebralcolumn' Why didn't I say somethmg? I felt so guilty'Sometimes we must challenge the prestige of other profes-sionals We must talk to wake them up, and make them usetheir common sense

The tummg point of the stones that changed from thenegative to the positive or vice versa was often regardedas connected with the corrununication or lack of com-munication between the mteractmg parties

An RN's story.

An old dymg man was prescnbed more blood I said to thephysician in diarge, 'Come with me and take a look at thepahent' Sit down here by his bed There was a homble androtten smell m there Now, look when I clean his mouth''Mucous came out and the physiaan said, 'I think we'll waitwith the blood' When you come into the close perspectiveof the pahent you often change your mmd

A physiaan's story.

There was a man with a severe vascular disease In spite ofthis he was operated on for the rupture of a scar He got

2012

Page 6: Intensive care: situations of ethical difficulty

Ethical difficulties m mtensive care

thrombosis and all the complicahons you can imagme Hewas treated m the mtensive care unit week after weekEveryone mvolved suffered There was no hope for him, andshll the treatment contmued It was not possible nor legal tobnng up the matter of treatment for discussion Oneweekend an mtemist amved askmg us to reconsider ourdeasion to contmue the haemodialysis on our patient Shesaid that the resources were limited and that patients withsome chance to survive needed these resources better Sowe were forced to discuss the matter and suddenly it wasquite all nght to talk about it We found that the mtemistwas quite nght, but the strange thmg was that we neededthe help of an mtermst to start such a reflechve discussion

DISCUSSION

Twenty ENs, 20 RNs and 20 physicians m intensivecare units narrated their bemg m ethically dif&cult caresituations An analysis of the 255 stones revealed thatthere were fewer differences between the stones asnarrated by RNs and physiaans than could be ex-pected, judgmg from previous research The most un-expected findmg was that so many of the RNs' stonesconcemed the choice of action, because previous papershave claimed that RNs are usually concemed withrelationships (eg Cooper 1990, Uden et al 1992)One explanation might be that RNs respond to thedeasions, or lack of decisions of physiaans as to whatactions to take or withhold Thus, physiaans can beseen as the 'authors' of the RNs' stones This may beparticularly evident m intensive care, where medicaltreatment is so dommatmg

Previous research has found differences between RNs'ethical reasorung in different settmgs Gansson & Norberg1989, 1992) In mtensive care the RNs have to implementmedical deasions to a considerable extent and thereforethey must consult physiaans several tunes a day So itseems reasonable that they regard the choice of the levelof treatment as problematic The stones showed theproblems RNs face when the treatment violates themtegnty of the patient The fact that the mam plot ofthe RNs' stones so often dealt with the choice of actiondoes not necessanly mean that RNs are not deeplyconcemed about relationships Our analysis focusedonly on the mam plot of the stones The mtegration ofaction ethics and relation ethics m the narratives will bereported elsewhere

The only apparent differences found were that ENsbrought up relationship problems more often than theothers This may be a consequence of the organization ofcare An EN sits alone with the patient and his/her familyand cannot take part m, or listen to, the discussions on

treatment among RNs and physicians ENs try very hardto make the most of a situation and to come dose to thepatients and their families, because a good relationship tothem IS a prerequisite to manage the implementation ofnursing tasks Thus it seems natural that relationshipproblems are important to them, espeaally as theymterad with people m traumatic cnses The fad that ENsspend so much time with patients and patients' familiesmakes it more difficult for them to distance themselvesfrom relationship problems (cf Duff 1987 about 'distant'versus 'close-up' ethics)

Too much treatment

The analysis of the 255 stones revealed that too muchtreatment was a big problem for the RNs and phys-iaans involved The way they narrated this mdicatedthat many of them regretted that patients have toomuch treatment as well as meanmgless treatment Theyregarded this as an ethical dilemma assoaated with thedecision to withhold and withdraw treatment Thistheme has been widely discussed m medical literatureand mtensive care, m Sweden (e g Berggren et al 1991)and m other countnes (eg Bone et al 1990) Anobvious similanty between the ENs, RNs and phys-icians was that they saw themselves as ladung minfluence m ethically difficult care situations The stones,however, often showed that they concealed this feelmgfrom their colleagues

The mterviewees' mam problem did not always seemto be to decide what was the nght and good thmg to do,but rather how to do the nght and good thmg Thisfinding IS similar to that of Uden et al (1992), who foundthat RNs often related stones about situations wherethey knew how to act but were stopped by physiaansPike (1991) also descnbed ethical problems ongmatmg mcommunication difficulties between RNs and physiciansThey said that with improved collaboration moral out-rage will decrease

Narratmg ethically difficult care episodes is one way tomake our personal values expliat and open to reflectionand discussion Thus, discussmg ethical matters meansdisdosmg more aspects of problematic situations,lmprovmg our abibty to perceive the complex pattems ofcare episodes

Acknowledgements

The authors would like to thank the mterviewees whopartiapated m the study, Ms Asa Sundh and Mr FolkeRhedm Umea, who revised the English

2013

Page 7: Intensive care: situations of ethical difficulty

A Soderberg and A Norberg

Berggren L, Olsson J & Sjokvist P (1991) Intensive care m thetermmal phase of life ethical considerahons (Swedish)I kartidnmgen 88(26-27), 2368-2370

Bone R C, Rackow E C & Weg J G (1990) Ethical and moralgiudelines for the mihation, contmuation, and withdrawal ofmtensive care- an ACCP-SCCM consensus panel Chest97(4), 949-958

Brown L M, Tappan M B, GiUigan C, Miller BA. & ArgynsD E (1989) Readmg for self and moral voice a method formterpretmg narrahves of real-life moral conflict and choiceIn Entenng the Circle Hermeneutic Investigation m Psychology(Packer MI & Addison RB eds). State University of NewYork Press, Albany, pp 141-164, 306-309

Cooj>er M C (1990) Reconceptualizmg nursmg ethics ScholarlyInquiry for Nursing Prachce An International Journal 4(3),209-218

Corley M & Selig P (1992) Nurse moral reasorung usmg thenursmg dilemma test Westem Journal of Nursmg Research14(3), 380-388

Duff R5 (1987) 'Close-up' versus 'distant' ethics deadmg thecare of infants with i>oor prognosis Seminars m Pennatology11(3), 244-253

Ford M R & Lowery C R (1986) Gender differences m moralreasorung a companson of the use of jushce and careonentations Journal of Personality and Soaal Psychology 50(4),777-783

Gerlach-Engborg P, Englund M-L, Samuelsson C & SandstedtS (1989) Elderly m mtensive care is it profitable for soaety?(Swedish) I kartidnmgen 86(44), 3765-3766

Gilmour IM & Rosenberg P ] (1989) Medicolegal consider-ahons m the mihahon and termination of resusatahon mCanada. Canadian Medical Assoaation Journal 140(3), 279-288

Jansson L & Norberg A. (1989) Ethical reasonmg concemmgthe feedmg of terminally ill cancer pahents Cancer Nursing12(6), 352-358

Jansson L & Norberg A (1992) Ethical reasonmg amongregistered nurses expenenced m demenha care Interviewsconcemmg the feedmg of severely demented pahentsScandinavian Journal of Canng Saences 6(4), 219-227

Kohlberg L (1981) Essays on Moral Development Vol 1 ThePhilosophy of Moral Development Haiper & Row, New York.

Lindseth A (1992) The role of carmg m nursmg ethicsIn Quality Development in Nursmg Care From Practice toSaence (Uden G ed). Health Service Studies, LinkopmgCollaboratmg Centre, Lmkoping, No 7, pp 97-106

Locke D (1983) Domg what comes mor^y The relahonbetween behaviour and stages of moral reasonmg HumanDevelopment 26(1), 11-25

Maclntyre A (1985) 4/Jer Virtue A Study m Moral Theory 2ndedn Duckworth, London

Mishler E (1986) Research Intervtewtng Context and Narrative

Harvard University Press, London

Munoz E, Josephson J, Tenaibaum N , Goldstem J, ShearsA M & Wise L (1989) Diagnosis-related groups, costs, andoutcome for pahents m the mtensive care unit Heart & Lung18(6), 627-633

Norberg A, Asplund K & Waxman H (1987) Withdrawmgfeedmg and withholdmg artifiaal nutnhon from severelydemented pahents Interviews with caregivers WestemJournal of Nursmg Research 9(3), 348-356

Omery A & Caswell D (1988) A nursmg perspechve of theethical issues surroundmg liver transpiantahon Heart & Lung17(6), 626-^31

Pike A W (1991) Moral outrage and moral discourse mnurse-physiaan collaboration Journal of Professional Nursing7(6), 351-363

Polkmghome DE (1988) Narrative Knowing and the Human

Saences State University of New York Press, New York.Puka B (1991) Interprehve experiments probing the care-

justice debate m moral development Human Development34(2), 61-80

Ricoeiir P (1976) Interpretation Theory Discourse and the Surplusof Meaning Texas Chnshan University Press, Fort Worth,Texas

Ricoeur P (1984) The model of the text mearungful achonconsidered as a text Soaal Research 51(1-2), 185-218

Sarbm TR. (1986) The narrahve as a root metaphor forpsychology In Narrative Psychology The Stoned Nature ofHuman Conduct (Sarbm TR ed), Praeger Speaal Studies,New York, pp 3

Tappan MB (1990) Hermeneuhcs and moral developmentmterpretmg narrahve representahons of moral expenenceDevelopmental Review 10(3), 239-265

Uden G, Norberg A, Lmdseth A & Marf\aug V (1992) Ethicalreasonmg withm nurses' and physicians' stones about careepisodes Journal of Advanced Nursmg 17(9), 1028—1034

Vitz PC (1990) The use of stones m moral developmentNew psychological reasons for an old education methodAmencan Psychoh^ist 45(6), 709-720

Walker R M , Miles SH, Stockmg CB & Siegler M (1991)Physicians' and nurses' perceptions of ethics problems ongeneral medical service Journal of General Internal Mediane6(5), 424-429

2014

Page 8: Intensive care: situations of ethical difficulty