Integrating ethics into clinical practice when caring for critically ill patients with serious infectious diseases (IDs) is challenging due to the complexities of the ethical considerations and multitude of populations at risk for IDs. It is imperative for critical nurses to understand the ethical tenets and integrate these ethical considerations into their clinical practice. Additionally, they should be aware of the resources available in their institution to assist with the care of their patients.

Goal: The objective of this study was to better understand how healthcare systems’ unit- and system-level leaders perceive and experience moral distress consultation services, including their utility, efficacy, and sustainability. Methods: A multimethod design was conducted in tandem across two academic medical centers with longstanding and active moral distress consultation services. Moral distress data for healthcare providers participating in moral distress consultation were collected. The authors also conducted interviews about moral distress consultation with unit and organizational leaders using a semistructured interview format. They analyzed interview transcripts using both inductive and deductive coding strategies. Relevant themes and categories were then transferred onto a thematic map for final analysis. Principal Findings: Twenty moral distress consults (10 at each institution) were held during the five-month study period. The mean reported moral distress score for all preconsult participants (n = 52) was 6.9 (SD = 2.5), with scores ranging from 0 to 10. In the combined presurvey and postsurvey group (n = 22), the mean moral distress score was 5.9 (SD = 2.2) prior to the consult and 5.3 (SD = 2.7) after the consult. Participants indicated that moral distress causes were primarily team-level-focused prior to moral distress consultation and system-level-focused after consultation. As consult data were collected, eight unit- and system-level leaders were interviewed. Leaders described moral distress consultation as valuable and empowering to unit-based staff. They endorsed the service’s ability to create safe spaces for open communication about morally distressing events. Leaders also suggested the need for more diverse professional representation (outside of nursing) among consultants and participants, as well as more transparent and consistent education plans related to the service, not only to increase leaders’ knowledge and awareness of moral distress, but also to increase the visibility of the consult service, both within and outside the organization. Finally, leadership teams valued qualitative accounts of morally distressing events from staff. Practical Applications: Addressing moral distress requires intentional and systemic collaboration, including open communication between moral distress consultation leaders, participants, and unit- and system-level leadership teams. Transparent education plans, broad professional representation, and flexible success measures—including both quantitative and qualitative metrics—are necessary and should be considered for any current or developing moral distress consultation services.

Outcomes 1. Identify ethical challenges around developing a GIP transition program in an acute inpatient setting.2. Delineate strategies to mitigate ethical and moral distress around GIP transition programs. Key Message With the everchanging complexity of patient care in the inpatient setting, there is a growing need to address acute inpatient mortality rates as a marker of quality, while not losing sight of quality of patient care. This presentation will identify and discuss ethical challenges faced by provider teams and discuss strategies for mitigating ethical dilemmas and moral distress. Abstract With the everchanging complexity of patient care in the inpatient setting, there is a growing need to address acute inpatient mortality rates as a marker of quality, while not losing sight of quality of patient care. This presentation will identify and discuss ethical challenges faced by provider teams and discuss strategies for mitigating ethical dilemmas and moral distress. Objectives Identify common ethical dilemmas for GIP transitions in the inpatient setting; Discuss sources of moral distress related to GIP within inpatient teams and hospice teams; Delineate approaches to mitigating these concerns. Conclusions The implementation of a successful GIP transition program in the acute inpatient setting requires balance of objectives from administration, regulatory compliance, quality patient care and staff well-being. There are a variety of options for fostering communication and collaboration between stakeholders with differing perspectives to work towards shared mission and outcomes. References 1. Cassel,JB (2020). Update on Hospital Mortality Measures and Their Implications [Power Point slides]. Retrieved from CAPC Webinar presentation. 2. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c09.pdf 3. https://www.nhpco.org/wp-content/uploads/2019/05/Clinical_Guide_GIP_Version.pdf 4. http://www.adldata.org/wp-content/uploads/2015/06/GIP_Tip_GIP_Sheet.pdf 5. Schorr CA, et al. (2020,March-April). The Association of Increasing Hospice Use with Decreasing Hospital Mortality: An Analysis of the National Inpatient Sample. Journal of Healthcare Management, 65(2),107-120. 6. Whitehead, P.B., et. al. (2023). Studying Moral Distress (MD) and Moral Injury (MI) Among Inpatient and Outpatient Healthcare Professionals during the COVID-19 Pandemic. The International Journal of Psychiatry in Medicine.59(4), 469–486. https://doi.org/10.1177/00912174231205660 7. Fantus S, Cole R, Usset TJ, Hawkins LE. Multi-professional perspectives to reduce moral distress: A qualitative investigation. Nursing Ethics. 2024;0(0). doi:10.1177/09697330241230519

This article discusses the definition of moral distress, sources, and some questions staff can consider when dealing with moral distress issues. A fictitious scenario is included for discussion purposes.

• A Moral Distress (MD) Consultation Service is an innovative intervention that identifies morally distressing sources and strategies to mitigate them in health-care organizations. • With the current workforce shortages, it is crucial to identify and mitigate MD to create a moral community and promote staff wellbeing. • Moral distress is common among nurses and needs to be acknowledged and addressed.

Outcomes1. Discuss the implications and barriers of the rules and regulations of the Hospice Certificate of Terminal Illness on timely, equitable access to Hospice.2. Describe how the limits of the Hospice Certificate of Terminal Illness affect goal concordant care for patients, clinician satisfaction, and fragmented care.Key MessageCMS regulations regarding APPs and the Hospice CTI as well as CNS inability to be Hospice Attendings create knowledge gaps for Providers, Hospices and Medicare Administrative Contractors. These barriers impact timely Hospice services for APP's patients often resulting in suboptimal outcomes including unnecessary ER visits, confusion, and delays in care.ContextRegulatory barriers include: inability of APP practice to the full extent of their education and clinical training, increased paperwork, provider dissatisfaction, inequitable and delayed access to hospice services, fragmented suboptimal care, and goal disconcordant care. Despite increasing need for access to hospice, Advanced Practice Providers (APPs) are unable to sign the Hospice Certification of Terminal Illness (CTI). While CMS regulations stipulate hospices should only require the signature of the hospice medical director, or physician member of the Hospice team of a patient with an attending APP, many Hospices continue to require a second MD signature.MethodsThe Home Health Coalition developed The APPs and the Hospice CTI Research Survey. This 15-question, online, Qualtrics, questionnaire assessed issues around the Hospice CTI, patient access, outcomes and provider satisfaction. IRB approval for this survey was obtained through Case Western Reserve University.ResultsThe survey was completed by 478 participants through 12 participating APP organizations. Anecdotal findings were categorized into three themes: Delays in Care, Confusion, and Unnecessary ER Visits.ConclusionRecommendations include: (1) overcoming negative patient outcomes related to restrictive APP practice; (2) increased health care costs; and (3) decreased clinician satisfaction; and (4) continued education and clarification regarding current CMS regulations.KeywordsInterdisciplinary Teamwork / Professionalism / Advocacy / Policy/ Regulations

The clinical nurse specialist (CNS) is 1 of the 4 advanced practice registered nurse roles and a vital component in palliative and hospice nursing care. The CNS is a specialty expert clinician capable of practicing in a variety of health care settings including acute care, primary care, and specialty ambulatory care. The CNS integrates palliative care standards across the 3 spheres of impact (patient, nurse, and system) to improve care patients receive at end of life, mentoring and coaching nurses in the unique aspects of palliative and hospice care (HPC), and serving as a clinical expert for the organization to ensure best practices and quality outcomes. Clinical nurse specialists are trained to diagnose, treat, and prescribe to provide holistic care to their patients. However, challenges exist for the CNS role due to variations in state regulations regarding title protection and scope of practice leading to inconsistency in and misperception of the CNS role. Clinical nurse specialists have a wealth of expertise that can lead to systematic improvement in patient outcomes, advances in hospice and palliative nursing practice, and management of HPC patients and their families. Clinical nurse specialists are a hidden treasure that should be integrated into HPC practice.

Moral distress reflects often recurrent problems within a healthcare environment that impact the quality and safety of patient care. Examples include inadequate staffing, lack of necessary resources, and poor interprofessional teamwork. Recognizing and acting on these issues demonstrates a collaborative and organizational commitment to improve. Moral distress consultation is a health system-wide intervention gaining momentum in the United States. Moral distress consultants assist healthcare providers in identifying and strategizing possible solutions to the patient, team, and systemic barriers behind moral distress. Moral distress consultants offer unique perspectives on the goals, successes, areas for improvement, and sustainability of moral distress consultation. Their ideas can help shape this intervention’s continued growth and improvement. This qualitative descriptive study features 10 semi-structured interviews with moral distress consultants at two institutions with longstanding, active moral distress consultation services. Themes from consultant transcripts included consultant training, understanding the purpose of moral distress consultation, interfacing with leadership teams, defining success, and improving visibility and sustainability of the service. These findings describe the beginnings of a framework that organizations can use to either start or strengthen moral distress consultation services, as well as the first steps in developing an evaluation tool to monitor their utility and quality.

Objective: COVID-19 increased moral distress (MD) and moral injury (MI) among healthcare professionals (HCPs). The purpose of this study was to examine MD and MI among inpatient and outpatient HCPs during March of 2022. The study sought to examine (1) the relationship between MD and MI; (2) the relationship between MD/MI and pandemic-related burnout and resilience; and (3) the degree to which HCPs experienced pandemic-related MD and MI based on background characteristics. Methods: A survey was conducted to measure MD, MI, burnout, resilience, and intent to leave healthcare at two academic medical centers during a 4-week period. A convenience sample of 184 participants (physicians, nurses, residents, respiratory therapists, advanced practice providers) completed the survey. In this mixed-methods approach, researchers analyzed both quantitative and qualitative survey data and triangulated the findings. Results: A moderate association was found between MD and MI (r = .47, P < .001). Regression results indicated that burnout was significantly associated with both MD and MI ( P = .02 and P < .001, respectively), while intent to leave was associated only with MD ( P < .001). Qualitative results yielded eight sources of MD and MI: workload, distrust, lack of teamwork/collaboration, loss of connection, lack of leadership, futile care, outside stressors, and vulnerability. Conclusions: While interrelated conceptually, MD and MI should be viewed as distinct constructs. Many HCPs were significantly impacted by the COVID-19 pandemic, with MD and MI being experienced by those in all HCP categories. Understanding the sources of MD and MI among HCPs could help to improve well-being, work satisfaction, and the quality of patient care.

Over the last several years I have been asked numerous times, “How can clinical nurse specialists (CNS) retain our unique nursing care focused contributions while integrating full practice authority?” After years of practicing as a palliative care CNS, the question proved to be a bit more daunting than I anticipated. Practice is the process of acting in response to a need requiring judgement and independent decision-making within a scope of autonomous authority. All nurses have an autonomous scope of practice with authority for decision-making granted by the registered nurse license. Within that scope, nurses deliver individualized care and comfort contextualized to individual circumstances such as a medical diagnosis, pharmacological and surgical treatment, personal preferences, and ethical principles to name a few. How then is CNS practice distinguished from the practice of nursing in general? Like staff nurses, CNSs are direct care providers. However, unlike the generalist nurse with registered nurse (RN) license, CNSs provide care as advanced practice registered nurses (APRN). APRNs are being granted full practice authority, a regulatory phrase currently used to mean an expanded scope of practice that includes diagnosis and treatment of disease and prescriptive authority. Thus, APRNs have an expanded scope of practice and corresponding expanded authority for decision-making. Like all APRNs, including nurse practitioners (NP), nurse midwives, and nurse anesthetists, CNSs have statutory authority to diagnose disease and pathological conditions, provide pharmacologic interventions, and order durable medical equipment. And like all APRNs, the exact scope of this authority is regulated at the state level and varies somewhat across all 50 states. As a staff nurse, I found clinical care challenging and rewarding. I chose the CNS role to be able to continue as a direct care provider AND to expand my knowledge and skills in improving nursing practice and leading changes in the clinical care delivery environment. I saw opportunities to create new programs for patients and study how these programs improved care delivery in organizations. The CNS role was a perfect fit since it integrates three domains of practice – direct clinical care, educating and mentoring nurses in best practices, and improving care across the system by creating care programs and removing barriers to best practices. Yet the central element of the CNS role is clinical expertise in a specialty area of practice, which keeps me aligned with direct clinical care. How does CNS practice differ from NP practice? The best care outcomes are achieved through interprofessional team-based care where physicians, RNs and APRNs, pharmacists, social workers, chaplains, and others collaborate to meet the total needs of a patient. Palliative care is one specialty where care is heavily dependent on teamwork and having full practice authority, including prescriptive authority, facilitates my CNS practice as an APRN team member. Thus, in palliative care practice, distinctions between CNS and NP as direct care providers may be obscured. Both APRNs provide similar care in the management of patients. For example, both CNS and NP may manage pain and other symptoms by prescribing pharmacologic agents and other nonpharmacological interventions. In the context of team-based care, physicians, pharmacists, and chaplains may also be involved in planning and delivering palliative care with some overlapping care but from the unique lens of their profession. Since CNS practice includes three domains, additional responsibilities arise. For example, recently several nurses shared during daily rounds that families with dying members were refusing basic care and essential symptom management medications. Confronted with refusal of care, the nurses were unsure of how to respond to these grief-stricken families. As the CNS team member, I mentored staff in best practices for communication and created a script for the nurses to use with families. Additionally, I collaborated with the physician and nursing management to devise a strategy to address this reoccurring communication challenge. In team-based care providers work together to achieve patient-centered outcomes. No one provider is “captain”, and no one works in isolation. It is particularly important that the CNS and NP collaborate for best practices in nursing care delivery. For example, should an NP colleague identify a reoccurring problem with the nursing staff delivering clinical care prescribed by a team member, I will take the lead on investigating, identifying the cause, reviewing best practice evidence, and working with the nurses, other stakeholders, and system administrators to devise a plan to resolve the problem for improved nursing practice. While all nurses, including APRNs are educated in using evidence to improve practice, it is the CNS that works most closely with staff nurses and managers to bring evidence-based change to nursing practice. And CNSs address sustainability of change by considering system-level implications, collaborating with organizational leaders and departments to assure success. Many a best practice change breaks down over time for failure to address corresponding system-level changes, such as modifying a pharmacy drug delivery procedure or procuring different supplies. Serving as a change agent is what makes the CNS role really appealing to many young nurses considering graduate school. However, much of a CNSs change related work takes place out of view of staff. The tendency for many elements of CNS practice to be invisible to others is one reason I created and facilitate a system-wide Moral Distress Consult Service. The service, which helps providers identify sources of moral distress and devise mitigation strategies, is available to staff nurses and APRNs, as well as all providers including physicians. CNS practice has been changing slowly as we are achieving full practice authority in many states resulting in a broader scope of autonomous authority. With full practice authority, our collective outcomes in direct care are taking on new dimensions. Our practice is unique among APRNs in that we integrate three domains of practice. In one domain, provider of direct care, CNSs should have access to an expanded scope of practice, including full practice authority with prescriptive privileges. As a result, at times our direct care practice may be the same as other APRN providers; however, it’s the sum of our practice outcomes across all three domains that make the CNS role unique. With the current post-pandemic workforce crisis, there has never been a more crucial time in healthcare for CNSs. Our mentoring, guidance, and clinical care support for specialty populations is needed in all settings, acute, long-term care, and ambulatory care. Our focus on quality and safety, evidence-based practice, and clinical care improvements are imperative. The CNS role and practice will continue to be shaped by external forces and individual employer demands. CNS practice outcomes, individually and collectively, constitute CNSs “unique contributions” and full practice authority only strengthens our options for assuring innovative, cost-effective, clinical care.

Background: Ethics education in medical schools lacks uniformity, yielding uncertainty when providers are faced with ethically complex patients. Without streamlined ethics training, providers are less confident in their ability to provide ethically appropriate care for all patients, particularly for those most ethically vulnerable. This case report seeks to elucidate ethical concerns when treating an ethically complex patient. Subsequently, the need for early ethics education is substantiated. The Case: A 58-year-old unhoused patient with no known medical history presented to the emergency department (ED) for evaluation of an infected foot wound. Imaging confirmed acute gas gangrene osteomyelitis. The patient refused the recommended below-the-knee amputation (BKA) but was amenable to intravenous antibiotic therapy. He was subsequently determined by psychiatry to lack decisional capacity and met the DSM-5 criteria for schizoaffective psychosis. Subsequently, the patient’s brother deferred decision-making to the patient, who he believed should make his own medical decisions. Following an ethics consultation, the brother’s decision, and by proxy the patient’s, was respected. Conclusion: In this case, the patient’s autonomy was prioritized, despite his high level of ethical vulnerability. Ethically conscious treatment was provided despite the implicit stigmatization of homelessness and psychiatric illness. However, an ethics consultation was necessary for this to occur. Ultimately, this paper should serve as a call to action for standardization and prioritization of ethics education during and beyond medical training.

Provide an evidence-based resource to inform ethically sound recommendations regarding end of life nutrition therapy. • Some patients with a reasonable performance status can temporarily benefit from medically administered nutrition and hydration(MANH) at the end of life. • MANH is contraindicated in advanced dementia. • MANH eventually becomes nonbeneficial or harmful in terms of survival, function, and comfort for all patients at end of life. • Shared decision-making is a practice based on relational autonomy, and the ethical gold standard in end of life decisions. A treatment should be offered if there is expectation of benefit, but clinicians are not obligated to offer non-beneficial treatments. A decision to proceed or not should be based on the patient’s values and preferences, a discussion of all potential outcomes, prognosis for given outcomes taking into consideration disease trajectory and functional status, and physician guidance provided in the form of a recommendation.

Dementia is a progressive, incurable condition that causes limitations in life and should be recognized as a life-limiting condition. Health care professionals should understand its trajectory to better manage symptoms and to provide early and ongoing advance care planning. Advanced practice registered nurses are uniquely qualified to work with patients and their families to identify care preferences and then to align treatments to them. Palliative care and hospice are important interventions that should be integrated into the management of patients with dementia. Additionally, early integration of palliative medicine can better manage symptoms and lessen the strain on loved ones.

Dementia is a progressive, incurable condition that causes limitations in life and should be recognized as a life-limiting condition. Health care professionals should understand its trajectory to better manage symptoms and to provide early and ongoing advance care planning. Advanced practice registered nurses are uniquely qualified to work with patients and their families to identify care preferences and then to align treatments to them. Palliative care and hospice are important interventions that should be integrated into the management of patients with dementia. Additionally, early integration of palliative medicine can better manage symptoms and lessen the strain on loved ones.

Conclusion(s).Hospice providers demonstrated high levels of BO and STS during the COVID-19 pandemic as compared to other HCWs.Younger providers were disproportionately affected.Visitation restrictions and other policy changes were reported to have a negative impact on patients, especially for providers who reported high CS in their work.Impact.The pandemic represents a challenge in supporting HCWs and patients in hospice while maintaining a safe environment.We must work together to find solutions that maintain patient safety while not sacrificing patient and provider well-being.