What the ‘moral distress’ of doctors tells us about eroding trust in health care
The article discusses the ethical dilemmas faced by healthcare providers when families demand life-sustaining treatments for patients unlikely to benefit, highlighting moral distress and trust issues.
Consider a typical case: A 6-month-old child has suffered a severe brain injury following cardiac arrest. A tracheostomy, ventilator and feeding tube are the only treatments keeping him alive. These intensive treatments might prolong the child’s life, but he is unlikely to survive. However, the mother – citing her faith in a miracle – wants to keep the child on life support. The clinical team is distressed – they feel they’re only prolonging the child’s dying process.
Often the question the medical team struggles with is this: Are we obligated to continue life-supporting treatments?
Bioethics, a modern academic field that helps resolve such fraught dilemmas, evolved in its early decades through debates over several landmark cases in the 1970s to the 1990s. The early cases helped establish the right of patients and their families to refuse treatments.
But some of the most ethically challenging cases, in both pediatric and adult medicine, now present the opposite dilemma: Doctors want to stop aggressive treatments, but families insist on continuing them. This situation can often lead to moral distress for doctors – especially at a time when trust in providers is falling.
Consequences of lack of trust
For the family, withdrawing or withholding life-sustaining treatments from a dying loved one, even if doctors advise that the treatment is unlikely to succeed or benefit the patient, can be overwhelming and painful. Studies show that their stress can be at the same level as people who have just survived house fires or similar catastrophes.
In the clinic, mistrust can create an untenable situation. Families can feel isolated, lacking support or expertise they can trust. For clinicians, the situation can lead to burnout, affecting quality and access to care as well as health care costs. According to the National Academy of Medicine, “The opportunity to attend to and ease suffering is the reason why many clinicians enter the healing professions.” When doctors see their patients suffer for avoidable reasons, such as mistrust, they often suffer as well.
At a time of low trust, families can be especially reluctant to take advice to end aggressive treatment, which makes the situation worse for everyone.
Ethics of the dilemma
Physicians are not ethically obligated to provide treatments that are of no benefit to the patient, or may even be harmful, even if the family requests them. But it can often be very difficult to say definitively what treatments are beneficial or harmful, as each of those can be characterized differently based on the goals of treatment. In other words, many critical decisions depend on judgment calls.
Consider again the typical case of the 6-month-old child mentioned above who had suffered severe brain injury and was not expected to survive. The clinicians told the ethics review committee that even if the child were to miraculously survive, he would never be able to communicate or reach any “normal” milestones. The child’s mother, however, insisted on keeping him alive. So, the committee had to recommend continuing life support to respect the parent’s right to decide.
Physicians inform, recommend and engage in shared decision-making with families to help clarify their values and preferences. But if there’s mistrust, the process can quickly break down, resulting in misunderstandings and conflicts about the patient’s best interests and making a difficult situation more distressing. https://www.youtube.com/embed/MY4e4l-eAFk?wmode=transparent&start=0 Moral distress in health care.
Moral distress
When clinicians feel unable to provide what they believe to be the best care for patients, it can result in what bioethicists call “moral distress.” The term was coined in 1984 in nursing ethics to describe the experience of nurses who were forced to provide treatments that they felt were inappropriate. It is now widely invoked in health care.
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Numerous studies have shown that levels of moral distress among clinicians are high, with 58% of pediatric and neonatal intensive care clinicians in a study experiencing significant moral distress. While these studies have identified various sources of moral distress, having to provide aggressive life support despite feeling that it’s not in the patient’s interest is consistently among the most frequent and intense.
Watching a patient suffer feels like a dereliction of duty to many health care workers. But as long as they are appropriately respecting the patient’s right to decide – or a parent’s, in the case of a minor – they are not violating their professional duty, as my colleagues and I argued in a recent paper. Doctors sometimes express their distress as a feeling of guilt, of “having blood on their hands,” but, we argue, they are not guilty of any wrongdoing. In most cases, the distress shows that they’re not indifferent to what the decision may mean for the patient.
But with the right support, we also argued, feelings of moral distress can be an opportunity to reflect on what they can control in the circumstance. It can also be a time to find ways to improve the care doctors provide, including communication and building trust. Institutions can help by strengthening ethics consultation services and providing training and support for managing complex cases.
Difficult and distressing decisions, such as the case of the 6-month-old child, are ubiquitous in health care. Patients, their families and clinicians need to be able to trust each other to sustain high-quality care.
‘I’ll have a coke – no, not Coca-Cola, Sprite.’
Justin Sullivan/Getty ImagesValerie M. Fridland, University of Nevada, Reno
With burgers sizzling and classic rock thumping, many Americans revel in summer cookouts – at least until that wayward cousin asks for a “pop” in soda country, or even worse, a “coke” when they actually want a Sprite.
Few American linguistic debates have bubbled quite as long and effervescently as the one over whether a generic soft drink should be called a soda, pop or coke.
The word you use generally boils down to where you’re from: Midwesterners enjoy a good pop, while soda is tops in the North and far West. Southerners, long the cultural mavericks, don’t bat an eyelash asking for coke – lowercase – before homing in on exactly the type they want: Perhaps a root beer or a Coke, uppercase.
As a linguist who studies American dialects, I’m less interested in this regional divide and far more fascinated by the unexpected history behind how a fizzy “health” drink from the early 1800s spawned the modern soft drink’s many names and iterations.
Bubbles, anyone?
Foods and drinks with wellness benefits might seem like a modern phenomenon, but the urge to create drinks with medicinal properties inspired what might be called a soda revolution in the 1800s.
An 1878 engraving of a soda fountain.Smith Collection/Gado via Getty Images
The process of carbonating water was first discovered in the late 1700s. By the early 1800s, this carbonated water had become popular as a health drink and was often referred to as “soda water.” The word “soda” likely came from “sodium,” since these drinks often contained salts, which were then believed to have healing properties.
Given its alleged curative effects for health issues such as indigestion, pharmacists sold soda water at soda fountains, innovative devices that created carbonated water to be sold by the glass. A chemistry professor, Benjamin Stillman, set up the first such device in a drugstore in New Haven, Connecticut, in 1806. Its eventual success inspired a boom of soda fountains in drugstores and health spas.
By the mid-1800s, pharmacists were creating unique root-, fruit- and herb-infused concoctions, such as sassafras-based root beer, at their soda fountains, often marketing them as cures for everything from fatigue to foul moods.
These flavored, sweetened versions gave rise to the linking of the word “soda” with a sweetened carbonated beverage, as opposed to simple, carbonated water.
Seltzer – today’s popular term for such sparkling water – was around, too. But it was used only for the naturally carbonated mineral water from the German town Nieder-Selters. Unlike Perrier, sourced similarly from a specific spring in France, seltzer made the leap to becoming a generic term for fizzy water.
Many late-19th-century and early 20th-century drugstores contained soda fountains – a nod to the original belief that the sugary, bubbly drink possessed medicinal qualities.Hall of Electrical History Foundation/Corbis via Getty Images
Regional naming patterns
So how did “soda” come to be called so many different things in different places?
It all stems from a mix of economic enterprise and linguistic ingenuity.
The popularity of “soda” in the Northeast likely reflects the soda fountain’s longer history in the region. Since a lot of Americans living in the Northeast migrated to California in the mid-to-late 1800s, the name likely traveled west with them.
As for the Midwestern preference for “pop” – well, the earliest American use of the term to refer to a sparkling beverage appeared in the 1840s in the name of a flavored version called “ginger pop.” Such ginger-flavored pop, though, was around in Britain by 1816, since a Newcastle songbook is where you can first see it used in text. The “pop” seems to be onomatopoeic for the noise made when the cork was released from the bottle before drinking.
A jingle for Faygo touts the company’s ‘red pop.’
Linguists don’t fully know why “pop” became so popular in the Midwest. But one theory links it to a Michigan bottling company, Feigenson Brothers Bottling Works – today known as Faygo Beverages – that used “pop” in the name of the sodas they marketed and sold. Another theory suggests that because bottles were more common in the region, soda drinkers were more likely to hear the “pop” sound than in the Northeast, where soda fountains reigned.
As for using coke generically, the first Coca-Cola was served in 1886 by Dr. John Pemberton, a pharmacist at Jacobs’ Pharmacy in Atlanta and the founder of the company. In the 1900s, the Coca-Cola company tried to stamp out the use of “Coke” for “Coca-Cola.” But that ship had already sailed. Since Coca-Cola originated and was overwhelmingly popular in the South, its generic use grew out of the fact that people almost always asked for “Coke.”
No alcohol means not ‘hard’ but ‘soft.’Nostalgic Collections/eBay
As with Jell-O, Kleenex, Band-Aids and seltzer, it became a generic term.
What’s soft about it?
Speaking of soft drinks, what’s up with that term?
It was originally used to distinguish all nonalcoholic drinks from “hard drinks,” or beverages containing spirits.
Interestingly, the original Coca-Cola formula included wine – resembling a type of alcoholic “health” drink popular overseas, Vin Mariani. But Pemberton went on to develop a “soft” version a few years later to be sold as a medicinal drink.
Due to the growing popularity of soda water concoctions, eventually “soft drink” came to mean only such sweetened carbonated beverages, a linguistic testament to America’s enduring love affair with sugar and bubbles.
With the average American guzzling almost 40 gallons per year, you can call it whatever you what. Just don’t call it healthy.Valerie M. Fridland, Professor of Linguistics, University of Nevada, Reno
This article is republished from The Conversation under a Creative Commons license. Read the original article.
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Each state in the U.S. has its own child abuse laws, and all states, tribes and territories aim to protect children from abuse. But all state laws also allow parents to hit their children if it does not leave an injury or a mark.
A typical example is Oklahoma’s definition of child abuse and neglect. It includes an exception that permits parents to use ordinary force as a means of discipline, including spanking, using an implement like a switch or a paddle. However, leaving evidence of hitting, such as welts, bruises, swelling or lacerations, is illegal and considered child abuse in all states.
Parental spanking of children is considered unique from other physical violence because of the relational context and the purpose. Laws entitle parents to hit their children for the purpose of teaching a lesson or punishing them to improve behavior. Children are the only individuals in society who can be hit by another person and the law does not regard it as assault.
Spanking’s impact on a child is unfortunately similar to abusive hitting. Spanking has been labeled as an “Adverse Childhood Experience,” or ACE. These are events that cause poor health outcomes over the span of one’s life.
The practice of spanking also affects parents. Acceptance of the physical discipline of spanking puts parents at risk for the escalation of physical punishment that leads to abuse.
Parents who spank their child have the potential to abuse them and be caught in a legal and child protection system that aims to protect children from harm. It is unclear what triggers a parent to cross over from discipline into abuse. Research shows that spanking at a young age, such as a 1-year-old, increases the chance of involvement by Child Protective Services by 33%.
Some school districts require permission from parents to allow disciplinary paddling in school, while others do not require any communication. State law does not assure agreement between parents and school districts on what offenses warrant a paddling. Parents may feel they have no alternative but to keep their child in school, or fear reprisal from school administrators. Some students are old enough to denounce the punishment themselves.
In this school district, physical punishment is used only when parents give written permission.
Is spanking considered the same as hitting?
The term spank conceals the concept of hitting and is so commonplace it goes unquestioned, despite the fact that it is a grown adult hitting a person much smaller than them. The concept is further concealed because hitting a child’s bottom hides any injuries that may occur.
Types of hitting that are categorized as spanking have narrowed over the years but still persist. Some parents still use implements such as tree switches, wooden spoons, shoes or paddles to “spank” children, raising the chances for abuse.
Most spanking ends by the age of 12, partly because children this age are able to fight back. When a child turns 18, parental hitting becomes the same as hitting any other adult, a form of domestic violence or assault throughout the U.S.
There is a lack of a consistent understanding of what constitutes a spanking. The definition of spanking is unique to each family. The number of hits, clothed or not, or using an implement, all reflect geographical or familial differences in understanding what a spanking is.
How do US adults view spanking?
People in the United States generally accept spanking as part of raising children: 56% of U.S. adults strongly agree or agree that “… it is sometimes necessary to discipline a child with a good, hard spanking.” This view has been slowly changing since 1986, when 83% of adults agreed with that statement.
The laws worldwide that protect children from being hit usually begin by disallowing nonparental adults to hit children. This is happening in the U.S. too, where 31 states have banned paddling in schools.
At a national level, efforts have been made to end physical punishment in schools. However, 19 states still allow spanking of children in public schools, which was upheld by a 1977 Supreme Court case.
With the slow but steady drop of parents who believe that sometimes children need a good hard spanking, as well as the ban of paddling in schools in 31 states, one could argue that the U.S. is moving toward a reduction in spanking.
What does research say about spanking?
Spanking’s negative influence on children’s behavior has been documented for decades. Spanking seems to work in the moment when it comes to changing or stopping the immediate behavior, but the negative effects are hidden in the short term and occur later in the child’s life. Yet because the spanking seemed to work at the time, the parent doesn’t connect the continued bad behavior of the child to the spanking.
An abundance of research shows that spanking causes increased negative behaviors in childhood. Spanking lowers executive functioning for children, increases dating violence as teenagers and even increases struggles with mental health and substance abuse in adulthood. Spanking does not teach new or healthy behaviors, and is a stress-inducing event for the child and the adult hitting them.
No studies have shown positive long-term benefits from spanking. Because of the long-standing and expansive research findings showing a range of harm from spanking and the increased association with child abuse, the American Psychological Association recommends that parents should never spank their children.
What are some resources for parents?
Consider these questions when choosing a discipline method for your child:
Is the expectation of your child developmentally accurate? One of the most common reasons parents spank is because they are expecting a behavior the child is not developmentally able to execute.
Can the discipline you choose grow with your child? Nearly all spanking ends by age 12, when kids are big enough to fight back. Choose discipline methods you can use over the long term, such as additional chores, apologies, difficult conversations and others that can grow with your child.
Might there be another explanation for your child’s behavior? Difficulty of understanding, fear or miscommunication? Think of your child as a learner and use a growth mindset to help your child learn from their life experiences.
Parents are the leaders of their families. Good leaders show strength in nonthreatening ways, listen to others and explain their decisions. Don’t spoil your kids. But being firm does not have to include hitting.
Is spanking children good for parents?
Doubtful. Parents who hit their kids may be unaware that it influences their frustration in other relationships. Expressing aggression recharges an angry and short-tempered internal battery that transfers into other parts of the adults’ lives.
Practicing calm when with your children will help you be calmer at work and in your other relationships. Listening to and speaking with a child about challenges, even from a very early age, is the best way to make it part of your relationship for the rest of your life.
Choose a method that allows you to grow. Parents matter too.Christina Erickson, Associate Dean in the College of Nursing and Professional Disciplines, University of North Dakota
This article is republished from The Conversation under a Creative Commons license. Read the original article.
(Family Features) Obesity is a lifelong health problem that affects more than 42% of American adults and impacts some ethnic and racial groups more than others. According to the U.S. Centers for Disease Control and Prevention, nearly half (47%) of Hispanic American adults live with obesity, making it one of the most serious health risks for Hispanics.
Obesity has been linked to serious conditions including diabetes, heart disease, cancer and digestive health issues, including gastroesophageal reflux disease and liver disease. Many patients do not make the connection between their weight and the impact on these other health conditions. They are unaware these conditions can be prevented and, in most cases, treated successfully by weight management.
“As a gastroenterologist, patients often come to my office for serious health issues such as liver disease, which they don’t realize is caused by obesity,” said Dr. Andres Acosta, an obesity doctor and gastroenterologist at the Mayo Clinic. “They often don’t know these issues can be prevented or reversed by staying at a healthy weight. This is very important for Hispanic American adults who have higher rates of obesity and liver disease than other ethnicities. Maintaining a healthy weight is an important way to prevent or reverse many conditions before they become severe.”
While some weight-loss programs, services and treatments are covered by insurance plans, many others are not, and without access to affordable, effective treatments, maintaining a healthy weight can be difficult.
There is an urgent need for expanded access to treatment and care, including screening and treatment of obesity from a diverse range of health care providers. This should include coverage of prescription drugs for long-term weight management, behavioral counseling and other prevention and treatment options.
People can act by advocating for changes in state-level policies to expand Medicaid coverage for obesity treatment and care by reaching out to their elected officials.
In addition to advocating for policy changes, consider these important obesity facts:
Poor lifestyle choices alone do not lead to obesity.
Certain health conditions caused by obesity can be reversed by losing weight.
Obesity treatments are available from a variety of health care providers.
You have the power to advocate for and impact the future of obesity treatment.
There are many helpful ways patients can try to manage their weight.
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Valerie M. Fridland, Professor of Linguistics, University of Nevada, Reno
This article is republished from The Conversation under a Creative Commons license. Read the original article.
(Family Features) Obesity is a lifelong health problem that affects more than 42% of American adults and impacts some ethnic and racial groups more than others. According to the U.S. Centers for Disease Control and Prevention, 
