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