AACN2001_108-111 22/1/09 03:58 PM Page 108

AACN Advanced Critical Care

Volume 20, Number 1, pp.108–111
© 2009, AACN

Ethics
in Critical Care Cynda Hylton Rushton, RN, PhD, FAAN
Department Editor

Ethical Discernment and Action:

The Art of Pause
Cynda Hylton Rushton, RN, PhD, FAAN

D o you ever notice how difficult it becomes when you are embroiled in an
ethical conflict to stop long enough to reflect on your own motivations,
much less the motivations of others? Or how easily we begin to create our own
story about the situation, often projecting meanings and understandings
through our own filters? Sometimes the most difficult thing to do is to create
enough space for something new to emerge. Often we are busy justifying our
own position, searching for the reasons the other person is wrong, and working
hard to manipulate the outcome to the one we desire. Sound familiar? This
dynamic becomes intensified when we are in situations where deeply held values
are at stake, where outcomes are irreversible, and where human beings’ lives
hang in the balance. Creating a space to pause and reflect can be an important
intervention for critical care nursing leaders. Many benefits are described below
for creating a space for a pause.

Exploring Urgency
When an ethical conflict arises, it is often accompanied by heightened emotions,
strained communication and relationships, and a sense of urgency to do some-
thing to relieve the conflict or discomfort. In the space created by a pause, there
is an opportunity to slow down the urgency of the situation. Often urgency is
created in response to one’s own anxiety or fear. Anxiety may be generated in
response to continuing to do things you think are harmful or with marginal
benefit, or the fear that prolonging the dying process will undermine important
values or the feelings of guilt about not being able to “fix” the situation that
arises when treatment options have been exhausted. Being aware of what is insti-
gating the sense of urgency can help name it and begin to ascertain whether it is
real or imagined. Questions that may help illuminate this include the following:
What has happened that has created this sense of urgency? What is different now
compared to yesterday or last week? These questions become essential when an
ethical conflict arises. Slowing down the process can help create an environment
in which mindful and intentional decision making can occur.

Expanding Group Consciousness

If consciousness is the lowest common denominator of any situation (L. Kaiser,
oral communication, 2008), then anything you can do to increase the level of
consciousness of one person will help raise the consciousness of the whole
group. By pausing, you model and invite a greater awareness of ourselves and
the situation that expands the consciousness of the entire group. Consider the

Cynda Hylton Rushton is Associate Professor of Nursing and Medicine, Core Faculty, Berman Institute
of Bioethics, Johns Hopkins University and Children’s Center, Baltimore, MD 21287 (crushton@son
.jhmi.edu).

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impact of pausing to truly listen to a nurse’s
retelling of a conversation with a patient or
family member regarding his or her hopes for
ameliorating cancer and his or her fears about
secondary pain and suffering that accompa-
nies aggressive treatment. Listening to the
meaning underneath the words provides an
opportunity to bring compassionate aware-
ness to the situation and thereby resist the urge
to interpret or intervene unconsciously. The
collective consciousness is expanded merely
with the introduction of a pause to listen and
reflect more deeply.
Validating Assumptions
A pause can also create a space for validating
assumptions. Have you ever noticed how
quickly a team of health care professionals
adopts a particular view of a person or situa-
tion? Sometimes all it takes is someone assert-
ing that “this family doesn’t get it” in the end
of shift report and by the next day this asser-
tion is taken as fact. At times, such statements
arise from a sense of frustration, anger, or
resentment toward the person or situation.
These feelings may influence how stories
about our patients and their situations are
told. Stories—their content, meaning, and
interpretation—are a critical aspect of our
health care culture and an integral method for
making sense of our world.
But sometimes the stories become projec-
tions of our own assumptions, and often these
assumptions are never validated or clarified.
Rather than reinforcing the commonly shared
assumptions, pausing can help shift awareness
and understanding by cultivating spaciousness
and attentional balance. This can reduce the
probability of projections and unverified
assumptions. Questions such as the following
may help clarify assumptions: What assump-
tions am I making about this person or situa-
tion? What evidence is there to support my
assumption? Is there another way to see this
person, his or her behavior, or the situation?
What additional information or input do I
need to see things clearly?
Pattern Recognition
Pausing can also provide a space to see patterns
of thoughts, behaviors, and emotions that were
invisible or unnoticed. Noticing patterns helps
give coherence to situations that are confusing
or ambiguous. Pattern recognition—seeing cases
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as similar or dissimilar—can help determine
how to apply ethical norms and principles.
Similarly, noticing patterns of thought or
behavior can help illuminate blind spots that
may not be obvious. The following questions
may help: What are we missing? What aspects
of this case are we over- or underemphasizing?
Is there a new way to see this patient or the
situation? Are we treating this case differently
than we would other, similar cases? Noticing
the patterns can help cultivate trustworthiness
and confidence in one’s process of ethical
deliberation and action.
Monitoring One’s Stance
Cultivating spaciousness to discover the truth
of the situation is foundational to developing
the ability to act from a place of clarity, neu-
trality, and compassion. Without attentional
balance, it is not possible to perceive things
realistically. In her book Change Your Ques-
tions, Change Your Life, Adams1 proposes a
way to become aware of one’s stance in any
situation. She suggests assessing one’s stance—
as either a “learner” or “judger”—to help
identify opportunities to shift the energy and
perspectives. When we adopt a judger mind-
set, we are operating from our unconscious
reactions where blame and win-lose thinking
predominate. In ethical conflicts, the options
may be framed as patient/family or health care
team as winning or losing or the health
care team “blaming” the family for making
the health care team do things that they believe
are wrong. When we choose to adopt a
stance of neutrality and open-mindedness, we
are able to explore possibilities within the
space that is created by suspending judgment
and focusing on mutually beneficial solutions.
Table 1 includes questions that can help assess
where we are and how we might shift to a new
possibility. These principles are particularly
useful when ethical conflicts arise.
Facilitating Reflection and Inquiry
Another benefit of pausing is that it offers an
opportunity for deeper inquiry and under-
standing. Adams1 suggests that the best
answers come from great questions. Questions
help expand our thinking, connect us with
each other, and challenge our assumptions and
viewpoints. Do you ever notice the shift when
someone asks questions rather than asserting a
position or viewpoint? Questions help us
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RUSHTON AACN Advanced Critical Care

Table 1: Learner-Judger Questionsa

pause is needed. This can be developed by
calming the mind, emotions, and spirit. Prac-
tices of mindful awareness can help train our
Judger Learner
minds to be open to the things around us—to
What’s wrong? What works? increase our capacity to notice. It is in the
space between the words that an opportunity
Who’s to blame? What am I responsible
for?
to reflect and to see what may not be obvious
or clear is created. In the midst of ethical
How can I prove What are the facts? conflict it can be particularly difficult to create
I’m right? space to get enough spaciousness in the
How can I protect What’s the big picture? situation to allow new awareness to emerge.
my turf? Here are some tips for creating more spa-
ciousness when ethical dilemmas arise:
How can I be in What are my choices?
control?
• Breathe: Simply focusing on the in-breath
How can I lose? What’s useful about and the out-breath for several moments can
this? help calm the nervous system and mind.
How could I get hurt? What can I learn? Give your full attention to your breathing.
Feel the air as it enters your nose and lungs
Why is that person so What is the other and as you gently inhale and exhale. Notice
clueless and person feeling or your thoughts and feelings as you do this.
frustrating? wanting?
Try expanding the out-breath by fully emp-
Why bother? What’s possible? tying the lungs for several breaths to notice
the difference in your response. Several deep
a 1(p49)
Used with permission from Adams. breaths before moving into a difficult situa-
tion can help focus awareness and neutralize
emotions.
move beyond positions, solutions, and opin- • Create a pause: Create a space for reflection,
ions to exploration. inquiry, and understanding. Slowing down
the cadence of the conversation, sitting in
Engaging New Possibilities silence for a moment, and not reacting to
When we pause, we create a possibility for emotionally charged energy can help shift
something new to emerge. Frequently, when the energy of situation toward spaciousness.
ethics consults are requested, it is because nei- Taking a “time out” to reassess the situa-
ther party is able to see new possibilities—the tion, create a moratorium on further action,
same stories are being retold over and over or agree on a time-limited trial of therapy
again while each party expects different with clear end points for reevaluation can
results. Pausing to explore other ethical posi- cultivate more space for new insights and
tions or viewpoints can help release the con- possibilities.
stricted energy associated with intractable • Be transparent: Acknowledging your own
conflict and inertia. More spaciousness is cre- biases and places of confusion, ambiguity, or
ated by letting go of our own position, our ambivalence can help create more room for
attachment to a particular outcome or goal, exploration. The following questions can be
and inviting other persons to do the same. used: What do you know? How do you
Being willing to be humbly engaged in discov- know it? What is unclear or ambiguous?
ering an alternative truth is facilitated by Where are you struggling to make sense of
intentionally pausing to foster new align- the situation?
ments, understanding, and possibilities. • Check in with your own mindset (Learner/
judger): Notice what stance you and others
Developing Skills in Pausing are assuming within the ethical conflict. If
How do we develop the capacity to pause long you notice that you are in a mindset of
enough to really notice what is going on? One judger, engage strategies to reframe the situ-
place to begin is with cultivating a self-aware- ation to invite greater dialogue, inquiry, and
ness that helps you notice an occasion where a understanding. Intentionally choose your

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words and actions to open the door to
engagement rather than alienation.
• Monitor your own responses: Intense emo-
tional responses such as anger, resentment,
despair, or feelings of self-righteous indigna-
tion, arrogance, or defensiveness can be trig-
gers for deeper exploration, particularly
when deep ethical conflicts arise. What is
the origin of these responses? What is being
triggered in you? Are you reacting or
responding? If you are reacting to something
in the situation, it is likely that you will
engage the negative energy of others. Alter-
natively, if you can maintain a place of open-
ness and inquiry, you can engage the
openness and good will of others.
• Ask questions: Questions help shift the
dynamic of the situation by taking the con-
versation away from win/lose to a process of
inquiry. Asking questions creates an oppor-
tunity for listening and exploring and can
help clarify places of congruence, diversity,
confusion, or clarity.
• Get clarification: When ethical conflicts
occur, check out the validity of your
assumptions. Avoid acting from a place of
projecting your own values or mindsets onto
others. Good decisions are based on good
facts; make sure that there is a firm founda-
tion for decision making.
• Be open to new possibilities: When we cre-
ate spaciousness, it is possible to see things
differently. Intentionally cultivating a space
for being changed by the situation or learn-
ing something new fosters connection and
understanding.
• Let go of outcomes: When we are attached
to a particular outcome or process that we
judge as right or wrong, we limit possibili-
ties. Attachment often breeds constriction in
ourselves and others. For example, when we
decide that the only ethically appropriate
outcome is the discontinuation of life-
sustaining therapies, it closes off our willing-
ness to consider information or options that
may be relevant to an alternative view.
Allowing ourselves to let go of things that
we have no control over, such as the mystery
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ETHICAL DISCERNMENT AND ACTION
of life and death, the behaviors and deci-
sions of others, the course of disease, or
injury can create more space for explo-
ration. This is particularly true when ethical
conflicts arise.
• Become a witness rather than an actor:
Adopt the stance of a witness rather than
that of an actor. Being a witness to the situa-
tion of the other and ourselves releases
energy to explore other possibilities. The wit-
ness assumes the place of deep listening and
understanding. Such a stance requires relin-
quishing control over oneself, others, and the
situation. Bearing witness allows one to be
with oneself in the presence of another. Wit-
nessing rather than fixing releases energy to
support everyone involved to discover the
most ethically justifiable response.
Conclusion
Cultivating the art of pause allows everyone
involved in a conflict situation to mindfully
consider the right and good thing to do. If
we are embroiled in our positions and con-
flicts in a way that constrains our conscious-
ness, we make decisions from a place of
contracted energy rather than expansive
wisdom. Be the instigator of pausing and be
ready for at least temporary resistance—like
most things we resist, it will eventually dissi-
pate. Stay the course and help facilitate a
foundation for ethical decision making in
which consciousness and insight determine
right action rather than reactive uncon-
sciousness. With increasing stability of mind
we create a nonreactive attentional balance
that allows us to see things as they really
are.
Acknowledgments
Deep gratitude is expressed to Roshi, Joan
Halifax, PhD, Leland Kaiser, PhD, and
Marilee Adams, PhD, for their mentorship
and profound wisdom.
Reference
1. Adams M. Change Your Questions, Change Your Life.
San Francisco, CA: Berrett-Koehler Publishers; 2004.
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