BUSI 506 Week 2 Discussion Board Forum 1 Replies Example

Discussion Board Forum 1 Replies: Moral Distress and Surrogate Decision Making

BUSI 506 Legal and Ethical Issues for Health Professionals, Discussion Board Forum 1 Replies

Thread by [Student Name]

The classmates and their threads are composites; the textbooks, Scripture and the peer-reviewed sources cited are real.

For Forum 1, I chose to reply to two classmates whose threads raised questions my own thread did not fully address: the toll that ethical conflict takes on nurses and the gap between what patients write in advance directives and what happens when someone else must speak for them. Both connect to the observation by Collins (2006) that people feel bound by a moral law, and both raise practical questions for administrators about how organizations either support or undermine that sense of obligation.

Reply to Rachel

Rachel, your thread described emergency nurses who feel they are participating in care they believe is wrong, such as aggressive treatment that only prolongs suffering, and you called this moral distress. I agree, and research suggests it is both common and costly. Your description of nurses continuing aggressive resuscitation they believed was futile, while families watched and physicians hesitated to change course, captured exactly the kind of conflict the literature describes, and your point that these nurses often have no one to talk to afterward deserves particular attention from leaders. Wang and Zhao (2026) synthesized qualitative studies of emergency nurses in three countries and found that moral distress grows from structural causes, such as power imbalances, scarce resources and policies that block ethical action, as well as from bedside conflicts over futile care and unrelieved suffering. Nurses described lingering guilt and shame, sometimes called moral residue, but they also described sources of resilience, including experience, supportive leadership and alignment between their values and their work. Dong et al. (2026) surveyed emergency nurses at seven tertiary hospitals and found that moral distress was strongly associated with burnout, that moral resilience accounted for about a quarter of that association and that moral courage strengthened nurses' resilience. Those findings suggest that leaders can influence the path from distress to burnout. Moral resilience and moral courage are not fixed traits; they grow in environments where staff see that raising a concern leads to a fair hearing and sometimes to a change in care, and they shrink where speaking up is ignored or punished. Birdseye et al. (2026) reviewed interventions for nursing students and found that structured ethics content, simulation and reflective approaches showed promise, though the evidence base remains small. The same approaches could be adapted for practicing nurses, for example through simulated family meetings about goals of care, which give staff practice in voicing concerns before they face a real conflict. Pozgar (2016) reminds administrators that organizations have ethical obligations to their staff as well as to patients, including fair processes for raising concerns. For your department, I would suggest three structural steps: regular ethics debriefings after difficult cases, easy access to ethics consultation when nurses disagree with a plan of care and leadership training on responding to moral concerns without defensiveness. Paul wrote that though our outer self is wasting away, our inner self is being renewed day by day (English Standard Version Bible, 2001/2016, 2 Corinthians 4:16), and organizations can create conditions in which that inner renewal is possible rather than leaving nurses to carry distress alone. Would your department consider a monthly debriefing led by someone outside the unit's chain of command? That separation often makes it easier for staff to speak honestly, and tracking themes from debriefings could show leaders which policies generate the most distress.

Reply to Daniel

Daniel, your thread argued that hospitals must honor advance directives even when families demand more aggressive treatment, and you described a patient whose written wishes were set aside after a family meeting. Evidence suggests your concern is well founded and that the problem may be larger than isolated cases. Your example of a patient whose clearly written refusal of intubation was set aside after a tense family meeting illustrates how quickly documented wishes can lose force when a frightened family and a busy team meet at the bedside. Oh and Song (2026) analyzed more than 1.1 million adult intensive care admissions in South Korea and found that orders about life-sustaining treatment were signed by surrogates more than three times as often as by patients themselves. Among patients who died within 90 days, the odds of invasive end-of-life care were more than twice as high when a surrogate signed the order, and even patients who had completed advance directives received more intensive care once a surrogate signed the final order, a pattern the authors called erosion of advance directives. Wu (2026) offers a reason, finding in an ethnographic study that intensive care surrogates were pushed to the edge of the information network, receiving fragmented, one-way updates that left them unprepared to make decisions faithful to the patient's wishes. Lee et al. (2026) piloted a simple information sheet for surrogates of people with advanced dementia facing decisions about mechanical ventilation and found that it substantially improved surrogates' knowledge, suggesting that modest tools can help. A directive that no one explains to the surrogate is a promise the hospital has not yet kept. The pilot was small, but the approach is inexpensive enough that a hospital could test it on its own units with little risk. Pozgar (2016) explains that surrogates should apply the patient's own known values to the decision in front of them, which means hospitals have a duty to help them understand both the patient's wishes and the medical situation. When that duty is neglected, the hospital also exposes itself to legal risk, since care that contradicts a valid advance directive can give rise to claims of battery or unwanted treatment. Moses set before Israel life and death and urged them to choose life (English Standard Version Bible, 2001/2016, Deuteronomy 30:19), but honoring a person also means respecting the choices that person made about how to face the end of life. For your hospital, regular structured family meetings, early palliative care involvement and written materials that explain the patient's documented wishes could help surrogates carry out their role faithfully and with less guilt. Would your hospital consider reviewing cases in which advance directives were not followed, to learn where communication broke down? A small sample reviewed each quarter by the ethics committee would show whether the problem lies in missing documents, unclear wording or conversations that never happened, and each answer points to a different fix.

References

Birdseye, V., Davis, C., Varagona, L., & Akintomide, M. (2026). Effectiveness of interventions to address moral distress in nursing students: An integrative review. Nursing Ethics, 33(5), 1618-1628. https://doi.org/10.1177/09697330261437260

Collins, F. S. (2006). The language of God: A scientist presents evidence for belief. Free Press.

Dong, Q., Bao, J., Yang, Y., Ma, S., & Huang, F. (2026). The effect of moral distress on emergency nurses' burnout: Mediating role of moral resilience and moderating role of moral courage. Frontiers in Public Health, 14, 1829866. https://doi.org/10.3389/fpubh.2026.1829866

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Lee, B. E., Vranas, K. C., Golden, S. E., Singh, R., Teno, J. M., Rosa, W. E., D'Andria Ursoleo, J., & Sullivan, D. R. (2026). A pilot study of an information sheet intervention to support surrogate decision making about mechanical ventilation in dementia. Journal of Palliative Medicine. Advance online publication. https://doi.org/10.1177/10966218261487645

Oh, T. K., & Song, I.-A. (2026). Patient versus surrogate decision making for life sustaining treatment and terminal care intensity. American Journal of Respiratory and Critical Care Medicine. Advance online publication. https://doi.org/10.1093/ajrccm/aamag276

Pozgar, G. D. (2016). Legal aspects of health care administration (12th ed.). Jones & Bartlett Learning.

Wang, J., & Zhao, X. (2026). Moral distress and demoralization experienced by nurses in emergency departments: A systematic review and meta-synthesis. Nursing Ethics. Advance online publication. https://doi.org/10.1177/09697330261483198

Wu, L. (2026). The dilemma of surrogate decision-making in the intensive care unit: A focused ethnographic study. Nursing Ethics, 33(2), 365-382. https://doi.org/10.1177/09697330251374393