scholarly journals P041 Moral dilemmas and ethical discomfort in paediatric pharmacists

2019 ◽  
Vol 104 (7) ◽  
pp. e2.47-e2
Author(s):  
Nicola Wilson ◽  
Elaine Liston ◽  
Lauren Williams
Keyword(s):  
Intensive Care ◽  
Moral Distress ◽  
Pharmacy Practice ◽  
Moral Dilemmas ◽  
Trisomy 18 ◽  
Paediatric Intensive Care ◽  
Trisomy 13 ◽  
List Type ◽  
Comfort Zone ◽  
Edwards Syndrome

SituationA five week old infant admitted to a tertiary paediatric hospital with coryzal symptoms on a background of Edwards Syndrome (Trisomy 18) and congenital cardiac disease. Despite her grave prognosis, she was intubated and ventilated. She spent many months in hospital, eventually having surgical repair of her cardiac defect which had little or no effect on her clinical condition. She was discharged to a children’s hospice after seven months in our hospital (with short periods at home and her local hospital), at the age of eight months, for end of life care. As pharmacists actively involved in her care, but with limited input to her ethical situation, we suffered moral distress.BackgroundEdwards Syndrome is a rare genetic condition which occurs in 1 in 5000 live births. Infants are severely disabled. Accurate figures for miscarried or terminated pregnancies are not available. Only 8% of babies survive beyond one year unless they have a less severe form (mosaic or partial).1 Our patient had a post-natal diagnosis and her parents were determined that she be given every opportunity that would be offered to a non-Edwards child. We are three pharmacists who work in paediatric intensive care and paediatric cardiology. We were actively involved in the care of this patient and her family for several months. Although we work closely with the multidisciplinary team, we were not included in discussions about appropriateness of interventions. We were however, expected to speak to her parents about medicines on a regular basis, including during a very difficult and prolonged wean of sedation which was causing physical distress to the patient and her parents.OutcomeBeing involved in interventions which are unlikely to improve or extend a patient’s life is difficult, but especially so when you have had little or no influence on the original decision. The eventual outcome was exactly as predicted on admission: she was discharged to a hospice and expected to deteriorate slowly. Her discharge was written by one of the PICU pharmacists and her parents were counselled by another, so we were involved until the end of her admission.DiscussionAs a pharmacy team, we only have each other to talk to: our distress cannot compare to that of medical or nursing staff who are more closely involved in the patient. We are limited in what we can discuss outside of work due to patient confidentiality. With the relatively recent introduction of pharmacist independent prescribing in our PICU and cardiology wards, we are often asked to prescribe outwith our comfort zone and are able to refuse. As our prescribing roles become more embedded, our comfort zone will expand and we will be expected to prescribe in morally ambiguous situations such as this one. Studies have shown that community pharmacists are prone to moral distress,2 as they work in a highly regulated profession and their actions are often bound by laws and contracts over which they have little control, and in hospital we suffer the same fate.3ReferencesWu J, Springett A, Morris JK. Survival of trisomy 18 (Edwards syndrome) and trisomy 13 (Patau Syndrome) in England and Wales: 2004–2011. Am J Med Genet Part A 2013;161A:2512–2518.Astbury JL, Gallagher CT, O’Neill RC. The issue of moral distress in community pharmacy practice: background and research agenda. International Journal of Pharmacy Practice 2015;23(5);361–6.Prentice T, Janvier A, Gillam L, et al. Moral distress within neonatal and paediatric intensive care units: a systematic review. Archives of Disease in Childhood 2016;1012(8):701–8.

scholarly journals Moral distress within neonatal and paediatric intensive care units: a systematic review

2016 ◽  
Vol 101 (8) ◽  
pp. 701-708 ◽  
Author(s):  
Trisha Prentice ◽  
Annie Janvier ◽  
Lynn Gillam ◽  
Peter G Davis
Keyword(s):  
Intensive Care ◽  
Intensive Care Units ◽  
Neonatal Intensive Care ◽  
Moral Distress ◽  
Medical Literature ◽  
Moral Dilemma ◽  
Small Sample ◽  
Paediatric Intensive Care ◽  
Best Interest ◽  
Paediatric Intensive Care Units

ObjectiveTo review the literature on moral distress experienced by nursing and medical professionals within neonatal intensive care units (NICUs) and paediatric intensive care units (PICUs).DesignPubmed, EBSCO (Academic Search Complete, CINAHL and Medline) and Scopus were searched using the terms neonat*, infant*, pediatric*, prematur* or preterm AND (moral distress OR moral responsibility OR moral dilemma OR conscience OR ethical confrontation) AND intensive care.Results13 studies on moral distress published between January 1985 and March 2015 met our inclusion criteria. Fewer than half of those studies (6) were multidisciplinary, with a predominance of nursing staff responses across all studies. The most common themes identified were overly ‘burdensome’ and disproportionate use of technology perceived not to be in a patient's best interest, and powerlessness to act. Concepts of moral distress are expressed differently within nursing and medical literature. In nursing literature, nurses are often portrayed as victims, with physicians seen as the perpetrators instigating ‘aggressive care’. Within medical literature moral distress is described in terms of dilemmas or ethical confrontations.ConclusionsMoral distress affects the care of patients in the NICU and PICU. Empirical data on multidisciplinary populations remain sparse, with inconsistent definitions and predominantly small sample sizes limiting generalisability of studies. Longitudinal data reflecting the views of all stakeholders, including parents, are required.

An Overview of Moral Distress and the Paediatric Intensive Care Team

2009 ◽  
Vol 16 (1) ◽  
pp. 57-68 ◽  
Author(s):  
Wendy Austin ◽  
Julija Kelecevic ◽  
Erika Goble ◽  
Joy Mekechuk
Keyword(s):  
Decision Making ◽  
Intensive Care ◽  
Moral Distress ◽  
Paediatric Intensive Care ◽  
High Tech ◽  
Individual Values ◽  
Team Members ◽  
Futile Care ◽  
End Of Life Decision ◽  
Life Decision

A summary of the existing literature related to moral distress (MD) and the paediatric intensive care unit (PICU) reveals a high-tech, high-pressure environment in which effective teamwork can be compromised by MD arising from different situations related to: consent for treatment, futile care, end-of-life decision making, formal decision-making structures, training and experience by discipline, individual values and attitudes, and power and authority issues. Attempts to resolve MD in PICUs have included the use of administrative tools such as shift worksheets, the implementation of continuing education, and encouragement to report. The literature does not yet show these approaches to be effective in the resolution of MD. The need to acknowledge MD among PICU teams is discussed and an argument made that, to facilitate understanding among team members, practice stories need to be shared.

scholarly journals P19 Direct observational study of infusion errors associated with smart-pump technology in paediatric intensive care

2020 ◽  
Vol 105 (9) ◽  
pp. e15.2-e16
Author(s):  
Moninne Howlett ◽  
Erika Brereton ◽  
Cormac Breatnach ◽  
Brian Cleary
Keyword(s):  
Intensive Care ◽  
Intensive Care Units ◽  
The United States ◽  
Error Rates ◽  
Paediatric Intensive Care ◽  
Electronic Prescribing ◽  
List Type ◽  
Paediatric Hospital ◽  
Smart Pumps ◽  
Smart Pump

AimsProcesses for delivery of high-risk infusions in paediatric intensive care units (PICUs) are complex. Standard concentration infusions (SCIs), smart-pumps and electronic prescribing are recommended medication error reduction strategies.1 2 Implementation rates are low in Irish and UK hospitals.2 3 Since 2012, the PICU of an Irish tertiary paediatric hospital has been using a smart-pump SCI library, interfaced with electronic infusion orders (Philips ICCA®). The incidence of infusion errors is unknown. This study aims to determine the frequency, severity and distribution of smart-pump infusion errors and to identify contributory factors to the occurrence of infusion errors.MethodsProgrammed infusions are directly observed at the bedside. Parameters are compared against medication orders and auto-populated infusion data. Identified deviations are categorised as either medication errors or discrepancies. Five opportunities for error (OEs) were identified: programming, administration, documentation, assignment, data transfer. Error rates (%) are calculated as: infusions with errors; and errors per OE. Pre-defined definitions, multi-disciplinary consensus and grading processes are employed.ResultsA total of 1023 infusions for 175 patients were directly observed on 27 days between February and September 2017. 74% of patients were under 1 year, 32% under 1 month. The drug-library accommodated 96.5% of all infusions. Compliance with the drug-library was 98.9%. 55 infusions had ≥ 1 error (5.4%); a further 67 (6.3%) had ≥ 1 discrepancy. From a total of 4997 OEs, 72 errors (1.4%) and 107 discrepancies (2.1%) were observed. Documentation errors were most common; programming errors were rare (0.32% OE). Errors are minor, with just one requiring minimal intervention to prevent harm.ConclusionThis study has highlighted the benefits of smart-pumps and auto-populated infusion data in the PICU setting. Identified error rates are low compared to similar studies.4 The findings will contribute to the limited existing knowledge base on impact of these interventions on paediatric infusion administration errors.ReferencesInstitute for Safe Medication Practices, ISMP. 2018–2019 Targeted medication safety best practices for hospitals2018 [Available from: http://www.ismp.org/tools/bestpractices/TMSBP-for-Hospitalsv2.pdf [Accessed: June 2019]Oskarsdottir T, Harris D, Sutherland A, et al. A national scoping survey of standard infusions in paediatric and neonatal intensive care units in the United Kingdom. J Pharm Pharmacol 2018;70:1324–1331.Howlett M, Curtin M, Doherty D, Gleeson P, Sheerin M, Breatnach C. Paediatric standardised concentration infusions – A national solution. Arch Dis Child. 2016;101:e2.Blandford A, Dykes PC, Franklin BD, et al. Intravenous Infusion Administration: A comparative study of practices and errors between the United States and England and their Implications for patient safety. Drug Saf. 2019;42:1157–1165

Moral distress: Developing strategies from experience

2020 ◽  
Vol 27 (4) ◽  
pp. 1147-1156
Author(s):  
Andrew Helmers ◽  
Karen Dryden Palmer ◽  
Rebecca A Greenberg
Keyword(s):  
Critical Care ◽  
Intensive Care ◽  
Work Environment ◽  
Moral Distress ◽  
Healthcare Providers ◽  
Pediatric Intensive Care ◽  
Paediatric Intensive Care ◽  
Care Providers ◽  
Front Line ◽  
Moral Resilience

Background Moral distress was first described by Jameton in 1984, and has been defined as distress experienced by an individual when they are unable to carry out what they believe to be the right course of action because of real or perceived constraints on that action. This complex phenomenon has been studied extensively among healthcare providers, and intensive care professionals in particular report high levels of moral distress. This distress has been associated with provider burnout and associated consequences such as job attrition, with potential impacts on patient and family care. There is a paucity of literature exploring how middle and late career healthcare providers experience and cope with moral distress. Objectives We explore the experience of moral distress and the strategies and resources invoked to mitigate that distress in mid- and late-career healthcare providers practicing in paediatric intensive care, in order to identify ways in which the work environment can build a culture of moral resilience. Research design An exploratory, qualitative quality improvement project utilizing focus group and semi-structured interviews with pediatric intensive care front-line providers. Participants Mid-and-later career (10 + years in practice) pediatric intensive care front line providers in a tertiary pediatric hospital. Research context This work focuses on paediatric intensive care providers in a single critical care unit, in order to explore the site-specific perspectives of health care providers in that context with respect to moral distress coping strategies. Ethical considerations The study was approved by the Quality Management Office at the institution; consent was obtained from participants, and no identifying data was included in this project. Findings Participants endorsed perspective-building and described strategies for positive adaptation including; active, reflective and structured supports. Participants articulated interest in enhanced and accessible formal supports. Discussion Findings in this study resonate with the current literature in healthcare provider moral distress, and exposed ways in which the work environment could support a culture of moral resilience. Avenues are described for the management and mitigation of moral distress in this setting. Conclusion This exploratory work lays the groundwork for interventions that facilitate personal growth and meaning in the midst of moral crises in critical care practice.

scholarly journals O7 General pharmaceutical council revalidation: what is the best approach for conducting a peer discussion for paediatric pharmacists?

2019 ◽  
Vol 104 (7) ◽  
pp. e2.59-e2
Author(s):  
Stephen Morris ◽  
Teresa Brooks
Keyword(s):  
Intensive Care ◽  
Experiential Learning ◽  
Medical Training ◽  
Learning Experience ◽  
Pharmacy Practice ◽  
List Type ◽  
Clinical Environment ◽  
Management Options ◽  
Peer Discussion ◽  
Case Based

AimIn 2018 the General Pharmaceutical Council (GPhC) made it mandatory for pharmacists and pharmacy technicians in the UK to conduct a peer discussion as part of their annual revalidation assessment. The criteria from the GPhC states that a practitioner must record why a peer was chosen, how the process of peer discussion has benefited their practice and how the process of peer discussion has benefited the people using their services.1 The GPhC describes several examples of who can act as a peer; for example a line manager, colleague or other healthcare professional. However, there is no specific format for the discussion, but it may include personal development plans, recent successes or challenges to the individual, medication related incidents or quality improvement work. Case based discussion (CBD) is a tool used for peer discussions, primarily in medical training. They are used to assess a clinician’s knowledge of a condition, the potential management options available to them and decision making abilities. It allows a clinician to objectively reflect on their own practice,2 and allow for abstract conceptualisation. This is a vital process that links learning to practice, as described by Kolb’s experiential learning theory.3The aim of this project was to assess whether a case based discussion between two experienced paediatric pharmacists will fulfil the GPhC requirements for revalidation.MethodsTwo experienced paediatric pharmacists participated in this study. Each took the turn as the subject and the peer. As part of the pre-discussion phase and with agreement from senior management, a job swap was arranged for two weeks to allow each pharmacist to gain an understanding of the demands of their colleague. At the end of this period, the two CBDs were conducted using cases selected from the 2 week period.ResultsThe two pharmacists selected were practicing in neonatal intensive care and paediatric intensive care. Each CBD lasted approximately one hour and both were conducted in the clinical environment. Using this format provided discussion around a variety of elements of paediatric pharmacy practice; such as clinical assessment skills, interpreting evidence and applying guidelines to practice, identifying knowledge gaps and exploring medication safety issues. The result of each CBD was that each pharmacist was able to successfully complete a peer discussion record that complied with the GPhC criteria.ConclusionThis abstract has highlighted that peer discussion has the potential as a powerful tool for ensuring quality and improvement in paediatric pharmacy practice. This is especially applicable to specialist practice. The Neonatal and Paediatric Pharmacist Group is a potential peer network for facilitating collaborations between paediatric pharmacists. The lack of specific framework is an opportunity for future development.ReferencesGeneral Pharmaceutical Council. Revalidation Framework. London: General Pharmaceutical Council; 2018.Emsden S, Thomson A. Getting the best out of case-based discussions. Paediatrics and Child Health 2010;20:585–588.Kolb DA. Experiential learning: Experience as the source of learning and development. Englewood Cliffs, New Jersey: Prentice-Hall; 1984.

Psychological impact of working in paediatric intensive care. A UK-wide prevalence study

2019 ◽  
Vol 105 (5) ◽  
pp. 470-475 ◽  
Author(s):  
Gareth A L Jones ◽  
Gillian A Colville ◽  
Padmanabhan Ramnarayan ◽  
Kerry Woolfall ◽  
Yvonne Heward ◽  
...  
Keyword(s):  
Intensive Care ◽  
Moral Distress ◽  
Psychological Impact ◽  
Maslach Burnout Inventory ◽  
Paediatric Intensive Care ◽  
Junior Doctors ◽  
Post Traumatic Stress ◽  
Work Related ◽  
Transport Services ◽  
Distress Scale

ObjectiveTo determine the prevalence of work-related psychological distress in staff working in UK paediatric intensive care units (PICU).DesignOnline (Qualtrics) staff questionnaire, conducted April to May 2018.SettingStaff working in 29 PICUs and 10 PICU transport services were invited to participate.Participants1656 staff completed the survey: 1194 nurses, 270 physicians and 192 others. 234 (14%) respondents were male. Median age was 35 (IQR 28–44).Main outcome measuresThe Moral Distress Scale-Revised (MDS-R) was used to look at moral distress, the abbreviated Maslach Burnout Inventory to examine the depersonalisation and emotional exhaustion domains of burnout, and the Trauma Screening Questionnaire (TSQ) to assess risk of post-traumatic stress disorder (PTSD).Results435/1194 (36%) nurses, 48/270 (18%) physicians and 19/192 (10%) other staff scored above the study threshold for moral distress (≥90 on MDS-R) (χ2 test, p<0.00001). 594/1194 (50%) nurses, 99/270 (37%) physicians and 86/192 (45%) other staff had high burnout scores (χ2 test, p=0.0004). 366/1194 (31%) nurses, 42/270 (16%) physicians and 21/192 (11%) other staff scored at risk for PTSD (χ2 test, p<0.00001). Junior nurses were at highest risk of moral distress and PTSD, and junior doctors of burnout. Larger unit size was associated with higher MDS-R, burnout and TSQ scores.ConclusionsThese results suggest that UK PICU staff are experiencing work-related distress. Further studies are needed to understand causation and to develop strategies for prevention and treatment.

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