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MORAL Balance

MORAL Balance

Practical Ethical Decisions at the Bedside

Update : We are aware of the significant challenge that COVID 19 is bringing to all aspects of patient care. #

Our ethical framework remains applicable to patient centred decision making especially when there are external constraints. We have created a series of hypothetical COVID 19 case examples. We hope they prove helpful. Key resources for understanding and using the MORAL Balance ethical framework. #

Struggle to make decisions at the bedside? #

Are you ever worried you can’t make the right choices with patients and their families in clinical practise? Do your cinical ethical choices leave you feeling conflicted, or cause controversy or conflict with patients, families and your collegaues?

You’re not alone. Studies show that many clinicians find making ethical decisions difficult, the results often disappointing, and such experiences are a potent cause of stress and burnout. It is not a suprise that many doctors and nurses find this hard, ethical decison making is suprisingly absent from many training programs.

This website is designed with one aim - to help you make better ethcial decisions at the bedside. It will teach you a little ethical theory together with a lot of ethical practice, and give you a framework to help analyse, balance and communicate ethical decisions.

Explore, learn and give it a go in practise. If you find it helpful, drop us a line and let us know. If you don’t, drop us aline and tell us why it’s not working for you and we’ll do our best to improve it.

(We’re developing it as fast as we can - please bear with us and check back soon)

Who are we #

Drs Dan Harvey & Dale Gardiner are Critical Care Consultants at Nottingham University Hospitals NHS Trust, UK. The MORAL Balance framework was developed as part of the National Deceased Donation Simulation Course, run by NHS Blood & Transplant to teach ICM trainee doctors about Organ Donation, but is widely applicable for all clinical ethical decision making.

Credits and Reproduction #

We encourage you to use the resources within this website in your practice and teaching, but ask you to credit this source please. Please reference either this website, or cite Harvey, D. J. R., & Gardiner, D. (2019). `MORAL balance’ decision-making in critical care. BJA Education, 19(3), 68–73. http://doi.org/10.1016/j.bjae.2018.11.006

Recent

Use of PPE for CPR

Updated analysis in light of conflicting advice The Resuscitation Council and Public Health England regarding chest compressions being an aerosol generating procedure.

Moral Balance Analysis 4 - Pregnant Staff

Is it unethical to ask staff at some risk due to health conditions to be patient facing, when their pregnant colleagues who are at no/very little additional risk (on the basis of very limited evidence) are given the choice of being patient facing?
This Moral Balance Analysis was carried out by Nottingham University Hospitals NHS Trust’s Ethics of Clinical Practice Committee on the 8th April 2020.

The full analysis can be downloaded here.

CRITCON Levels - winter flu vs pandemic

CRITCON Levels are based (though for some reason are in reverse order) to DEFCON levels which tells us how close we are to nuclear war.

They have been modified for use by critical care networks in Winter Flu to describe the strain an ICU is under. See London Critical Care Network example.
CRITCON levels for Winter Flu do not work as well in pandemic situations. The difference is that the CRITCON levels for Winter Flu were designed to describe the current number of ICU patients and how they may, or may not be exceeding normal bed capacity. The desired ambition is to get the numbers of patients back within the normal bed state.

New one-page MORAL Balance Framework

We have created a new one-page version of MORAL Balance.

It lacks the Balancing Box - but may allow for quicker use and documentation.

First - be clear about what decision you are trying to make.

Second - identify and Make sure of the facts and Outcomes of Relevance to the Agents (an agent is anyone who cares about or is impacted by the decision).

Third - Level out the arguments. Try and achieve a Balanced decision.