Presentation at the 7^th Annual Conference of the Saudi Critical Care Society held at Burj Rafal Hotel Kempenski in Riyadh on April 21, 2016 by Professor Omar Hasan Kasule Sr. MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Chairman of the Human and Medical Ethics Committee

OVERVIEW

· Describe the theory and principles of medical ethics and how they integrate into clinical practice

· Define professionalism, its dimensions, and its assessment

· Discuss ICU practice from the perspective of the dimensions of professionalism

ETHICS AND PROFESSIONALISM-THE INNER AND OUTER DIMENSIONS

· Ethics and professionalism are closely inter-linked in good patient care but they come from different conceptual backgrounds. Both are difficult to define exactly.

· In my view ethics is the inner dimension while professionalism is the outer dimension. Ethics is difficult to police but some consequences of lack of ethics can be detected

· Professionalism being an outer dimension would have been easy to police if it was easy to define.

· The relation between ethics (right vs wrong) and law (legal vs illegal) is complex and differs between the Islamic and Western perspectives. Is right = legal? Is wrong = illegal? How about exceptional circumstances (dharurat)?

MAQASID AL SHARI’AT AS THE MEDICAL ETHICAL THEORY

· Preservation of morality (hifdh al diin)

· Preservation of life (hifdh al nafs)

· Preservation of progeny (hifdh al nasl)

· Preservation if intellect (hifdh al ‘aql)

· Preservation of resources (hifdh al maal)

PRINCIPLES OF MEDICAL ETHICS: Western perspective

· Principle of autonomy: the patient is the ultimate decision maker in all matters relating to medical care

· Principle of beneficence: all medical activities should aim at accruing benefit for the patient

· Principle of non-malefacence: medical procedures should not cause harm to the patient

· Principle of justice: delivery of medical care should be equitable

PRINCIPLES OF MEDICAL ETHICS (qawa’id al fiqh): Islamic perspective 1

· Principle of intention (qa’idat al qasd): all medical decisions are judged by the underlying intention (al umuur bi maqasidiha)

· Principle of certainty (qa’idat al yaqeen): medical procedures must be based on certainty i.e must be evidence-based

· Principle of hardship (qa’idat al mashaqqat): in case of necessity, normal rules are suspended (al dharuuraat tubiihu al mahdhuuraat)

· Principle of custom (qa’idat al ‘aadat): what is generally accepted as normal practice guidelines must be respected (al ‘aadat muhakkamat)

PRINCIPLES OF MEDICAL ETHICS (qawa’id al fiqh): Islamic perspective 2

· Principle of injury (qa’idat al dharar): the benefits of a procedure must exceed the side effects for it to be carried out

· The principle of injury covers the principles of autonomy, beneficence, and malefacence

· Autonomy = it is only the patient who can best protect his/her interests

· Beneficence = benefit (maslahat)

· Nonmalefacence = harm (mafsadat)

CASE# 1:

ICU night nurses are stressed by having to work for 13 hours because they have to wait for day nurses to take over after the morning huddle and endorsement. Day nurses are stressed by being asked to give topics during the morning huddle. There is stress from CHABI and JCIA. There is daily stress from doctors, patients and their family. Due to these working conditions in ICU nurses are unable to concentrate on patient care due to the stressful environment.

CASE #2:

Physician A called in for consultation assessed the patient and told physician B (the attending physician) that the patient needed ultrasound to rule out acute abdomen. Physician B quoting official hospital policy disagreed insisting that if acute abdomen is suspected general surgeons should be called in. Physician A suddenly started to raise his voice with high tone and shouting in front of the patient with all staff and patients and visitors watching. Physician A then left while physician B was thinking ‘this attitude is affecting me as a health care provider. Shouting and disrespecting me in my work place and I wonder, why he would do such attitude to me’

DEFINITION OF PROFESSIONALISM

· Professionalism is a topical issue in the practice and teaching of medicine. The definition of professionalism varies by place, time, and culture[1]^,[2]

· Professionalism is defined as behaviors and attitudes. A fair level of agreement can be reached by physicians, nurses, and the public on tangible behaviors that constitute professionalism[3]^,
[4].

· Professionalism is part of the social contract involving responsibility of the professional to society[5].

· In earlier times professionalism could be defined as a set of skills but today this is not possible

· It is easier to define professionalism negatively as professional malpractice and negligence.

INTANGIBLES OF PROFESSIONALISM

· Behaviors are easier to observe and measure than are attitudes and other intangibles that are acquired by apprenticeship or experience, but which cannot be described in concrete terms.

· Intangibles that can explain similar reactions by professionals to a situation without having to discuss or refer to a rule or code. The intangibles can almost be called ‘trade secrets’ or practical wisdom (phronosis)[6].

· Intangibles can be considered under the Islamic legal principle of custom, ‘urf, with various formulations such as: what is known as customary has the force of law, al ‘aadat muhakkamat (Majallat Article No 36)[7] and what is known customarily is considered an agreed condition among the practitioners of a profession like trade, al ma’aruf ‘urfan ka al mashroot shartan (Majallat Article No. 43 and 44)[8].

THE AMERICAN BOARD OF INTERNAL MEDICINE (ABIM) listing of 6 dimensions of good professionalism[9]

· Altruism

· Accountability

· EXCELLENCE

· Duty

· Honor and integrity

· RESPECT FOR OTHERS

THE AMERICAN BOARD OF INTERNAL MEDICINE (ABIM) listing of elements that erode professionalism

· Abuse of power and sexual harassment

· Conflicts of interest

· Professional arrogance

· Physician impairment

· Fraud in research.

PROPOSED ISLAMIC FORMULATION OF THE BASIC VALUES OF PROFESSIONALISM

· Faith (iman)

· Consciousness (taqwat)

· BEST CHARACTER (AHSAN AL AKHLAQ),

· EXCELLENT PERFORMANCE (ITQAAN AL ‘AMAL),

· Strife toward perfection (ihsan),

· Responsibility (amanat),

· Self-accountability (muhasabat al nafs).

CAUSES OF STRESS 1: patient care

· Stress leads to job fatigue both physical and mental among all nurses not only those in ICU[10]

· ICU is stressful because of contact with patients in distress and provision of intensive care[11].

· ICU nurses experience moral distress and burnout. Moral distress was not correlated to burn-out[12] indicating they may have different causation. Burnout was correlated to anticipated turnover.

· DNR is a source of moral stress but it did not affect nurse performance. No passive and active change in nurse activities after implementation of the DNR decision[13]

· Physical demand was the most important stressor for nurses[14].

CAUSES OF STRESS 2: staffing

· Staffing relate to patient outcomes[15] [16] and patient safety[17]

· Hour-compliant duty increased resident sleep quality and quantity as well as increased satisfaction[18]

· The implementation of mandatory 24-h, in-house, attending intensivist coverage was associated with earlier decision-making across a number of domains related to end-of-life care. Time from ICU admission to decision to withdraw mechanical ventilation and time to decision to change to do-not-resuscitate code status both were shortened by 2 days[19]

CAUSES OF STRESS 3: shifts

· High-intensity daytime physician staffing in the ICU was not significantly associated with lower mortality in a modern cohort[20].

· Night shift is expected to affect work performance but it was found that Night shift nurses well adapted to night work[21] , despite the high percentage of morning chronotypes, possibly due to their 8-h shift duration. Parental responsibilities may, however, influence shift work tolerance.

CAUSES OF STRESS 4: environment

· Employment and organizational issue contribute to nurse stress in ICU[22]

· The ICU environment (noise and workplace) is stressful

· Difficulty in finding a place to sit down, hectic workplace, disorganized workplace, poor-conditioned equipment, waiting for using a piece of equipment, spending much time seeking for supplies in the central stock, poor quality of medical materials, delay in getting medications, unpredicted problems, disorganized central stock, outpatient surgery, spending much time dealing with family needs, late, inadequate, and useless help from nurse assistants, and ineffective morning rounds[23]

COPING WITH STRESS

· Nurses cope today and leave tomorrow

· Nurses had the resilience to continue working in a stressful environment[24]

· 5-minute Minded fullness meditation before the shift was found useful[25]

· The addition of a dedicated service corridor works in the new unit for improving noise control and staff stress and satisfaction[26].

· Leadership style affects performance: whenever the nursing workload peaked, the determine and persuade styles were used[27]

RESPECT FOR OTHERS / CONFLICTS

· ICU nurses subject to bullying with weak preventive measures[28]

· Inter-professional communication to improve patient outcomes[29]

· Conflicts occur in the in ICU: team-family, intra-tear, and within the family[30] [31] [32]. Some of the team-family conflicts non-rational[33] .

· Nurse involvement in decision making protects against ethical conflicts[34]

· Stress and speed impact the research consent process? Informed consent for research in ICU: is it proper?[35]. Can we have non consensual research[36]. Pre-emptive consent[37]

REFERENCES:

[1] N Z Med J. 2012;125(1358):64-73.

[2] Med Educ. 2012;46(3):257-66.

[3] Acad Med. 2009; 84(5):566-73.

[4] Clin Med. 2010; 10(4):364-9.

[5] Perspect Biol Med. 2011;54(4):455-69.

[6] J Med Philos. 2011;36(2):114-32. Epub 2011 May 16.

[7] Majallat al Ahkaam al Adliyyat Dar Ibn Hazm Beirut 2004 G / 1424H page 90.

[8] Majallat al Ahkaam al Adliyyat Dar Ibn Hazm Beirut 2004 G / 1424H page 91.

[9] American Board of Internal Medicine. Project Professionalism sponsored by the ABIM Committee on Evaluation of Clinical Competence in conjunction with the ABIM Clinical Competence and Communications Programs. Seventh printing Philadelphia 2001.

[10] Wei Sheng Yan Jiu. 2010 Jan;39(1):76-8.

[11] Rev Esc Enferm USP. 2009 Dec;43(4):841-8.

[12] Nurs Ethics. 2015 Feb;22(1):64-76.

[13] Nurs Ethics. 2011 Nov;18(6):802-13.

[14] Health Promot Perspect. 2016 Jan 30;5(4):280-7..

[15] Crit Care Med. 2016 Feb;44(2):e107-8.

[16] Semin Respir Crit Care Med. 2001;22(1):95-100.

[17] Chest. 2009 Apr;135(4):1038-44.

[18] J Grad Med Educ. 2014 Sep;6(3):561-6.