Reflections on Moral Distress and Moral Success
9.2 Examples of Moral Success
Robert Truog (a pediatric intensivist and Director of the Center for Bioethics at Harvard Medical School) eloquently describes how healthcare providers, especially in a critical care setting, might feel trapped by having to perform cardiopulmonary resuscitation (CPR) on a patient who is clearly and imminently dying. In these cases, the healthcare provider might think that CPR is inappropriate despite the family or surrogate decision maker’s insistence.
began to have patients with complications due to our inability to give all the patients the care they required. I documented these concerns repeatedly to administration, but while the Director of Nursing was sympathetic, nothing changed. I even docu- mented the particular patient complications that we knew were attributable to inad- equate nursing care. We requested that beds be closed to allow for a more appropriate patient: nurse ratio, but the Chief of Neurosurgery was incensed by this idea. Finally, the staff said the only thing they could think to do was go on strike (this was not a unionized hospital), and they asked for my support. This threat precipitated a meet- ing with the staff, the CEO, the Chair of Neurosurgery and the Director of Nursing.
The staff clearly articulated their moral distress (though we did not have that term then!) over the repeated compromises they had to make in providing care to our complex and mostly bedridden patients, and their unwillingness to continue without some relief. Within days, the administrative leaders agreed to close four beds, as we requested, and supported our desire to have adequate staffing ratios to deliver the quality of care we knew how to deliver. The beds stayed closed until we got our staffing numbers up. That was a moral success, though it was a long time coming.”
Bob Truog explains why feeling trapped into providing “inappropriate” CPR can cause moral distress, and then suggests that by adopting the perspective of the fam- ily or surrogate, and a feasible, yet perhaps controversial, solution, one can find a
“success” that mitigates moral distress (see Box 9.3).
Box 9.3 Robert Truog—An Innovative Way to Mitigate Moral Distress from Inappropriate CPR
Moral distress is emerging as a critically important issue for the psychological and physical well-being of clinicians, and in particular those working in criti- cal care environments. In my experience, one of the most high-risk situations is when family members insist on cardiopulmonary resuscitation (CPR) for patients who are imminently dying.
Doctors and nurses often experience this situation as one of senseless and inappropriate violence and brutality. In performing chest compressions, we are subjecting the patient to pain and suffering at precisely the time when we believe the focus should be on creating a comfortable and peaceful environ- ment for everyone involved.
I’ve experienced these feelings myself, and I don’t want to minimize them in any way. But I’ve also found it helpful at times to reflect on what the experi- ence might be like from the perspective of the patient and family themselves.
The experience of the healthcare system for those who come from under- served backgrounds is often one of having been repeatedly denied access to essential medical services, and the perception that they are now being denied a potentially life-saving intervention (that is, CPR) can be seen as the final insult in a long series of past injustices. Or for those who have family roots in the developing world, the thought of having to tell the relatives “back home”
Shaké Ketefian describes education of Doctors of Nursing Practice as key to developing the confidence and skills that nurses need for moral success. She asks
“How do nurses gain power and concurrent “voice” that goes with it in patient care decisions? By power I do not refer to raw political power over anyone. Rather, the power I have in mind is the kind that comes from the exercise of unique nursing knowledge and expertise nurses bring to patient care, and the self-confidence that comes with the acquisition of such expertise. How can this be done?” Her answer is higher education, and she writes:
Nursing has taken the major step of developing a Doctor of Nursing Practice (DNP) degree in the past decade, which has spread quickly nationwide. With this professional doctorate, the graduates will have an education, knowledge base and expertise commensurate with that of other health professionals, which will give them the professional qualifications and the confidence to offer views and perspectives that have equal weight along with the views of others.
In order for needed changes to come about, the DNP graduates need to populate the practice arena... Currently, the majority of practicing nurses are associate degree, diploma, or baccalaureate degree (entry level professional preparation) graduates… Educational preparation at these levels is not sufficient to provide in-depth understanding of the com- plex, multidimensional problems patients present, or to deal with professional issues or health policy, nor would they have had the opportunity to develop intellectual agility and skills, or the necessary self-confidence to weigh-in during discourse with other profession- als and be viewed with credibility. But I believe DNP graduates would be viewed as credi-
that at the end of their loved-one’s life they agreed to “give up” and forego CPR may be intolerable, particularly when they know that their extended fam- ily overseas has no ability to understand the limitations of a high-tech health- care system that they have never experienced. And most importantly, in many such cases we know that the patient has herself insisted on receiving CPR, even if only to help assuage the grief of her family and friends.
In situations like these, I have sometimes found that a brief “code” can be conducted in a way that allows the family to feel that “everything” has been done and with little risk of pain and suffering for the patient, particularly in situations where the patient is mechanically ventilated and generous amounts of sedation and analgesia can be administered beforehand.
This approach is, admittedly, controversial. So called “slow codes” have been criticized and reviled for decades. But if we believe we are treating not only the patient, but also the family who will live with their memories of this event for a long time to come, I think that sometimes this may be justified.
And instead of experiencing the moral distress that comes with telling others
“I feel horrible today because I was forced to assault a dying patient at the demands of an unreasonable family,” I may be able to say, “Today I did some- thing that I would never want for myself or anyone I loved, but I did what I thought was right at the time for this particular patient and family.”
ble peers…. There is an urgent need to address the development of institutional policies and standards, and promote interprofessional dialogue and understanding to bring about sup- portive and ethical work environments to enable nurses to provide optimal patient care and bring their voices to bear in decisions concerning patients. In all of these activities a critical mass of DNP-prepared nurses can have major impact.
Ann Hamric and Elizabeth Epstein describe a pathway to promoting moral suc- cess through a moral distress consultation service. They incorporated a moral dis- tress consultation service into the more traditional ethics consultation service that is often part of healthcare organizations. In an evaluation of their consultation service experience, they report that moral distress consultations were conducted on 25 dif- ferent units, including intensive care, and other acute and outpatient areas, they identified more than 30 different root causes of moral distress from 56 consults (including, e.g., inadequate team communication, lack of continuity in care, unclear treatment goals, futility concerns, abusive families, and more), and they conclude that a system-wide approach is warranted. These authors found that the opportunity to dialogue and confront morally distressing issues with interdisciplinary colleagues not only gave some legitimacy to the experience of moral distress, but also led to an empowered voice (particularly for nursing staff), an increased sense of collabora- tion, and engagement for organizational or unit change [2].
Nancy Berlinger describes moral distress as a “…collective action problem. It is produced by a system, it is experienced by individuals or groups on the lower, receiving, end of hierarchies, and it can’t be resolved by an individual or a lower- status group, so its resolution, including the analysis of upstream problems, depends on more-powerful individuals or groups taking an interest on behalf of the system and those it includes and those it serves. So moral success—if we’re taking this term to be the opposite of or antidote to moral distress—must be more than a moral distress- free day at work, or being “ethical.” It must also have a systemic dimension, and must involve some effort to get at factors that produce moral distress. One example of moral success would be when morally distressed professionals agree that simply feeling bad, even tortured, does not, itself, improve conditions for their patients, and further agree to take the first steps toward collective action: airing their perspectives, getting at what, exactly, triggers that “trapped” feeling in some cases, but perhaps not in others, and identifying opportunities for further action. This takes time, space, a skilled facilitator, and a goal beyond venting or mutual support. Once it’s clear whether there is an actionable problem, separate from the feelings associ- ated with the problem, the routes to action may be clearer. For example, if profes- sionals working in the same unit recognize that the dual perceptions associated with moral distress—wrongness and helplessness—are triggered by cases in which a patient cannot gain access to a medically appropriate service available to other patients, for reasons such as undocumented status, homelessness, or dual diagnosis, the next step to alleviating moral distress would be investigating whether or not there are ways for these patients to receive the care that they need. This is likely to be most effective if done collectively, and by engaging the next level of the hierar- chy, rather than by parallel advocacy efforts on behalf of individual patients; this
may feel like success, even moral success, but leaves the basic problem—can access be expanded?—untouched. This next level of engagement will take more time, space, facilitation, and the articulation of an achievable goal, one that is likely to require the spending of political capital within a system: can system leaders be con- vinced to invest in services that will compensate for a barrier to care, or to advocate for public policy reform to expand access to include an excluded group? If moral success is to be a meaningful concept in patient care, the success should be experi- enced on behalf of patients, with an easing of professional distress as a result, rather than the main goal.
Cynda Rushton (a distinguished nurse bioethicist at Johns Hopkins University) has championed a concept of “moral resilience.” Rushton and Alisa Carse note that
“It is crucial that we find ways to empower clinicians in heeding this call-to support clinicians' moral agency and voice, foster their moral resilience, and facilitate their ability to contribute to needed reform within the organizations and systems in which they work” [3]. Rushton also notes the need for additional conceptual work to help refine the meaning of moral resilience and how to find ways to employ resilience in mitigating the negative effects of moral distress. [4] Sheryl Sandberg and Adam Grant discuss a concept of “collective resilience,” in their book entitled “Option B:
Facing Adversity, Building Resilience, and Finding Joy.” [5] Although their focus is not on healthcare or healthcare provider moral distress, they note that “by helping people cope with difficult circumstances and then taking action to alter those cir- cumstances, collective resilience can foster real social change.” ([5], p. 135). In their view, “collective resilience requires more than just shared hope—it is also fueled by shared experiences, shared narratives, and shared power” (p 130). Moral distress has created a certain sense of “shared identity” among healthcare clinicians, and perhaps shared experiences, narratives, and power could promote collective resilience.