Moral Distress Part 1: At the Bedside Segment

Core IM Podcast

Time Stamps

• 04:59 Definitions
• 06:50 Moral Distress
• 09:01 Moral Residue
• 11:34 Moral Injury
• 13:32 Causes of Moral Distress and Moral Injury
• 18:18 Consequences

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Show Notes

• INTRODUCTION
  • Beth Epstein, PhD, RN, HEC-C, FAAN
  • Wendy Dean, MD
• DEFINITIONS
  • Moral distress
    • Definition (Dr. Epstein): “Moral distress occurs when clinicians are:
      • Constrained from taking what they believe to be ethically appropriate actions; or
      • Forced to take actions that are ethically inappropriate based on their professional obligations.
      • Results in a sense of complicity and wrongdoing.”
    • Different constraints based on training level
      • Med student/Resident/Fellow – clinical decision making beholden to the judgment of senior staff/attendings
      • Attendings – beholden to performance metrics, administrative pressures, institutional policies, documentation/billing codes, insurance requirements (e.g., pre-authorizations, peer-to-peer appeals)
    • Three major sources
      • Patient/family member interactions
      • Poor unit/team/colleague dynamics
      • Systems level
  • Moral residue
    • Definition: Cumulative psychological scarring that results from repeated and unevaluated instances of moral distress
    • Each instance leading to an ever rising “crescendo effect”
  • Moral injury
    • Definition: The damage done to one’s conscience or moral compass when that person perpetrates, witnesses, or fails to prevent acts that transgress one’s own moral beliefs (see: The Moral Injury Project); often the result of repeated exposure to morally distressing situations
    • Alternate Definition: Betrayal by a legitimate authority in a high stake situation that leads you to transgress your deeply held moral beliefs and expectations
    • I.E., not just a question of “What am I doing?”, but “Who am I now?”
  • Burnout
    • Definition: A nonspecific syndrome of chronic workplace stress that has not been successfully managed; characterized by feelings of energy depletion or exhaustion; increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and reduced professional efficacy (from ICD-11)
    • Can be the result of morally distressing experiences
    • One should imply investigation for the other; i.e., where there is burnout, look for moral distress, and vice versa
  • Constraints
    • Definition: Barriers to acting on moral beliefs
      • External: Limited authority, lack of time/resources, patient demands, breakdowns in communication/collaboration, financial limits, Policies, hierarchy, law, insurance structures, cultural norms
      • Internal: Deference to authority, fear of retaliation, paralysis, perceived powerlessness, inexperience, self-doubt, less reflective/sensitive
    • Often multidimensional and complex
  • Common clinical scenarios that induce moral distress:
    • Prolonging the dying process by having to provide futile care
    • Failure to have an end-of-life conversation
    • Witnessing provision of false hope to patients and their family
    • Having to provide care that is not in the best interest of the patient; putting the needs of other stakeholders (insurers, health system, EMR, productivity metrics) before the needs of the patient
    • Providing low-quality care in broken systems (inadequate support staff, colleagues with low clinical competency)
    • Following family wishes for care out of fear of litigation
    • Inadequate pain relief, particularly at the end of life
    • Inappropriate use of resources
• CONSEQUENCES
  • Physical: Fatigue, exhaustion, headaches, palpitations, sleep issues, neck/back pain
  • Emotional: Guilt, anger, frustration, helplessness, detachment
  • Existential: Loss of professional integrity/identity, job dissatisfaction, negative self-image, cynicism, burnout
  • Behavioral: Negative coping through distancing/avoiding patients, depersonalization, poor care quality/safety
  • Not a deficit in resilience: physicians on average demonstrate higher resilience scores than the general employed US population
  • Not a personal failing: it’s a sign that we care, and a red flag of where a problem needs to be addressed
• CONCLUSION

Transcript

Dr. Jafar Al-Mondhiry: I remember the first time I felt it, working as a resident in the ICU, trying to keep someone with widely metastatic cancer and multisystem organ failure alive, while additional family members came from out of town to argue with the ICU staff about how healthy he was up to this point, and why can’t we save him? And then I felt it working with a transplant patient, where the transplant team and the ICU team argued about how aggressive we need to be in our failing resuscitation efforts, where we were told it wasn’t appropriate to talk to the family yet about transitioning goals of care. And I felt it again, sitting on the phone waiting to make an appeal for my patient’s cancer medications, only to be told that this was not an appeal conversation at all, that an insurance representative was going to explain their denial decision, but not actually have any discussion about altering their decision. Every situation ended the same way, with the same question: “Why am I doing this?” These are some examples of what Moral Distress in medicine feels like—that moment when you know in your heart what the right thing to do is, but find yourself in a situation when you’re blocked from doing it. It’s a feeling all too common in the practice of medicine, tearing us away from our own moral convictions, making us feel complicit or at least witness to care we don’t agree with. Sometimes it comes in big moments like these that never leave us, but also in so many other small moments we may not even appreciate. The cumulative toll is enormous, driving many out of the profession, but for most of us it’s a psychic pain we’ve learned to endure. We want to take some time here today to really name it, talk about it, and hopefully unpack some of this hidden weight we carry in the practice of medicine. Hi, I’m Jafar Al-Mondhiry, a medical oncologist, here for another installment of CORE IM’s At the Bedside series.

Dr. Margot Hedlin: I’m Margot Hedlin, a hospitalist and clinical ethics consultant

Dr. Tamar Schiff: And I’m Tamar Schiff, I trained in internal medicine and am currently a postdoc in bioethics.

Dr. Jafar Al-Mondhiry: Today, we’re joined by two fantastic leaders in the literature, and really the ongoing cultural conversation about Moral Distress, each with a unique approach to the topic.

Dr. Beth Epstein: I’m a professor in the school of nursing at the University of Virginia. I’m also a professor in the Center for Health Humanities and Ethics at the University of Virginia School of Medicine. I have been on the Ethics Consult Service for 10 years, and I direct our moral distress consult service as well.

Dr. Jafar Al-Mondhiry: Dr. Epstein has been writing and publishing for over 20 years on the topic.

Dr. Beth Epstein: My interest in moral distress started when I was doing my doctoral dissertation. I was very interested in the end of life experiences of physicians, nurses, and parents in the newborn and intensive care unit, which is where I was a nurse before I went to graduate school. There were a group of six or eight deaths that were very, very distressing and they were ethically challenging, but they were also morally distressing in that teams knew or felt they knew what the right thing was to do for an infant, but they could not put that into practice, and that was really problematic for them. So since then I have been looking at this phenomenon because I’m really worried that it’s impacting the workforce, nurses, physicians, social workers, all kinds of healthcare professionals.

Dr. Jafar Al-Mondhiry: Also with us today is Dr. Wendy Dean.

Dr. Wendy Dean: I’m Wendy Dean. I am the CEO and co-founder of the Moral Injury of Healthcare. And I’m a psychiatrist by training who had an wandering path to get there.

Dr. Jafar Al-Mondhiry Dr. Dean has authored a number of influential and highly publicized pieces in JAMA, STAT News, and The Washington Post, among many other outlets, and with Dr. Simon Talbot authored the recent book, If I Betray These Words: Moral Injury in Medicine and Why It’s So Hard for Clinicians to Put Patients First. With her foundation, she has devoted herself fully to writing, speaking, researching, podcasting, consulting and doing advocacy work on the topic of Moral Distress and Moral Injury in healthcare. She speaks openly and honestly about her frustrations with the commercialization of medicine that led her to stop doing clinical work, and the crisis of values clinicians face in our current healthcare environment. While we hope much of today’s episode will help equip us with a language to understand and appreciate this topic, with some helpful strategies to mitigate its impact, some of the most important root causes of moral distress come from the design of our entire healthcare system—problems we can’t solve today, but we can start seeing and discussing now.

DEFINITIONS

Dr. Tamar Schiff: We want to start by defining a few terms and, importantly, distinguishing among them. With a growing spotlight on burnout and wellness initiatives in clinical medicine, and in the workplace at large, a lot of terms can get conflated, but it’s important to tease them apart.

Dr. Wendy Dean: When we are not specific, then we start lumping all kinds of different drivers and symptoms under the same umbrella. We end up trying to treat that variety of different potential conditions with the same solutions, and we end up not being effective at any of them. So the more specific we can be with our language, the more likely we are to find effective solutions to those challenges.

Dr. Tamar Schiff: To accurately reflect, describe, and maybe even address these experiences, it’s important that we use the same terminology consistently in how we write about and research the topic. We’re going to focus on the definitions of moral distress, moral residue, and moral injury. But before diving into those, we want to recognize that medicine is full of moral dilemmas. So many clinical decisions require complicated and difficult considerations: the patient’s quality of life, their preferences, possible resource constraints, social norms, and many, many others. We’ve touched on a good number of examples of these in previous episodes: like considering when someone needs to be treated against their objection, intervening when a colleague seems to be impaired, deciding when it’s safe to let someone leave the hospital against medical advice. And in the end, a lot of these decisions don’t actually have a wholly right and wrong solution, or one course of action that will clearly lead to an optimal outcome. Moral dilemmas are part of the nature of clinical practice that can’t be avoided, and that’s hard to come to terms with. We wanted to give voice to that, while still emphasizing that, as Jafar mentioned, moral distress is something different. Let’s talk about how it’s different.

MORAL DISTRESS

Dr. Beth Epstein: Moral distress occurs when clinicians are constrained from taking what they believe to be ethically appropriate actions, or they are forced to take actions that are ethically inappropriate based on their professional obligations. And that results in a sense of complicity and wrongdoing.

Dr. Tamar Schiff: Dr. Epstein also gave us a great way of thinking about what can lead to moral distress.

Dr. Beth Epstein: Over time, we have found that there are basically three buckets of causes of moral distress. There are causes that happen at the patient or family level where prolonged aggressive treatment, that kind of thing happens, like that’s a patient level. The unit or team level, which is really poor collaboration or communication processes, unit routines that really kind of get in the way, like rounding that doesn’t happen in a timely fashion or something like that where communication patterns just aren’t clear. And then at the system level, where policies are missing or policies just aren’t helpful or updated or excessive documentation requirements or really things well outside the unit that impact the entire organization.

Dr. Tamar Schiff: And as Dr. Dean pointed out, this can impact anyone, including those in training and, later on, in independent practice.

Dr. Wendy Dean: When you’re in training, you don’t have the ability to make decisions for yourself. You’re always answerable to someone who has a clear idea, a clear and distinct idea of what your decisions should be, because their liability depends on that. So it becomes very difficult if you have a difference of opinion or if you have a difference of values, you aren’t free to be deciding those things on your own. On the other hand, when you’re out in practice, you suddenly are faced with a lot of other constraints that you aren’t necessarily faced with as a resident. So suddenly your liability, your responsibility is dependent on the administrative decisions that have been made for you.

MORAL RESIDUE

Dr. Tamar Schiff: Sometimes, with time and the right resources, we can process scenarios that cause moral distress and move forward. But other times, these experiences leave a real emotional and psychological dent.

Dr. Beth Epstein: If I ask you, have you ever experienced moral distress, most people will nod their heads. And then if I ask, when was your experience? Clearly a case popped into your head, when did that case happen? And people will say, yesterday, this morning, 30 years ago. And if I ask, can you remember the details as if it happened yesterday? Do you remember what the patient looked like and what you felt like? The frustration, the guilt, the distress? A lot of people can just pull that up very, very quickly. That is moral residue: what you drag along with you throughout your career. And what we’re worried about is this sense of guilt and not being able to resolve a situation and improve the patient care quality or safety over and over and over again builds up over time.

Dr. Tamar Schiff: And in time, and with additional experiences, this moral residue can get compounded, leading to what Dr. Epstein and others have called the “crescendo effect.”

Dr. Beth Epstein: There are actually two crescendos. One is the moral distress crescendo as a situation is unfolding. So it often takes days to weeks for a morally distressing situation to kind of unfold where you can kind of feel your moral distress rising or you can see the moral distress rising amongst the team. You hear team members talking in the staff room about Why are we doing this? This is so unsafe. Why isn’t administration listening to us? So that’s the moral distress crescendo. And as soon as that particular situation resolves, the patient is discharged, the patient dies, the staffing gets better, whatever the level of moral distress decreases, but it never doesn’t usually go back to zero because there’s that residue, you’re kind of scarred, and that scar really never goes away. So you go along until the next situation of moral distress happens, and that one the situation rises again and then declines as when the situation resolves. And then you’ve got the first scar plus the second scar. Over and over and over again. You may have heard people say, here we go again. This patient is just like Mr. Jones, it was six months ago. Can you believe we’re here again? So it just is never ending. And so that is the moral residue crescendo.

MORAL INJURY

Dr. Tamar Schiff: Finally, the accumulation of morally distressing situations, and the moral residue they leave behind, lead to what is defined as moral injury, which can have a much larger impact on how we see ourselves and our professions.

Dr. Wendy Dean: Moral distress is knowing what the right thing to do is and being unable to do it. We know what our professional obligations are, how we should be caring for our patients. We can’t do it. And when we run into that challenge over and over again, we can process some of it or most of it, but there’s this bit of it leftover, which is moral residue if it occurs often enough that builds up and creates a condition or an experience called moral injury. The distinction for me between moral distress and moral injury is that when you get to the moral injury place, you’re now starting to question, “can I still be the good physician, the good person that I thought of myself as if I continue to work in this situation?” So you’re beginning to question your own moral compass in that situation. Moral injury is also defined as a betrayal by a legitimate authority in a high stake situation that leads you to transgress your deeply held moral beliefs and expectations.

Dr. Tamar Schiff: We also quickly want to loop in a term we hear pretty often these days. “Burnout” tends to be used as a catch-all term, but Dr. Dean and others have described it as a set of nonspecific symptoms that can be seen as a sort of end stage manifestation of moral injury.

Dr. Wendy Dean: Although moral injury and burnout are two separate parts of distress and together they make a more complete diagnosis, that doesn’t mean that they’re entirely separate. They do also influence each other. And so what’s important about that to us is that if you see burnout, you should probably be looking for moral injury and vice versa, because one can drive the other and intensify the experience of the other.

CAUSES OF MORAL DISTRESS AND MORAL INJURY

Dr. Tamar Schiff: Crucially, once we’ve named these experiences – moral distress, residue, injury – we can also talk more specifically and clearly about what causes them.

Dr. Wendy Dean: I think before we talk about the factors that contribute to moral injury or moral distress, we really need to think about the three different levels of moral challenge. And we tend to think of them as on the personal level, where are your own personal values challenged? On a professional level, where are your professional obligations challenged? And then on a societal level, we made as clinicians, we make a covenant with society that we will, in joining this profession, we promise certain things in exchange for others, meaning, respect, and the ability to self govern, et cetera. And so first you need to think about at what level are we speaking? And I tend to think about it at a professional level. So what are the professional obligations that are challenged that lead to moral injury? So these are the promises that we made, and sometimes they’re an explicit oath, sometimes they’re an implicit oath, but they’re what we thought we were going to be doing when we joined the profession of medicine. We thought that we would be taking care of our patients as our priority rather than our own self-interest, our employer’s self-interest, et cetera. And when we are faced with that misalignment of values, that’s when we start to experience or be at risk for things like moral injury.

Dr. Tamar Schiff: So much of what leads to moral injury occurs at the level of systemic constraints, which come in a wide variety of flavors.

Dr. Wendy Dean: Each physician faces a slightly different set of these challenges. Sometimes it’s the prior authorization that is relentless and it delays patient care, it worsens outcomes, et cetera. And it doesn’t save money, by the way. Sometime it’s the EMR, that is well-intentioned, but isn’t well executed, and so it separates them from their patients during the day. They can’t make eye contact. It separates them from their family at night because they can’t get everything done during the day. There were also physicians who could not because of constraints in the expectations of their organization, they couldn’t refer their patients to the physicians that they hoped they would be able to, meaning even though there was not somebody who was a subspecialist in the patient’s particular illness or condition, they had to refer within their own hospital system because they didn’t want that revenue to leak out of the system. So the challenges are everywhere from the mundane to the frankly dangerous and everything in between. And I think when people stop and reflect on what they’re experiencing, when you get that gut punch of this is not what I promised to do, I think people will know. It’s that thing where I can’t tell you every situation where someone’s going to be at risk of moral injury, but I guarantee you that people know it.

Dr. Tamar Schiff: And importantly, when thinking about causes of moral injury, it’s not the individual clinician’s shortcomings.

Dr. Wendy Dean: So I think there are two misconceptions that people have about moral injury in particular. One is that it started with the pandemic, and we are very clear that it was happening long before the pandemic. It just intensified as the vulnerabilities of our healthcare system were magnified in the context of the crisis. But the other misconception is that this is a clinician problem. And in fact, we’ve done work that shows that almost half of executives and managers also experienced moral injury in the context of the pandemic. So for them, they knew what their workforce needed and couldn’t get it for them, and that was exquisitely painful. What that says to me is that we have really common experiences and common language that we can use to start thinking about what our healthcare of the future will look like. We can start working together to create that different place and that different vision.

Dr. Tamar Schiff: Now that we have the language to accurately describe moral distress and injury, and their causes, Margot will take us through some of the repercussions of these experiences.

CONSEQUENCES

Dr. Margot Hedlin: I think many of us can intuitively understand the consequences of moral distress. For me, sometimes it’s a memory that comes up at a bad time, or a wave of emotions when a new patient reminds me of someone I feel like I failed. Before I knew what moral distress was, I would feel my heart racing before I could understand why. Studies have identified a wide range of ways that moral distress can affect us. Emotionally, people can feel guilty, angry, frustrated, helpless, worthless, discouraged. Physically, this can manifest as a range of symptoms: fatigue, sleeping problems, pain, headaches, and heart palpitations. And left unchecked, this can lead to burnout and poor job satisfaction. When unaddressed moral distress calcifies into moral injury, it can have huge impacts on individual clinicians, and on the broader healthcare system itself.

Dr. Wendy Dean: Sure, the consequences range anywhere from an individual who has no choice and stays in an organization but is disengaged, and they’re not as engaged with their colleagues. They’re not willing to go the extra mile. They take good care of their patients, but maybe not great care of their patients. So they’re a little bit checked out. It can go beyond that and people may quit. We may be losing them because they’re diverting to other industries because they’re just quitting and going to work on a farm. I mean, wherever. And unfortunately, I do think we don’t have data now, but I do think that this is at least a component from feedback that I’ve gotten. It’s a component in the physician suicide crisis, and I think we need to be realistic about that. On an organizational level, it can dramatically increase turnover. It can make recruitment a challenge and retention a challenge. It can break down the collegial relationships between clinicians so that maybe a specialist hesitates to come into the ER or is resistant to coming into the ER when their colleague needs them, rather than saying, yep, I trust you, I’ll be there. So as the fabric of the community starts to fray, the well-oiled machine of healthcare starts to get very creaky. And I think that’s what we see. And then it sort of magnifies the problem, right? Because then it becomes harder to take care of your patients. It feels like this isn’t what you signed up to do, and there we are.

Dr. Margot Hedlin: There are consequences for our patients, too. Moral distress can cause us to avoid challenging interactions, or depersonalize our patients as a way of protecting ourselves.

Dr. Wendy Dean: We know that this isn’t good for patients. We know. Patients feel it when their physicians are in distress. They are two times more likely to have lower satisfaction scores. If they’re not engaged and connected with their physician, they’re much less likely to follow through on treatment plans, which means their outcomes are going to be worse, which means their health is going to be worse. So it’s good for us, but it’s also good for our patients to take good care of ourselves and each other.

Dr. Margot Hedlin: While moral distress can take a tremendous toll, it’s important not to think of it as a personal failing or a weakness. It’s a sign that we care.

Dr. Beth Epstein: People who are numb to the moral aspects of their work are not going to be effective nurses and doctors. It’s hard to be somebody who takes care of people who are suffering and dying and fearful and anxious and rejoicing and cured and not cured, and not engage in all of that from an emotional sense and from an emotional source and from a moral source. And so the fact that you’re experiencing moral distress is actually a good thing about you. It’s not a good thing. It’s a good thing about you. You can feel it. So I would say to bring it up if you feel it, because it’s a matter of patient care.

Dr. Margot Hedlin: Similarly, Dr Dean also pointed out that moral injury isn’t due to a resilience deficit.

Dr. Wendy Dean: Colin West and his colleagues put out a research paper in July of 2020, perfect timing, that said, physicians are significantly more resilient than the average employed population. So part of the challenge is that our administrators who are non-clinicians don’t understand what it’s like to be a clinician. We need to be more intentional about explaining to them what our challenges are. But they’ve been borrowing these strategies from other industries that have worked in other industries, maybe because those populations are different. They are fundamentally different than we are.

Dr. Margot Hedlin: In fact, some argue that our resilience is what has kept the healthcare system together, despite its many flaws.

Dr. Wendy Dean: Danielle Ofri wrote a beautiful piece in New York Times in 2019 titled something like The Business of Healthcare Depends on the Exploitation of Doctors and Nurses. And she really spoke very eloquently about how physicians and nurses and other healthcare workers are not going to let patients suffer because it’s part of the promise that we made when we entered our professions that I’m going to put you first because you are the one who’s vulnerable before my own self-interest, before my own needs. And no matter what our organization is asking of us, we aren’t going to let our patients suffer.

Dr. Margot Hedlin: As Dr. Ofri points out in her editorial, there are so many ways that clinicians step up to protect patients from an overburdened system. PCPs spend countless hours charting, nurses skip lunch-breaks, all of us caring for an increasingly sick population without a commensurate increase in staffing. But our resilience can’t be the definitive solution to a broken system. We can think of moral distress and moral injury as tools to help us to recognize that there’s a problem.

Dr. Beth Epstein: Yes, the experience of moral distress opens doors to solving problems. If you don’t recognize it, then you can’t fix it. And the problems with patient care just keep going on and on and on. So I think it is an opportunity when we see staff that are morally distressed, we see it as a red flag over here. There’s something bad happening over here that we need to fix. It’s important to be able to raise the flag and say, this level of staffing is a crisis level of staffing, and our patients are not safe today. You need to know that as a leader, as an organizational leader, this patient is suffering and has been suffering. We have been doing daily wound care that takes two hours to do that. It’s excruciating, and the patient is septic and has metastatic cancer and is not going to survive. This patient is suffering and we need to do something different because this is not sustainable for this patient. It’s not fair to do to this patient. Let’s work together as a team. So it’s an opportunity to be able to collaborate and problem solve. And in my experience, when we encounter morally distressed staff, that’s exactly what they want to do. They want to problem solve.

Dr. Tamar Schiff: As we’ve touched on throughout this episode, morally distressing situations and their compounding effects can feel really corrosive to who we are and how we see our roles in healthcare. We recognize that having language to reflect and describe our experiences is only the beginning, but being able to to use these specific terms can maybe also reduce some of the isolation we feel. And now that we’ve reviewed the definitions of moral distress, residue, and injury, as well as some of their root causes and consequences, we hope you’ll join us for part 2 of this episode, where we’ll discuss ways to start approaching some solutions.

Dr. Tamar Schiff: Thanks for tuning in! We know these topics can stir up more questions than answers, and we look forward to hearing more about your experiences with moral distress and moral injury. Please continue the conversation with us online at our facebook page, on twitter, or email us directly. Find show notes and contact information for us on our website: coreimpodcast.com

If you enjoyed listening to our show, please give us a review on itunes or whichever podcast app you use; it helps other people find us. We work really hard on these podcasts so we’d love to hear from you. Let us know what we are doing right and how we can improve. And as always opinions expressed in this podcast are our own and do not represent the opinions of any affiliated institutions.

Finally, special thanks to all our collaborators on these episodes, our wonderful audio editor Daksh Bhatia, music editor Solon Kelleher, our illustrator Ariella Coler-Reilly, moral and executive support from Shreya Trivedi, and most importantly thanks to you, our listeners!

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