The Deep Wounds of Moral Distress

Let’s delve into the concept of moral distress. Remember, moral distress occurs when we take an action or witness an action that violates our inner values. It’s important to acknowledge that our inner values differ from person to person. What bothers one person deeply might not affect another as much. These values are shaped by various factors such as upbringing, culture, religious background, personality, and past experiences. Moral distress arises when something goes against these deeply held values.

Sometimes moral distress is triggered by a single event, while other times it's a result of systemic issues, policies, or cultural norms—like water dripping on a rock until its strength is eroded. In this chapter, I (Patrick) will share two personal experiences of moral distress.

Zero-Visitor Policy

At the onset of the pandemic, many healthcare facilities, including nursing homes and hospitals, implemented a zero-visitor policy. At the time, I was a department director and the chairperson of the Ethics Committee for a large health system. I was responsible for advising on whether we should adopt this policy, which would close our doors to visitors, family included. Given the circumstances, I recommended that we follow suit, which unfortunately meant patients would die without their loved ones by their side, only accompanied by healthcare workers.

Despite my recommendation, our health system did not immediately implement the zero-visitor policy. Although the delay felt lengthy at the time, in hindsight, it probably wasn’t very long. Nonetheless, as chair of the Ethics Committee, I felt our recommendation should be promptly followed, as it was thoroughly considered and well-intentioned.

Three aspects of this situation caused me significant moral distress. First, the Ethics Committee's recommendation was briefly ignored, conflicting with my belief that such recommendations should be heeded. Second, I felt terrible about making the recommendation. As the leader of the chaplaincy department, it was a complete reversal of our usual values, which emphasized the presence of loved ones during critical moments. Third, about a year later, our state passed a law prohibiting zero-visitor policies in the future, making me feel morally distressed for having supported a now illegal policy.

The Full-Code Patient

Now, let’s shift to a more clinical example of moral distress experienced by nurses. Years ago, we had an elderly, frail patient with necrosis of the brain and metastasized cancer. She had multi-organ failure and was vent-dependent. She was in bad shape, to say the least. My heart went out to her. However, despite her dire condition, her family insisted on keeping her a full code, demanding that everything possible be done to preserve her life.

For the healthcare team, this was a source of moral distress. They knew that resuscitating her would not change the inevitable outcome due to her severe conditions. Even a non-clinical reader can easily understand that if this patient regained pulses following CPR, that would not remedy her cancer, dead brain tissue, and organs that had stopped working. Day after day, nurses, patient care techs, respiratory therapists, physicians, and others, dreaded the possibility of this frail patient’s heart stopping.

Late one night, the situation came to a head when she flatlined, and all the alarms sounded. Following protocol, the team performed CPR, including chest compressions and other resuscitative measures on this frail patient. This was deeply distressing for the staff, who felt they were violating their own values by providing aggressive care that seemed futile and inhumane. Not to mention that the only family member in the room was the patient’s granddaughter. Since she was not the designated decision maker for the patient, she could only watch her grandmother’s last moments on earth, characterized by the trauma of CPR.

It was awful.

While these examples may seem extreme, healthcare workers know that morally distressing situations are commonplace.

An office policy about the number of patients to be seen requires a physician to rush her visits and express less compassion that is natural for her. HIPAA laws keep front desk coworkers from being straightforward about the work happening around them, sometimes leading to interpersonal conflict. Financial pressures prevent a nurse from providing the medications or supplies he believes would be most appropriate for a certain patient. These sources of distress are woven into the daily lives of healthcare workers.

I used to feel as though there was an evil person behind every morally distressing situation. If we could just find him and remove him, the stress and obstacles would all dissolve. Of course, that was a child’s fantasy.

While there are plenty of misguided or inept leaders making things more difficult, the system itself provides moral distress and burnout opportunities even if every executive is kind and supportive.

Despite being normal and commonplace, moral distress inflicts a cost on us—particularly when it is sudden or profound. This can lead to moral injury, a deeper wound to our inner selves. Moral distress and injury can pave the way to burnout, making it challenging to reverse the damage done.

Soon, we will consider how burnout feels. But first, Erin explains the phenomena of vicarious trauma, moral injury, and compassion fatigue.