There is no doubt that working in the ICU can be a source of moral distress. I’ve been spending the last few months doing hospice home care and I’ve been thinking about going back to the hospital for various reasons. The last time I worked as a nurse in the ICU was the summer of 2009. I took a three month contract in the MICU. Not my first choice of employment, but I needed the money, and the work was familiar to me.

That summer was filled with moral distress.

I did chest compressions on a frail, elderly, woman because the day shift crew failed to get a much needed DNR order. (Could I have refused? I could have sauntered off pretending to busy myself with something else. On that unit there was always a young gun wanting to get experience being part of a code.)

I attempted and failed to drop an NG tube on a delirious liver failure patient. The fumbling young intern wanted to do some gastric lavage. I very tactfully expressed my disapproval but did not have reason enough to outright refuse. There was a good enough reason to do it. (Should I have refused?)

I watched an elderly man with end stage cancer, self-extubate. He was intubated in the field. The story was that he didn’t wish to be on a ventilator but a family member insisted. In the ICU he began to wake up from the sedation and started tearing at the tube with the strength of a bull. I couldn’t titrate his sedation up high enough and the next step was restraints. He tore through those in no time and eventually he self extubated. As a nurse, my job was to make sure that didn’t happen. The whole time I was advocated for extubating him, but very few residents are likely to take that chance during night shift. And ultimately it’s the resident’s decision not mine. But inwardly I was rooting for him to rip that tube out. Eventually he did, and he lived at least until the end of my shift.

How screwed up is it that what is expected of me, and what I feel is the right thing to do are completely conflicting? How does one deal with that on a daily basis? Of course there is a notion that the nurse must advocate for the patient. But on night shift in the ICU you are out there in the battle field with no armor and no weapons. The tough conversations about dying, and goals of care need to happen long before the patient reaches the ICU.

What should the nurse do?

I often think that the moral distress I experienced in the ICU is a major reason for taking such a long break from nursing (6 years!) It’s most likely the reason I became a hospice nurse. And it has been gratifying to carry out patients wishes, to enable them to have a peaceful death, surrounded by loved ones. It’s interesting though. In hospice I still end up caring for patients in which the tough conversations about dying and goals of care haven’t happened yet. But at least I have the liberty to initiate these conversations when appropriate.

(Creative Commons photo by Flickr user Helge V Keitel)