Thursday, June 17, 2010

Working Through Moral Distress

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By Julie Childers, MD
Originally posted at the Institute to Enhance Palliative Care, University of Pittsburgh Medical Center
Vol 10, No. 6 - June 2010

Case: Mrs. L was a 95 year old woman who was admitted to the acute care hospital from her nursing home with decreased mental status. She was found to have pneumonia, and though her infection improved with antibiotics, her mental status did not recover and she continued to be only slightly responsive to her family, unable to eat or interact On the sixth day of Mrs. L’s hospitalization, palliative medicine was consulted to help the family with decision-making. By the time the palliative care consultant saw the patient, a temporary feeding tube had been placed, and the family had reached consensus on a trial of artificial feeding to give her a chance to regain strength, though they acknowledged that her prognosis was poor.

The next day, the patient was still unable to communicate, but was moaning and grimacing. She repeatedly tried to cough weakly to clear the copious secretions in her upper airway. The palliative care consultant recommended low doses of intravenous morphine to treat pain and shortness of breath, with a medication to clear secretions. However, Mrs. L’s attending physician was concerned that treating pain with opioids would cause respiratory depression and lead to Mrs. L’s death. The next night, the bedside nurse charted several times that Mrs. L was screaming, but they were only able to give her Tylenol for pain; she required wrist restraints to prevent her from pulling out her feeding tube. The palliative care physician was haunted by the image of the dying 95 year old woman, tied down and denied treatment for her suffering.

Discussion: Moral distress occurs when the clinician knows the appropriate action to take, but is unable to carry it out, and feels forced to give care contrary to her values. It is more often described in the nursing literature, but is beginning to come to the awareness of physicians as well. Moral distress often occurs in end-of-life situations when the decision is made to provide aggressive life-sustaining treatments that are felt to put excessive burden on patients and families.

Clinicians who see patients at the end of life may be particularly vulnerable to moral distress. For those of us who serve as consultants, our involvement in a case is at the discretion of the attending physician. In cases such as Mrs. L’s, we feel constrained by our role as advisors to the consulting physicians and the expectation of professional courtesy towards other physicians’ decisions. When we serve as attending physicians ourselves, our ability to relieve patient suffering may be limited by the family’s preference that every possible life-sustaining measure be taken.

Moral distress is also a common problem in the nursing field, particularly critical care nursing. For clinicians in any of these roles, moral distress arises when the system or other people interfere with our ability to relieve a dying patient’s suffering.
In the nursing literature, moral distress has been shown to contribute to decreased job satisfaction and to burnout. The American Academy of Critical Care Nurses recommends addressing moral distress with a four-step process:
  • Ask: You may not even be aware that you are suffering from moral distress. Signs of moral distress may include physical illnesses, poor sleep, and fatigue; addictive behaviors; disconnection with family or community; and either over-involvement or disengagement from patients and families.
  • Affirm: Validate the distress by discussing these feelings and perceptions with others. Make a commitment to caring for yourself by addressing moral distress.
  • Assess: Identify sources of your distress, and rate its severity. Determine your readiness to act, and what impact your action would have on professional relationships, patients, and families.
  • Act: Identify appropriate sources of support, reduce the risks of taking action when possible, and maximize your strengths. Then you may decide to act to address a specific source of distress in your work environment.

In Mrs. L’s case, the consultant discussed the case with the interdisciplinary team, receiving support for her concerns. Despite fear of negative repercussions from the primary service, she called the patient’s son herself and gently explained the signs of suffering that Mrs. L was showing. He agreed that his mother should have low-dose morphine. The primary team added this order without any expressed objections to the consultant stepping over her boundaries. Mrs. L died a few days later.

1. Weissman, D. Moral distress in palliative care. Journal of Palliative Medicine. October 2009, 12(10): 865-866.

2. The American Association of Critical Care Nurses. The 4 A’s for managing moral distress. (free pdf)

6 Responses to “Working Through Moral Distress”

CyndiC, RN said...
June 18, 2010 at 1:38 PM

This is a "hot topic" in nursing!
Imagine the nurse who was listening all night to the patient screaming and had no power to do anything beyond non-medication interventions?

This is when nurses need to use all the non-medicine "tricks" they have learned--but this is woefully inadequate when what the patient needs is analgesics that the nurse can not order...

This is just another reason to encourage and promote "family presence". If family member(s) had been there to hear the patient's misery--you know they would have asked for more aggressive pain management.

Thank you for helping nurses realize that you are agonizing over this also.
We have a tendency to feel that disembodied physician voice on the phone just rolls over and goes back to sweet sleep...maybe the MD who refused to help the patient--but not everyone...

Christian Sinclair said...
June 18, 2010 at 1:42 PM

I think too often health care providers do not talk about or recognize the moral distress that exists in the other disciplines around them. We need to have a much more free environment to discuss the actions (or inaction) that is the root cause of moral distress. Great comment Cyndi.

ShredaNP said...
October 21, 2010 at 8:52 AM

What a profound yet typical case for us in PC.

The situation described is very similar to one that still haunts me from just last month. To see a pt in 4-point restraints, in severe pain, tied down, on a vent and moaning in the middle of a busy ICU where no one is even acknowledging the horrific situation, is unbelievable to me but it happened. It all seemed so surreal in the moment and I was stunned to find that the primary team had given the patient a "drug holiday" in order to wean him from the vent and it had been 14 hours since the last small dose of pain meds but no one thought to restart the opiates despite a hole the size of my hand in his leg, profound fluid overload from CHF and liver failure. The poor man was awake, aware and in such pain that my heart shattered into a million little pieces, all over the ICU floor. No one noticed as I froze, just taking in the scene. Nurses and aides talked about their weekend, their off-time, their boyfriends, anything but what was in front of them. Their laughter spilled out through the room but was not loud enough to mask the moaning, nor did it detract from the terror in the man's eyes.

Where is the humanity, the compassion, the gentleness that we all deserve when we are ill and in pain? That day was a Saturday, it was late and I has been in a hurry until I came upon the scene and all that I could do was stop and watch. I can still feel the despair and the horror as I remember it. I shudder to think of what would have happened to the man had I not taken the time that day to see him, or worse, all the patients that we don't get to see who are in the same situation. It's heart-wrenching and I don't understand why others can't see the horror in that scene or why it is even acceptable to anyone, much less everyone in the ICU that day- the residents, the nurses, the attendings. Unbelievable....

caring rn said...
March 13, 2011 at 9:44 PM

I'm guessing the family was not available? I would have caused quite a scene, I believe. I would have called an ethics team person, or hospital attorney, or chief of ICU. There is a tendency to become desensitized to pain and suffering if the whole group is doing the same. These images prevent us from being happy with our work, and sleeping well at night. I have been professional, but outspoken all my nursing life. I'm 68 and still working as a nurse....teaching others to stand up for what is right and have no fear. Have I been "called into the office"? Oh yea. Too bad. Have I reported a neurosurgeon who cursed me out for calling on behalf of his patient? Oh yea. Did I report him? Oh yea. Don't be afraid. We are the patients' advocates...even when others forget that they are, also.

Vcarreiro said...
January 17, 2013 at 5:20 PM

Please, all you on the care team -- Call the Board Certified Chaplain for your patient.  Of all the members on the interdisciplinary care team, in palliative care, intensive care and all the medical/surgical units, the chaplain is the one health care clinician who has specialized in spiritual care and that includes addressing issues of moral distress.   We help other team members as well as patients and families, by sorting out feelings and perspectives, by searching for meaning and values, and by a well-practiced listening presence.

Christian Sinclair said...
January 17, 2013 at 10:52 PM

Excellent point. The Chaplain plays a key role in challenging situations like this. And Board Certification is a helpful reminder of the professional nature of this support. It is not just as simple as being a nice listener.