The Many Faces Of Moral Distress:
Maintaining Professionalism Among The IDT Cynda H Rushton , PhD, RN, FAAN • Suzana Makowski, MD, MMM, FACP, FAAHPM
Overview
What is moral distress?
Delving into dissonance: lessons from the humanities
Contemplation and resilience: practical tools
Gratitude…
Joan Halifax Roshi
Tony Back, MD
Susan Bauer-Wu, PhD, RN, FAAN
Gary Pasternak, MD
Barbara Dossey, PhD, RN, FAAN
Alisa Carse, PhD.
Jon Kabat-Zinn, PhD.
Christina Puchalski, MD
Warren Reich, STD
Saki Santorelli, EdD
Monica Sharma, MD
What brings you to this work?Silent reflection
On Professionalism
altruism, accountability, excellence, duty, service,
honor, integrity and respect for others
8 elements of professionalism (from ABIM):
What gets in the way of Professionalism?
Moral distress: definitions
“Moral distress is the pain or anguish affecting the mind, body or relationships in response to a situation in which the person is
aware of a moral problem,
acknowledges moral responsibility,
and makes a moral judgment about the correct action;
yet, as a result of real or perceived constraints, participates in perceived moral wrongdoing” (ANA, 2002).
Moral distress: definitions
Moral distress is the psychological disequilibrium that occurs when a person believes he or she knows the right course of action to take, but cannot carry out that action because of some obstacle, such as institutional constraints or lack of power.
"At times, I have acted against my conscience in providing treatment to children in my care.”
54% of house officers 48% of critical care nurses 38% of critical care attending
physicians
38% of hematology/oncology nurses 25% of hematology/oncology
attending physicians
Mildred Z, Solomon et al. New and Lingering Controversies in Pediatric End of Life Care, Pediatrics, Oct 2005; 116: 872 - 883.
Personal reflections
Columbine Lake, San Juan Mountains, CO – Jack Brauer Photographer - www.widerange.org/photo/columbine-lake-reflection/
Find a partnerShare your story – • what was at stake for you? • what supported you? • how have you made sense of it?
Moral distress: contributing factors
Perceived powerlessness
Socialization to follow orders
Hierarchies within the healthcare system
Lack of administrative support
Compromised care due to pressure to reduce costs
Providing prolonged, overly aggressive treatment
Ineffective communication among team members
Lack of time
Inadequate staffing
Lack of collegial relationships
Policies/priorities in conflict with care needs
Fear of litigation
Inadequate informed consent
Increased moral sensitivity
http://www.azbioethicsnetwork.org/wp-content/uploads/2011/05/Moral-Distress.pdf
Moral distress: consequences
Diminished professionalism
Decreased patient/family satisfaction
Potential decrease in quality of care
Increased organizational costs
Burnout
http://www.azbioethicsnetwork.org/ethics-cases/moral-distress/
Burnout & Compassion Fatigue
Acknowledging moral distress
A sign of weakness A sign of courage
“Simply” notice
On dissonance
On dissonance
On dissonance
Music would not speak if it were devoid of dissonance.
Dissonance in practice
42 year old Syrian immigrant with metastatic non-small cell lung cancer, intubated for post-obstructive pneumonia. Septic shock on maximal pressor support. Now with multiorgan failure.
Diagnosed 6 months prior. Now has a 3 month old baby
“Do everything.”
• We know he’s dying, but he needs to stay for his son.
Family
• He’s in multi-system organ failure. I know he’s young, but he won’t survive. But we will keep him full code, since that’s what they want.
Intensivist
• This feels like futile care. He’s not awake. He’s in isolation. His baby can’t even see him. I don’t know why we’re doing what we are.
Nurse
Reflecting on moral distress
On curiosity
Leaning in to dissonance
Cognitive dissonance involves the ability of the mind to hold two seemingly opposite truths in a moment “We know he’s dying, but we
need him to stay for his son.”
“He doesn’t want to die, but he doesn’t want to suffer either.”
“As the family Priest, I should give them advice and support, but I am afraid of this suffering as well.”
Being curious How else might he be able
to linger?
Moral distress in the hospice IDT
Patient &
family
Hospice nurse
Hospice Physician
Attending Physician
Social WorkerChaplain
Home health aide
Volunteer
Only people who are capable of loving strongly can suffer great sorrow, but this same necessity of loving serves to counteract their grief and heals them.
Tolstoy
Contemplative practiceIntroduction to Metta
This is not just to make you feel good
Antoine Lutz, Julie Brefczynski-Lewis, Tom Johnstone, Richard J. Davidson. Regulation of the Neural Circuitry of Emotion by Compassion Meditation: Effects of Meditative Expertise. PLoS ONE, 2008; 3 (3): e1897 DOI: 10.1371/journal.pone.0001897
A. Voxel-wise analysis of the Group by State by Valence (negative versus positive sounds) interaction in insula (Ins.) (z = 2, corrected, colors code: orange, p<5.10ˆ-2, yellow, p<2.10ˆ-2, 15 experts (red) and 15 novices (blue)). B. Average response in Ins. from rest to compassion for experts (red) and novices (blue) for negative and positive sounds. C–D. Voxel-wise analysis of BOLD response to emotional sounds during during poor vs. good blocks of compassion, as verbally reported. C. Main effect for verbal report in insula (Ins.) (z = 13, corrected, colors: orange, p<10ˆ-3, yellow, p<5.10ˆ-4, 12 experts and 10 novices). D. Average response in (Ins.) for experts (red) and novices (blue).
doi:info:doi/10.1371/journal.pone.0001897.g002
Create a pause
Anchor yourself in your breath
Pause
Be transparent
Monitor your mindset
Explore personal responses
Ask questions
Get clarifications
Be open to new possibilities
Let go of outcomes
Become a witness, rather than an actor
Addressing Moral Distress
Engage in contemplative practices
Cultivate moral sensitivity Modulate emotions Care for yourself so you
can care for others Reconnect to meaning Build your “resilience
muscle” Be generous and kind to
self and others Develop institutional
systems
In Summary
Moral distress – can occur in any clinician, it adds to risk for compassion fatigue and burnout, but there are things we can do
Reflective practices
Learning to watch
Goethe
In breathing there are two kinds of grace:
To draw air into, then out of, your space.
The one presses down, the other refreshes;
Thus marvelously life's web intermeshes.
You thank God whenever he hems you in,
And thank him whenever he frees you again.
Please Answer the Following Question:
Sometimes I feel we are saving patients who should not be saved.
Agree
Uncertain
Disagree
Please Answer the Following Question:
Sometimes I feel as though we give up on patients too soon.
Agree
Uncertain
Disagree
Please Answer the Following Question:
Sometimes I feel the treatments I offer/provide to patients are overly burdensome.
Agree
Uncertain
Disagree
Please Answer the Following Question:
At times, I have acted against my conscience in providing treatment to patients in my care.
Agree
Uncertain
Disagree
Moral distress: causes
poor-quality and futile care,
unsuccessful advocacy,
and raising unrealistic hope
Schulter et al (2008)
Mildred Z. Solomon, Deborah E. Sellers, Karen S. Heller, Deborah L. Dokken, Marcia Levetown, Cynda Rushton, Robert D.Truog, and Alan R. Fleischman
New and Lingering Controversies in Pediatric End of Life Care, Pediatrics, Oct 2005; 116: 872 - 883.
Survey of 781 clinicians at 7 institutions
209 attending physicians
116 house officers
456 nurses.
Definition: Burnout
• A response to chronic, and cumulative stress (often related to work). Includes:
– Emotional exhaustion
– Depersonalization
– Diminished personal accomplishment
(Maslach C, Jackson SE: Maslach Burnout Inventory Palo Alto, California:Consulting Psychologists Press; 1986.)
Burnout: Selected Data
Burnout shown to predict mood disorders and poor general health in physicians (Hillhouse et al., 2000)
Burnout associated with: - increase in self-reported medical errors (West et al., 2006)
- suboptimal patient care practices (Shanafelt et al., 2002)
60% of practicing physicians report symptoms of Burnout (Krasner, wt al, 2009 )
50% of PICU attending were at risk or burned out (Fields, et al, 1995)
38%-66% Nurses report symptoms of Burnout (Aiken et
al, 2001; Laschinger, et al, 2006)
Linked to poorer quality of care Decreased patient satisfaction Increased Medical errors and lawsuits Decreased ability to express empathy (Krasner, et al, 2009)
Burnout: Impact
Burnout: Selected Data
• 76% of medical resident respondents reported symptoms of burnout: – High depersonalization
(e.g., “I’ve become more calloused towards people since I took this job.”)
– Emotional exhaustion (e.g., “I feel emotionally drained from my work.). Shanafelt, colleagues (2002)
• Half the residents who feel burned out suffer from depressive symptoms. Shanafelt, colleagues, (2002)
Compassion Fatigue
Is a form of secondary trauma characterized by exhaustion, helplessness and dysfunction as a result of prolonged exposure to compassion stress and trauma.
Usually evolves in caring professionals who absorb the traumatic stress of those they help (Najjar et al , 2009).
No uniform definition
May be misnamed: Compassion cannot cause fatigue or that becomes fatigued
How many agreed with this statement?
"Sometimes I feel we are saving children who should not be saved,“
and"Sometimes I feel we give up on children too
soon." 20 times more nurses agreed with 1 than with 2 15 times more house officers, 10 times more attending physicians
Mildred Z. Solomon et al Pediatrics 116: 872 - 883