The Case of Freda: Nursing Staff in Moral Distress When Patient’s Wishes Not Followed

Bioethics Forum

Freda is a thirty-two-year old woman in an advanced fixed stage of multiple sclerosis. She is no longer able to move independently or feed herself. She is able to speak with great difficulty. Her decisional capacity is intact.

Freda's inability to swallow has caused her to lose weight to the point that she is clinically malnourished. Three decubitus ulcers have developed and are not responding to treatment. In conversation with long-term care nursing staff, social workers, and her attending physician, she has made it clear that she does not want a gastric feeding tube. In conference with staff, her mother, and an aunt, she has declared that she wants her two young children to be in the care of their father (who is not her husband), and that she ought to be allowed to die as peacefully and gracefully as possible.

Her mother takes her to a neurologist at a nearby teaching hospital where she has been followed in the past. The neurologist is persuaded by the mother and arranges the insertion of a gastric feeding tube.

When the patient returns to the long-term care facility, the nursing staff is in a high state of moral distress. They view the feeding tube as a flagrant violation of the patient's clear statement of preferences. They lash out at the mother and accuse her of manipulating the patient. Freda is frozen in a catatonic state and cannot, or will not, communicate with staff or family. The attending physician shows no willingness to try to reverse the decision to maintain the patient on the feeding tube. The nursing staff morale sinks very low as they see no way to avoid doing to the patient what she very clearly did not want done. They finally confront the attending physician and demand that something be done to relieve the patient's suffering and their moral distress.

Questions

What factors about Freda's case led to moral distress on the part of the long-term care facility staff?
Is their attack on the mother an appropriate response? Can it be justified?
What explains the attending physician's acquiescence to the existence of a feeding tube in his patient?
What arguments can you provide the staff when they confront the physician?
What should they do, if the physician remains unwilling to act on their concerns?
Has the neurologist acted responsibly?
What ethical principles, virtues, or consequences do you think play a role in the patient's suffering, and the staff's moral distress?
What information do you have that would lead you to believe that the patient has decisional capacity?
Do patients have the right to refuse artificial nutrition and hydration? How would you help Freda explain her wishes to her mother and aunt?

Reflecting on Cases involving Moral Distress

Each case should be analyzed according to its particular merits and context. The following questions, however, will help individuals or ethics committees clarify the nature of the conflict, the impasse, and the sort of moral distress that characterizes each situation.

Have the healthcare providers clearly stated what they believe is the right and good and wise action that ought to be taken for the patient?

Has the barrier (persons, rules, policies) to taking the right, good and wise action also been named?

The following questions test whether adequate attempts have been made to deal with the moral distress created by the conflicting goods:

What strategies for implementing the right, good and wise action, including compromise, have been carefully considered and weighed for their potential?

Before you give up in "moral despair" ask if there is someone outside the situation who can break the impasse.

These questions are important elements in all ethical deliberation.