When you just can’t fix it: Moral distress in health care

For the third time this week, you’ve been assigned to the ICU where Harold is on day 386 of mechanical ventilation. A young man, the father of four children, with a career as a financial planner ahead of him, Harold suffered a catastrophic brain injury during surgery for a chronic disease. After long months of ICU visits and unanswered prayers at the bedside, his family rarely visits him. Nonetheless, Harold’s mother remains steadfast to her promise to fulfill his wish that everything possible be done to save his life. Harold’s emaciated body lies in the bed contracted into a fetal position, his eyes staring blankly straight ahead of him. Some health care workers (HCW) enter his room and silently execute their tasks. Others address him by name and offer snippets of news or procedural explanations when they touch him. Nothing changes the focus of his gaze.

Harold’s caregivers are frustrated by the apparent futility of his care. The team feels that they are causing harm as the ventilator forces air into his lungs, and HCWs suction his secretions, puncture his body for lab samples, and clean his bodily wastes. They perceive that they are prolonging his death, not saving his life, and that he is consuming ICU resources that might save another patient’s life. It feels ethically and morally wrong, and the team feels powerless to change it.

Harold’s situation is just one example of those in health care that gives rise to moral distress (MD) among HCWs. Introduced in 1984 by Andrew Jameton, MD in the clinical setting is composed of two key components: 1) the perception of HCWs ¬that they know the ethically appropriate action to take in a clinical situation and, 2) a sense of powerlessness to execute that moral action. Health care settings are replete with examples of such situations (Jameton 1984). The use of life sustaining technologies at the end of life present an array of value differences and conflicts.

MD is contextual, affective, and unique to the individual. Several authors have “tweaked” Jameton’ s definition to clarify the concept. MD is “the psychological disequilibrium and negative feeling state experienced when a person makes a moral decision but does not follow through” (Wilkinson, Moral distress in nursing practice: experience and effect 1987/1988), or “the painful psychological disequilibrium that results from recognizing the ethically appropriate action, yet not taking it…” (Corley, Elswick, et al., Development and evaluation of a moral distress scale 2001), or “the feelings and experiences which result from a moral conflict where one knows the correct action to take but constraints lead to either inability to implement this action or an attempt to carry out moral action which fails to resolve the conflict” (Gutierrez, Critical Care Nurses' Perceptions of and Responses to Moral Distress 2005). The slight differences in each definition underscore the complexities of ethical conflicts in the clinical environment.

Some authors have found the current definitions of MD inadequate to describe the experience of the nurses and pharmacists at a hospital clinic who experience resource-driven moral dilemmas. In these situations, HCW often cope with the problems by breaking the rules. For example, nurses facing a shortage of hospital beds at a clinic placed patient beds in hallways and lavatories in violation of regulations. Pharmacists unable to dispense necessary medications to indigent patients with a critical need dispensed their medications regardless of ability to pay. They were forced to choose between two “right” actions: “meet the patient’s needs” or “comply with legal regulations.” Their MD was not a result of inability or failure to do what was “right,” but of having to choose which action was the “right” thing in this situation (Kälvemark, et al. 2004).

Since ethical actions are contextual, it is important to recognize that equally ethical individuals may disagree about what is morally and ethically correct. (Berlinger 2009) HCWs experience MD because they perceive that they know the right thing to do and are powerless to do it. To perceive that one knows a thing is not the same as to know it. There may be important personal, spiritual, and/or cultural factors affecting the patient and family of which the HCW is unaware. A discussion of the ethical issues, perhaps facilitated by an ethics consultant or the ethics committee, allows all voices to be heard and promotes collaboration among the affected parties. In that setting, the position of moral certitude giving rise to MD may evolve to one of moral reflection, with enhanced understanding of the values and differences each party brings to the table (Baxter 2012).

Beyond clinical factors, MD may also be rooted in: policies and procedures, laws and regulations, the demands and wishes of patients and families, the structure of the health care hierarchy, and such internal factors as inexperience, anxiety, and self-doubt. Laws, policies, and regulations may prevent HCWs from providing the resources they believe the patient needs. Hierarchical structures may inhibit effective communication, making it more difficult to resolve conflicting perspectives on the priorities of care. Decision makers may fail to include all affected clinicians in decision making. When patient or family wishes conflict with the advice of the health care team, providers may be constrained from taking the action they consider to be best for the patient. Individuals new to their profession may lack confidence in their knowledge. Even experienced HCWs may feel intimidated by others and fear retribution or humiliation. HCWs who have experienced repeated MD may feel hopeless and become apathetic when faced with a new morally challenging situation (Corley, et al. 2001; Hamric, Borchers and Epstein 2012; Wilkinson 1987/1988).

Experiences in which individuals feel their values to have been seriously compromised can be so painful that they “sear the heart” (Webster and Baylis 2000). Time may soften the acute impact of such pain, but with each experience, the residual level of distress increases, resulting in a higher baseline level of MD termed “moral residue” (Webster and Baylis 2000). The acute distress fades over time, but the residual builds to greater levels with each subsequent experience in a crescendo / decrescendo pattern. With increasing levels of moral residue, the HCW progresses from acute symptoms of MD (anger, frustration, insomnia, headaches, etc.) to more serious consequences. Two especially serious consequences are: 1) becoming inured to and apathetic about ethically challenging situations and, 2) burnout, sometimes severe enough that the individual chooses to leave health care as a profession.

There is a well documented inverse relationship between levels of MD among clinical staff and their perception of the workplace ethical climate. In an ethical work environment, employees feel valued and respected, well informed about and included in the activities that affect them in the workplace, and feel free to speak openly about work issues to increase understanding and move toward resolution of disagreements (Olson 1998). The same factors mitigate or prevent MD.

The American Association of Critical Care Nurses has published The 4A’s to Rise Above MD (Nurses 2004) a guide to address the problem before it becomes a serious threat to employees’ emotional and physical health. The 4As are: 1) ASK: are members of the team showing signs / symptoms of MD? 2) AFFIRM: validate feelings with co-workers; commit to addressing MD 3) ASSESS: identify the source of the MD and 4) ACT: make and implement an action plan.

Additionally, it is important to explore the diverse points of view, values, and spiritual or cultural influences on the ethical opinions of others, being mindful of the moral complexities at issue. The consensus of Harold’s health care team was that it was “wrong” to continue his care in the ICU. His mother made her decisions in accordance with her understanding of her son’s wishes. Reconciliation of their polar positions took place over a long time period, and only with concerted efforts at respectful discourse between the two sides.

References

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