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A recent article in the Journal of Medical Ethics (JME) talks about the instructions “allow natural death” versus “do not resuscitate” and how either of these three words can change a life. Even more, the article underscores a role and voice that is often forgotten in this conversation - the one of nurses.

With a focus on a cooperative model of healthcare decision-making, the article discusses the context of a DNR order and to a greater extent, the necessity for such contexts to include multiple stakeholders including patients and their significant others as well as other medical personnel, like nurses. This change demands the need to understand such things like DNR from multiple perspectives. As the article states, “because nurses frequently play an active role as liaison between the different cultures of the medical community and lay-persons, they are ideally suited to educate patients and diffuse conflict with family members, resulting in better medical care.”

Oncology nurse Theresa Brown, a regular contributor to NY Times Well blog writes extensively about the life of a nurse. In a recent article she documents one of her first patients that asked “what’s wrong with me? and “am I going to die?” She told him, “I don’t completely know, but whatever happens I am here with you.” There they were as she describes – nurse and patient, talking quietly in an exam room, confronting questions of life and death. As a nurse, she sees it all: “the struggles with treatment, the confrontation with death, the success that gladded all our hearts.” Furthermore, her experiences capture the complexity, messiness and tension-filled environment where everyday life enters the clinic in complete chaos.

In another article, Can Nurses Care Too Much?, Theresa Brown again discusses how when we talk about compassion in medicine, most of the focus is on doctors. But what about nurses? In medical oncology (where she works) patients stay for weeks or even months. They leave and come back often. Nurses get to know them, their families and other loved ones. She states, “because we know them so well, in such an intense and intimate setting, we end up caring about them.” What does it mean to be a nurse in oncology? A no-win situation is what Brown believes. That is, a situation where compassion routinely gets stripped away by grief. If you die in a hospital, the person caring for you in your last days, hours, and minutes will be a nurse. The doctors care, too, of course, and check in and write orders, “but we’re the ones who are always there.” A nurse on her floor once told her, “you girls get too attached.” And she’s right, of course as Brown states. Feeling attached and feeling trapped are consistent feelings for nurses and doctors…

Similarly, Pauline Chen MD reports that doctors and nurses “feel trapped” by the demands of administrators, insurance companies, lawyers, patients’ families and even one another. And yet they are forced to collaborate on what they believe is best for patients. This is known as moral distress.

Moral distress, first described in 1984 in a book on nursing ethics is an inability to act because of obstacles inherent in a situation. How much can a person take? And how much can a person do? Later researchers focused primarily on the experience of nurses and found that those who suffered from moral distress often become reluctant to interact with patients and other providers. The article asks, “are we working as respectful partners or are we afraid?”

So what can be done?

In a highly intense, emotional, intimate environment this question is not easy. The last few weeks we’ve discussed EMRs and other health IT initiatives that for many constitute healthcare reform and collaborative interaction. But how might conversations about healthcare collaboration be different if nurses were active participants in these discussions? How could nurses and their unique spoken and embodied role caring for – and caring about – patients inform an agenda for responsible and cooperative patient care?

More specifically, how do you perceive the role of nurses? What are your experiences of cooperation and collaboration in nurse-surgeon teams? And how might you begin to engage nurses in these conversations?

Thanks to Kuby!, Pembroke Dave and amanda cee for their images!

Carey Candrian

Tags: a natural death, allow natural death, cooperative patient care, DNR, do not resuscitate, electronic health records, electronic medical records, emr, healthcare decision-making, Journal of Medical Ethics, M.D., medical ethics journals, medical record, moral distress, moral distress nursing, nurse role, nurse-surgeon teams, nurses, NY Times, NY Times Well Blog, patient care, Pauline Chen, R.N., role of nurses, the nurses role, Theresa Brown

This entry was posted on Tuesday, March 24th, 2009 at 8:42 am and is filed under Blog.