Physicians' Perspectives on Ethically Challenging Situations: Early Identification and Action

Background: Limited information on risk factors for ethically difficult clinical situations exists. Identifying common factors in these situations could encourage a more proactive, system-wide approach to ethical issues, which could mitigate patient and family suffering, providers' moral stress, and costly ethical conflicts. Methods: Quantitative and qualitative data analyses were performed on physician responses to an online survey that queried physician perceptions about ethically complex situations in a large academic medical center and community hospital. Results: Representing 30 specialties, 114 physicians responded. The most frequently encountered situation was working with patients who lacked capacity for decision making. End-of-life treatment decisions and family adamancy were ranked as the most intense situations. Interactional risk factors such as different moral perspectives and poor communication were most prominent (53.9%); patient and family risk factors were also described (33%). Physicians identified early and frequent communication with seriously ill patients and their families as the primary protection against ethical conflict. Ethics skill-building, good teamwork, and creating an ethics-minded culture were also featured as important preventive measures. Pressure from others to take morally uncomfortable action was most often cited as a source of moral stress. The pressure of limited time to address ethical issues was also frequently mentioned. These pressures could progress to ethical conflicts, which often compounded moral stress. A majority of physicians reported willingness to work with nurses on ethically difficult situations. Conclusions: Physicians are very aware of ethical complexities in their clinical practice and take their moral responsibilities very seriously. Communicating effectively with patients, families, and other health care team members and advocating for adequate resources, including ethics resources, are important avenues to mitigate ethical conflicts.