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A nurse ethicist illuminates her specialty

Monday February 27, 2012
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Throughout nursesí careers, they confront ethically challenging situations while caring for patients and family members struggling with making the right decisions about treatments and transitions. Nurse ethicists serve as resources. To learn more about the role of the nurse ethicist, Nurse.com talked with Lucia D. Wocial, RN, PhD, a nurse ethicist with Indiana University Health and the Charles Warren Fairbanks Center for Medical Ethics and an adjunct assistant professor at the Indiana University School of Nursing in Indianapolis.

What exactly does a nurse ethicist do?

To start, this is not a black-and-white sort of job, where I come to work every day and know I will do XYZ. I present inservices related to ethics for nurses coming into IU Health. I talk about case examples and help them apply the abstract concept of ethics in their roles. With IU Healthís unit-based ethics program, I facilitate informal conversations regarding ethical issues. I help people learn to talk about and consider patient care issues in the context of ethics principals. I also serve on committees and do consultations.

But my role may differ from other nurse ethicists. When I went to graduate school, I wrote a job description for my ideal job as a nurse in ethics, and this is it. I spend about 40% of my time at the Fairbanks Center, 40% with the department of nursing at IU Health and 20% at the IU School of Nursing.

Do nurse ethicists review patient cases?

Yes. The most frequent reason for assistance on a patient care issue is concern about a patientís or familyís request for nonbeneficial or futile treatment, trying to keep their loved one alive when the medical team does not think it is possible long-term or it is causing harm. That most commonly occurs in critical care or oncology.

Ethics is about more than death and dying, although issues surrounding end of life are the most ethically challenging. Because we are trained to help, itís hard to cope with these issues. Sometimes, the patient will request a withdrawal of curative treatment before the healthcare team is ready for that.

Whatever the case, I will read the chart and talk with all of the stakeholders ó the patient, the family, the nurses and physicians. I might mediate a discussion between patients and families and the healthcare team. I try to identify the language to use to help gain an understanding of each otherís perspectives. I will follow up informally with nurses involved with the care to help them with the ethical language and justify the approach taken. I help people think about the case beyond the emotional aspects and in the broader context.

What are your greatest contributions to the healthcare arena?

The greatest value I bring is as a resource on ethics when someone is grappling with the right thing to do. I can help them ďunpackĒ their issues and separate them in a way that makes sense. Usually itís an emotionally charged situation. Sometimes people need to set aside their emotions and think it through.

The benefit I provide is an ability to look at it through the lens of a nurse in clinical practice for more than 20 years. I know what it means to be a nurse taking care of patients. When I look at things with an ethicistís eye, it is always through the lens of a nurse.

What types of situations do you usually encounter?

People can tell me anything. I am a safe harbor for them to talk about the ethical crises they face. It could be patient care situations, issues of respect in the workplace or relationships with physicians and the work environment. For nurse managers, it could be issues of fairness and the best allocation of resources. It could be the ethical behavior of the organization. IU Health has confidential reporting, and sometimes people will bounce their ideas off of me before making a call.

What are the long-term goals of a nurse ethicist?

From an institutional standpoint, I want to help create a core group of nurses who have a passion for ethics and can be resources for other nurses in the trenches. There is only one of me, and on the main campus where I spend most of my time, there are about 5,000 nurses. I want to help people understand the potential positive impact a nurse ethicist can have on patient care.

My area of research interest is moral distress in professional caregivers. Moral distress is when you believe you know the ethically correct thing to do, but something or someone keeps you from acting on it. Itís not just life-or-death situations. Whether itís a nurse ethicist or a physician ethicist, having someone with expertise in ethics helps people sort through and evaluate the conflicts.

What will the goals be as healthcare evolves?

The hard choices are not going away. In the U.S., we make choices every day about who gets what healthcare. If you donít have insurance, your care is effectively rationed. If you do have insurance and go out of network, you pay more.
The goal of anyone in ethics is to help us deal with the limits of what we can do and the limits of the resources we have. We have to take the heat out of the debates. Sound bites are inflaming people. We cannot do everything for everybody.

The other piece is we are all going to die. Weíve had so many wonderful successes in helping people live better with chronic illness and in treating cancer that we forget people will die. Sometimes medical science has nothing to provide other than comfort. We have limits and must start paying attention to how we feel about it.

Some of the most exquisite care is not expensive and not high tech. We have to come back to remembering that I may not be able to heal you, but I will take care of you. We have an obligation to care for people, but that doesnít mean to throw every piece of technology or science at them. The trick is in knowing what the right time is.
If nurses find their voices, they could help patients understand that discussing certain issues is not about death panels. Itís about the importance for patients and physicians to discuss what matters, and that the physician should be reimbursed for that time. We have to get better at this.

The goal for anyone in healthcare ethics is to stop the rhetoric and, in a nurturing way, help people talk about the tough stuff that matters the most.

What would you say to nurses considering becoming more involved in ethics?

I would tell them that when you are involved in ethics you must constantly check your own values, whatís important to you and how it meshes with your professional life. Your values will color ethical analyses. Look at the ethical opportunities where you work. Talk to people, network, read. There are opportunities to do things online.

At the heart of ethical issues are people struggling with something they feel at the core of their being, and they deserve face time with someone who will listen. The ethics intervention requires a skilled communicator, intentional in what you say. As healthcare providers, we owe it to our patients to do the hard work of figuring out the right thing to do.

Debra Anscombe Wood, RN, is a freelance writer. Post a comment below or email specialty@Nurse.com.