Doctors and Nurses Working With Critically Ill Patients Are Walking Off The Job


Five years ago, Canadian critical care specialist Dr. Daren Heyland walked out of an intensive care unit and never went back.

That day, Heyland had been performing CPR and intubating a critically ill 84-year-old woman with a heart so worn out it could no longer be saved. Somehow the staff at the intensive care unit had been given orders to take every known measure to prolong her life. And she went into cardiac arrest.

“We were breaking her ribs and putting her on machines and doing all these distressful things,” Heyland, 52, recalls. “And eventually she passed away, and I had to tell the husband, ‘Sorry, there’s nothing more we can do.’ And she passed away under these awful conditions.”

Then it happened all over again, with a second patient, and Heyland remembers thinking: “I’m doing the wrong thing for this patient. I’m adding to their suffering and the suffering of their family and I don’t want to do this anymore.” He left the ICU after his shift. He never returned.

As more people die in intensive care units, where machines can keep diseased and failing lungs, kidneys and other organs alive and functioning in even the sickest of patients, new Canadian research is bringing into sharper focus something once rarely acknowledged: the moral distress experienced by doctors and nurses working with critically ill patients.

Canada’s population is aging and people are living longer with chronic illnesses that eventually will kill them. Today, most Canadians die in hospital and, of those hospitalized, one in five will take their last breath in an ICU.

Researchers from the University of British Columbia who surveyed 1,400 ICU nurses, doctors and other health professionals have found worrying levels of distress in the very places growing numbers of Canadians will exit this life. Half the critical care nurses surveyed, and 27 per cent of ICU doctors, said they have considered quitting their jobs because of distress with the way patient care was handled at their hospital.

Eighteen per cent of nurses, and seven per cent of doctors, said they are considering leaving their positions now.

Intensive care specialist Dr. Peter Dodek describes moral distress as the angst of feeling trapped between “what people think they ought to do, and what they’re compelled to do.”

The distress is being driven by end-of-life controversies, his team’s research shows, including inconsistent care plans, families demanding doctors not withhold or stop aggressive treatments even when all hope for recovery is gone, and too much — or too little — life support.

“The concern was that in some cases there hadn’t been any conversations with patients in advance,” Dodek said. “They come to the ICU without any plan and they get full speed ahead interventions — all the life support — even if it’s not necessarily what the patient would have wanted.”

For their research, Dodek and his team anonymously surveyed about 870 ICU nurses, 68 physicians and 450 other health-care professionals working in 13 Vancouver and Fraser Valley ICUs. Focus groups and interviews were held with staff at the three hospitals reporting the highest levels of moral distress.

Researchers rated the frequency and intensity of moral distress using a 21-item scale that describes certain situations and statements, such as witnessing a health-care provider providing false hope to a patient or family, or having to start life-saving actions “when I think they only prolong the dying process.”

Doctors in some cases reported feeling distressed about the care provided by other ICU doctors, or providing false hope to patients. Nurses reported distress over doctors not being upfront with patients or families. Some said patients are frequently not even told they are dying.

Levels of moral distress were higher in nurses and other health professionals than doctors, possibly because of the power hierarchy that can exist in an ICU. Doctors write the orders, but it’s nurses who must execute them.

The most experienced nurses reported the highest levels of distress and the consequences can be serious: frustration, stress, burn out and feeling worn down. Other studies have shown distress can lead to “compassion fatigue,” medication errors and attrition, “which is really tragic when you consider what goes into training a critical care nurse,” Dodek said.

In the ICU, nurses provide one-on-one care. They are the constant, and when the prognosis is poor, “often times the team reaches that conclusion much earlier than families do,” said Denise Morris, nurse manager of the medical/surgical intensive care unit at the Toronto General Hospital.

“And because you’re continuing with active care, it can be distressing, because they’re already at the place thinking, ‘we need to have a family meeting,’” Morris said.

“But that may not be on the family’s radar — they may not be in a place to hear that message. It could take days, sometimes weeks.

“And that waiting time for nursing staff is difficult, because the question in their heads is, is the patient comfortable? Are we actually doing harm versus doing good? Are we prolonging the dying process, rather than prolonging life?”

Heyland said advance care planning needs to start before a patient is ever admitted to hospital or an ICU. “It needs to start in the community, with the GP.”

A professor of medicine and epidemiology at Queen’s University in Kingston, Ont., Heyland has now dedicated the majority of his research career to preventing the kinds of deaths that drove him from the ICU after 20 years of practice.

His own research has shown that when frail, elderly patients are asked whether they would want to be kept alive by artificial means or “heroic measures,” the patients’ preferences agree with the orders written in their charts only 30 per cent of the time.


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    Editor-in Chief:
    Kirsten Nicole

    Editorial Staff:
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    Stan Kenyon
    Robyn Bowman
    Kimberly McNabb
    Lisa Gordon
    Stephanie Robinson

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    Stan Kenyon
    Liz Di Bernardo
    Cris Lobato
    Elisa Howard
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