Moral Distress: What Is Next?*

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Moral distress has been described as “mental anguish” or “psychological imbalance” that results from the inability to follow one’s sense of moral responsibility that dictates the ethically right action (1). Moral distress, first described in nursing ethics, should be differentiated from moral dilemma where the health professional is not certain about what ethical decision to make (2). Jameton (1) divided moral distress into initial distress occurring acutely on the spot and reactive distress which follows (3). In moral distress, the health professional is clear about the right action to do but is prohibited by internal restraints, external obstacles, or various clinical situations. The internal restraints include poor understanding of the patient’s medical condition, a feeling of helplessness, and a fear of compromise of self-integrity. External obstacles include limitation of resources, shortage of staffing, family wishes, hospital policies, team dynamics, organizational influences, and legislation (4). End-of-life care, futile treatment, informed consent, and lack of provider continuity are frequently encountered clinical ethical issues (5).
In this issue of Pediatric Critical Care Medicine, Larson et al (6) measured objectively with validated scores the level of moral distress in pediatric and neonatal intensive care practitioners and studied its relationship with demographic factors, burnout, and uncertainty in a large pediatric tertiary care hospital. Moral distress was present in all ICUs and provider groups studied including physicians, nurses, and respiratory practitioners. The results of the study, showing the presence and correlation of moral distress with burnout, uncertainty, and feeling unsupported, have been experienced by most health workers in ICUs for decades though not objectively assessed. Previous studies using the Revised Moral Distress Scale (MDS-R) have been conducted in adult and neonatal ICUs and in pediatric settings (7–9). The strength of the study is reflected by being the first study reporting PICU-specific MDS-R scores. End-of-life care and communication, as causes of moral distress, scored highest whereas inadequate resources, hierarchies of decision-making, and witnessing unethical behavior occurred less frequently but still ranked as highly distressing.
Moral distress occurs in all healthcare disciplines, not only nurses, with little variation in its intensity and a direct correlation with clinical situations (10). Dodek et al (7) reported a higher frequency of moral distress in ICU nurses and other nonphysician professionals than in physicians, with an increase in its frequency with years of experience in nurses, and an inverse relation with age in other nonphysician professionals. Larson et al (6) confirm the increase of moral distress in PICU experienced nurses. However, they are the first to report lower levels of moral distress among physicians with more experience though the modest number of physicians involved in their study is an important limitation.
Why is moral distress a common occurrence in PICU and why is it becoming a striking phenomenon? The PICU is a stressful workplace where the best interests of the child should prevail; however, it is often the site of ethically challenging problems. The advances in high technologies, specially the life-sustaining ones, have led at times to aggressive futile treatments. A healthy ethical climate dictates the need to make important medical decisions after discussion with all team members including the family. Conflicting opinions on treatment and prognosis contribute to an increase in moral distress. Breaking bad news to the families and discussing with the parents the benefits of continuing life-saving interventions on their beloved child are great sources of moral distress.
Moral distress challenges one’s moral integrity and inflicts negative consequences to patient care (11). Increasing levels of moral distress have been associated with job dissatisfaction, higher levels of burnout, and poor job retention.

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