MORAL DISTRESS

L A U R A G U I D RY- G R I M E S , P H D
A S S I S TA N T P R O F E S S O R O F M E D I C A L H U M A N I T I E S & B I O E T H I C S
CLINICAL ETHICIST
DISTRESS
CONCEPTS
ACTIVIT Y
S P L I T I N TO G R O U P S O F 2
WHAT IS MORAL DISTRESS?
When you judge what ought to be done (morally) in a
situation, but you are constrained from acting on that
judgment.

• Moral distress…
– Leads to moral residue – the remaining “ick” of possible
complicity in moral badness, feeling compromised as an agent.
– Involves perceived or actual powerlessness.
– Threatens moral integrity – “the sense of wholeness and self-
worth that comes from having clearly defined values that are
congruent with one’s actions and perceptions” (Epstein & Delgado,
“Understanding and Addressing Moral Distress”).
CONSTRAINTS ON THE MORAL AGENT
• Role obligations and competence (e.g., resident, not attending)

• Laws, policies, codes

• Power hierarchy

• Realities of time

• Limited resources, staff

• LOS pressures
MORAL DISTRESS VS. EMOTIONAL DISTRESS
• An adolescent dies suddenly
after you have cared for him
during years of hospitalizations.
• An elderly patient with
dementia pleads with you to
protect her from any more
testing.
• After a new attending comes on
service, he changes a mutually
agreed-on plan of care,
disregarding hours of discussion.
• You have bonded with a
patient who has to be
transferred to another facility
in another state.
• A family threatens a lawsuit if
any LSTs are withdrawn,
despite what the team
believes is in the patient’s
interests.
• In an emergent situation, a
spouse refuses life-saving
blood products for a patient.
MORAL VS. EMOTIONAL :
WHY DOES THIS MATTER?
• So we can accurately communicate our distress:
– Is this really about doing/not doing the right thing? Or am I upset
for other reasons?
– What do I need to say to my supervisor or the ethics team?
• So we can adequately address our distress:
– Does this situation call for bereavement support, counseling, or
other professional support? (emotional distress)
– Do we need help clarifying moral values, resolving moral tensions,
or otherwise morally framing this tough situation? (moral distress)
SOURCES OF MORAL DISTRESS
Case-level
• abusivept/family
• demands for inappropriate tx
• poor communication
• misunderstanding of EOL options
Unit-level
• hostileclimate
• high turnover
• rescue mentality
• not enough staff
Institution-level
• lackof safe reporting
mechanisms
• unclear or problematic policies
• insufficient training
CRESCENDO EFFECT
• Repeated moral distress  build up of moral residue
– Insufficient preventive ethics? Unclear or inadequate resolutions?
– Nature of complex and messy healthcare system

“This again?!”

“Moral Distress, Moral Residue, and the Crescendo Effect” by Epstein & Hamric. Journal of Clinical Ethics (2009)
RED FL AGS
ACTIVIT Y
S P L I T I N TO S M A L L G R O U P S
SNAPSHOT OF THE PROBLEM
EFFECTS
Alienation

Physical and
Job psychological
dissatisfaction effects

Burnout
Compromised
patient care

Moral
insensitivity
COPING WITH AND PREVENTING
MORAL DISTRESS
• AACN Guide:
– ASK: Become aware when MD is present.
– AFFIRM: Make a commitment to address MD.
– ASSESS: Identify sources of MD and make action plan.
– ACT: Implement strategies to preserve integrity.

• “Participating in informal or formal ethics consultations is a

purposeful action that fosters the exercise of individual
moral agency” (Wocial, “Moral Distress – The Role of Ethics Consultation in the
NICU”).
The 4 A’s to Rise above Moral Distress by AACN Ethics Work Group (2004)
 AN IMPORTANT NOTE
Doing right by our patients, their loved
ones, and each other should be made
as easy as possible by your institution.
• For the healthcare institution to consider:
– What moral problems arise within these walls?
– How can this institution facilitate doing the right thing
without overly burdening our providers and staff?
• “[E]xercising courage is not sufficient to address moral distress
in dysfunctional systems and certainly should not be seen as a
‘magic bullet’ to eliminate moral distress”
(Hamric, Arras, and Mohrmann, “Must We Be Courageous?”).
MRS. S
C A S E TO K I C K O F F D I S C U S S I O N
THE SITUATION
Medical Summary
• 65 yo woman
• PMH: stage D/class III CHF, chronic
hypotension, DM
• Admitted for heart palpitations and
pain – claims husband turned off her
milrinone pump in her sleep
• Deemed ineligible for LVAD due to
her social situation
• Will die soon without the LVAD
(stable for discharge)
• Capacitated but has some cognitive
deficits
The Challenge
• Pt says her husband (at hospital with
her) has been emotionally abusive
throughout their 40 years of
marriage, says he likes seeing her ill
• Per cardiologist, pt is being “double
victimized” – interprofessional
disagreement on how to respond
• Has 7 children and a sister, but non
one is willing to take her home or
help with her care
• Dispo tricky due to being on 2
inotropes + reaching EOL + pt’s
feeling unsafe at home
THE MORAL DISTRESS OF IT

• Who is expected to experience moral distress?

• What are the sources and contributing factors of

MD?

• What are ways to handle or cope with MD in this

case?
THANK YOU!
L G U I D RY G R I M E S @ U A M S . E D U