To help understand what moral distress looks like and how to manage and prevent it, the Society of Critical Care Medicine recently hosted the webcast Managing Moral Distress During a Pandemic.
In 1984, moral distress was defined as the psychological distress of being constrained from acting on what is known to be right.
1 The impact of moral distress on healthcare professionals has been in the spotlight as a result of the ongoing COVID-19 pandemic. To help understand what moral distress looks like and how to manage and prevent it, the Society of Critical Care Medicine recently hosted the webcast “
Managing Moral Distress During a Pandemic.”
The webcast was moderated by Joshua Kayser, MD, MPH, MBE, FCCM, professor of clinical medicine and medical ethics at the University of Pennsylvania Perelman School of Medicine and section chief of medical critical care and the medical ICU director at the Corporal Michael J. Crescenz Veterans Affairs Medical Center in Philadelphia. Dr. Kayser moderated a panel comprising these faculty:
- Connie M. Ulrich, PhD, MSN, RN, FAAN, Lillian S. Brunner Endowed Chair in Medical and Surgical Nursing, professor of nursing, and professor of medical ethics and health policy at University of Pennsylvania School of Nursing
- Sarah Hoehn, MD, MBe, director of pediatric supportive care and comfort team and co-director of ethics consultation service at the University of Chicago Comer Children’s Hospital and associate professor of pediatrics at the MacLean Center for Clinical Medical Ethics.
To structure the conversation, Dr. Kayser provided the following three cases for Drs. Ulrich and Hoehn to discuss.
Case 1
A 35-year-old man is admitted with COVID-19 pneumonia and acute respiratory distress syndrome. He has refractory hypoxemic respiratory failure despite optimized ventilator settings, heavy sedation, neuromuscular blocking agents, inhaled nitric oxide, and pronation. Venovenous extracorporeal membrane oxygenation (ECMO) is initiated. Six weeks later he remains ECMO dependent without evidence of lung recovery. He is now in multiorgan failure on numerous vasoactive medications, with progressive renal failure. Multiple healthcare team members have expressed frustration over family requests for continued care. On rounds, one team member remarks, “Why are we doing this to him? There’s no hope of him getting better. This is torture.”
This is a clear example of a situation causing moral distress, Dr. Hoehn explained. She pinpointed a single word—
torture—that is cause for concern. “You feel like you are an active participant in an ongoing injury to the patient and their well-being,” she said of moral distress. “That really gets to people at their core. It goes against when we say, ‘First do no harm.’ The whole concept of moral distress comes from people who feel like they’re violating that.”
Moral distress is exhibited by more than just words. A person may cry, withdraw from a situation, or battle with feelings of powerlessness, exhaustion, shame, or guilt. Some people may confuse moral distress with psychological or emotional distress. While there are some similarities, it is moral distress that often is the catalyst for the other two, Dr. Ulrich said. “There’s a sense that there is an erosion of your self-respect, or your self-esteem, or your sense of your moral values, or your personhood, or a sense of your moral integrity,” she said. “[Moral distress] is different because it’s more damaging to who you are as a person because of the violation of your moral core.”
Dr. Hoehn offered a simple first step for those who feel they may be suffering from moral distress: Change your perspective. If you are focused on how tortuous treatment is for a patient, view the scenario from the patient’s perspective. Consider whether there is anything you as a healthcare professional can do to make the experience less tortuous, such as adjusting the dosage of a pain medication or perhaps something as simple as playing the patient’s favorite music on a speaker in the patient’s room. The act does not need to be grand or heroic—a simple step can go a long way toward how you view the situation, as well as how the patient feels. Ultimately the goal is to empower the people feeling moral distress to act on it.
Case 2
A 76-year-old woman with relapsed refractory multiple myeloma is transferred from the oncology service to the ICU with neutropenic septic shock and acute-on-chronic renal failure. She is volume resuscitated and initiated on broad-spectrum empiric antimicrobial coverage. Two vasoactive medications are initiated for persistent shock. An oncology consultation confirms that no chemotherapeutic options remain for her. Healthcare team members meet with the family to discuss her goals of care. Despite informing the family of her grave prognosis and recommending against cardiopulmonary resuscitation, the family requests that “everything” be done to rescue her. It is suspected that she will require renal replacement therapy in the next 24 hours and her in-hospital predicted mortality exceeds 90%. Three days later, she remains critically ill with refractory shock. Because of the differing opinions about her management, the family becomes suspicious of the healthcare team’s motivations, accusing them of not doing enough and “wanting her to die.” Healthcare team members are avoiding family members and are frustrated by the lack of transition to a comfort-oriented focus of care for the patient.
Dr. Ulrich was quick to point out that avoiding a patient or family member in an attempt to avoid conflict can ultimately create more conflict and lead to a heightened sense of moral distress. While the healthcare professional’s frustration may feel warranted, it is again important to view the situation from others’ perspectives, in this case, the family members.
Dr. Hoehn added that this case demonstrates the power of words, and truly how impactful words can be in tense situations. For example, saying you will do everything you can to help the patient is different from saying you will do everything you can to help the patient without harming the patient. Instead of simply recommending against cardiopulmonary resuscitation, this healthcare team needed to explain why they were making the recommendation and specify how cardiopulmonary resuscitation would cause undue harm to the patient. Empathy for the patient can soften the conflict and reduce the moral distress felt by both the healthcare professional and the family members.
Words can also lead to distrust, for example, when family members talk to team members who are unaware of the most recent patient care instructions. When different team members tell the family different things or use different terminology, family members begin to question whether the care team is cohesive and whether they can be trusted. When healthcare professionals feel like their patients do not trust them, their moral distress increases.
Case 3
It is month 21 of the COVID-19 pandemic. An ICU team member known for his good humor, kind demeanor, and compassionate bedside care has recently started arriving late to work. He is disheveled and seems easily annoyed by routine patient care. He is notably more forgetful than in the past and has developed a short temper when asked questions about patient follow-up. He often complains of being exhausted and seems easily distracted. On more than one occasion, team members have heard him voice frustration over visitation policies, lack of adequate resources, and being “forced to care for unvaccinated critically ill COVID patients.”
Dr. Ulrich explained that this ICU team member has a clear case of moral distress and burnout. More data are needed, but Dr. Ulrich hypothesized that moral distress leads to burnout, and burnout ultimately leads many to leave the profession. In August and September 2021, the American Nurses Foundation conducted a survey of nearly 10,000 nurses from across the United States about their mental health and wellness. Fifty percent of respondents said that they intended to leave or may leave their position within the next six months.
2 “We need to urgently identify institutional strategies that can assist individuals,” Dr. Ulrich said.
Dr. Hoehn pointed out that, while it is great that many health systems offer employee assistance programs, there are often concrete logistic hurdles preventing healthcare professionals from getting the care they need. For example, if a clinician needs to call the program, where can they call from? They can’t do it in the ICU, they can’t take over a patient room, and they certainly can’t make the call in a public lobby. The onus should be on administrators to understand what resources are needed for employees to function, work, and cope with life. “We don’t prioritize mental health in the way we prioritize physical health,” she said. “When [employees] walk out of a hospital today, they’re feeling drained and not necessarily feeling valued. From an administrative and institutional perspective, people really need to think about how to make that person leaving after a horrible 12-hour shift feel valued. What did you do for them today that [makes] them want to come back to work?”
This educational activity was funded in part by a cooperative agreement with the Centers for Disease Control and Prevention (grant number 1 NU50CK000566-01-00). The Centers for Disease Control and Prevention is an agency within the Department of Health and Human Services (HHS). Its contents do not necessarily represent the policy of CDC or HHS, and should not be considered an endorsement by the Federal Government.
References
- Jameton, A. What moral distress in nursing history could suggest about the future of health care. AMA J Ethics. 2017 Jun 1;19(6):617-628.
- American Nurses Foundation. Pulse of the Nation’s Nurses Survey Series: Mental Health and Wellness. Taking the pulse on emotional health, post-traumatic stress, resiliency, and activities for strengthening wellbeing. October 13, 2021. Accessed December 9, 2021. https://www.nursingworld.org/~4aa484/globalassets/docs/ancc/magnet/mh3-written-report-final.pdf
