A clinician's guide to managing moral distress

As health care reform takes shape in the U.S., vast amounts of attention have been given to the fact that more and more people with pre-existing illnesses will have access to professional care to relieve their physical and emotional suffering. Far less public attention has been given to the nurses and physicians who provide that care, and the authors of a recent study say there is evidence that many already experience serious "moral distress" that may interfere with their own health and their efforts on behalf of seriously ill and dying patients.

"Studies and case histories suggest that clinicians may experience feelings such as empathy, tenderness, sadness, remorse, shame or anger in response to perceived conflicts in values, interpersonal disagreements and institutional constraints," says Cynda Rushton, PhD, RN, FAAN, a nurse ethicist specializing in palliative and end-of-life care. Rushton is the Anne and George L. Bunting Professor of Clinical Ethics, a joint faculty position at Johns Hopkins' School of Nursing and Berman Institute of Bioethics.

In a pair of articles published in the Journal of Palliative Medicine, Rushton and her colleagues explain how a clinician's physical and emotional experience of moral distress can be detrimental to the patient and themselves, and how by learning to stabilize their own nervous system and emotional reaction, they can respond in a more principled, compassionate manner. The authors propose a framework for "creating a healthy work environment supporting clinicians to practice with integrity" and reducing the toll on caregivers and patients alike. "Conflicts of conscience are common among clinicians, particularly involving the care of patients at the end of life," they write. For example, "some… may have concluded it was unconscionable to participate in [care] that caused disproportionate suffering and pursue goals perceived as unattainable."

The authors add, "Clinicians struggling to address the dissonance between what they are doing and their professional roles often express this conflict as a lament of 'why are we doing this?' Coupled with an experience of injustice on behalf of the patient and/or broader society, this conflict can lead to unhealthy emotional arousal and moral distress. Acting against informed moral judgment creates a conflict of conscience by abandoning, consciously or unconsciously, convictions, ethical values or norms, and/or personal integrity."