Ethicists Get Consult Requests for Moral Distress

By Stacey Kusterbeck

Some ethics consults are requested specifically because a clinician is experiencing moral distress. The term “moral distress” might have somewhat different meanings to different people, however. “The term is used quite commonly now to refer to a range of stressful experiences that clinicians perceive in today’s healthcare delivery climate,” says Anita J. Tarzian, PhD, RN, program advisor for the Maryland Health Care Ethics Committee Network.

Tarzian co-authored a recent paper on a case study involving a nurse who requested an ethics consult because of moral distress.¹ The authors focused on how clinicians use the term “moral distress,” and the ethics consultant’s role in responding to clinicians’ reported moral distress. Some ethicists narrowly define moral distress as when a clinician is forced to act contrary to what is ethically right, explains Tarzian. For example, some ethics consults involve surrogates who insist on full code resuscitation status against the patient’s stated wishes. In such cases, clinicians are asked to attempt interventions, such as cardiopulmonary resuscitation (CPR), that they believe are harmful to the patient.

Other clinicians view moral distress more broadly. Some call ethics for help with distress because of providing treatments perceived as inappropriate, despite ethical justification for those procedures. For example, clinicians may report “moral distress” stemming from their role in the care of a patient who spent months in the intensive care unit (ICU) receiving various forms of life-sustaining treatments before dying, even if the patient explicitly requested all efforts be taken to prolong life.

“If moral distress is the main motivation for the consult, some ethics consultants might not consider this appropriate for ethics consultation,” notes Tarzian. Some ethics services provide “moral distress consultations” specifically to address these cases.² However, other ethicists agree to consult with clinicians who report moral distress, even if the consult does not involve a clear-cut ethical question. “There might not be an ethical concern, per se, but there are unresolved emotions that staff may benefit from addressing,” explains Tarzian.

One of the most common reasons for ethics consultations is moral distress experienced by staff who are asked to provide interventions they view as inappropriate, reports Ann L. Jennerich, MD, MS, an associate professor of medicine at the University of Washington.

For instance, the family of a patient in a coma, with recurrent infections and other complications related to being bedbound, might want to maintain a full code order. However, clinicians may feel strongly that a do not attempt resuscitation order is more appropriate. In such cases, clinicians may have ethical concerns about the patient’s quality of life and potential harm to the patient that might occur if CPR is attempted in the event of a cardiac arrest.

“Clinicians want to help alleviate distress and may be seeking ‘permission,’ for lack of a better word, to act in accordance with what they believe to be the correct course of action,” says Jennerich. In Jennerich’s experience, the ethics team often defers to the decision-making authority of the patient or family member, even if decisions being made provoke significant moral distress for the medical team.

“Emphasis on patient and family autonomy generally tips the scales in favor of the choices of patients and their family members. This leaves clinicians to feel that their concerns are unimportant,” says Jennerich.

The ethics team can help by providing a way for clinicians to share their concerns with the patient or family without provoking additional stress or causing guilt. “Most people understand that there is not a simple solution to many of these issues. Even so, all parties want to feel heard,” says Jennerich.

That includes family members of patients dying in the hospital, who are under extreme emotional strain. However, data on the experiences of family members in this situation is scarce. “It is a difficult topic to study. Enrolling them in research studies or asking them about their experiences in real time could be very burdensome,” says Jennerich.

Jennerich and colleagues wanted to find a way to understand common concerns of family members during the dying process, without being intrusive. “Nurses play a pivotal role in the provision of end-of-life care, spending time with the dying patient and their family members. We knew nurses would have valuable insights,” says Jennerich.

The researchers surveyed 82 ICU nurses in 2020 and 2021 about their experiences caring for patients who were discontinuing life-prolonging interventions and transitioning to comfort measures only.³ Some key findings:

• While most nurses wanted to be present when physicians or advanced practice providers talked to the family about switching to comfort measures only, just 31% were present always or most of the time.

• Time to death, changes in breathing, and medications taken to relieve the patient’s symptoms were common questions from family members.

• Most (62%) nurses reported moral distress at least some of the time when providing comfort measures only.

Nurses who felt well-prepared to answer questions from family members were less likely to report moral distress. “For many clinicians, educational opportunities focused on the ethical aspects of care are relatively limited,” observes Jennerich. Very little time is spent on ethics during training. “If ethicists could spearhead practical sessions, perhaps covering a typical consult and the thinking involved, and provide intermittent teaching sessions for staff, it may go further than ‘in the moment’ education, which sometimes is hard to digest when you’re actively experiencing moral distress,” suggests Jennerich.

REFERENCES

1. Tarzian A. Responding to a nurse’s perceived moral distress prompting an ethics consultation request. Am J Bioeth 2024;24:129-131.
2. Epstein EG, Shah R, Marshall MF. Effect of a moral distress consultation service on moral distress, empowerment, and a healthy work environment. HEC Forum 2023;35:21-35.
3. Tong HH, Creutzfeldt CJ, Hicks KG, et al. Questions from family members during the dying process and moral distress experienced by ICU nurses. J Pain Symptom Manage 2024; Feb 10. doi: 10.1016/j.jpainsymman.2024.01.041. [Online ahead of print].