Moral Distress In Nursing

Have you ever felt a sense of constraint in the healthcare setting as a result of being unable to pursue what you believe is the most ethical course of action? The purpose of this article is to discuss moral distress and offer some suggestions on how to effectively address the issue. Nurses Announcements Archive Article

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TheCommuter, BSN, RN

102 Articles; 27,612 Posts

Specializes in Case mgmt., rehab, (CRRN), LTC & psych.
And when it comes to our own moral compass, it needs to be left at the door.
The nurse who leaves his/her moral compass at the door is typically the same type of person who might be lacking in ethics or empathy.

Would you be okay with the patient with stage 4 metastatic cancer who writhes in intractable pain because her son (the POA) only wants her to have one regular strength Tylenol Q6h and nothing else? I cared for a patient like this several years ago. She screamed in agony and begged to go home to "be with the Lord" because the pain was so bad. BTW, she had 9 pressure ulcers in various spots on her body. She died 6 weeks later. Those final 6 weeks were filled with torture.

The moral commitment that nurses make to patients and to their coworkers includes upholding virtues such as sympathy, compassion, faithfulness, truth telling, and love. Nurses who act with moral courage do so because their commitment to the patient outweighs concerns they may have regarding risks to themselves.
Creating Workplace Environments that Support Moral Courage

Amber628

53 Posts

I deffinitely agree with this post 100%. My grandmother is 78 with moderate/severe alzheimer's. I thank god everyday my mother is her POA and believe in quality of life over quantity.

When my grandfather was dying of cancer my grandmother tried everything to keep him alive. The last few months of his life were hell in a hospital bed in the living room of my grandparents house. I remember being 6 years old and when my grandfather finally refused to eat, my grandmother trying to force feed him because she didn't want him to die. They were together since they were teens and she couldn't deal with the grief of him dying. I understand her sorrow and pain but it was terrible what I saw him go thru. I remember the last 3 days of his life as his lungs shut down he would exhale black foam, and sometimes aspirate.

Now that my grandmother is sick my uncles argue with my mom over her being a full code and my mom stands her ground no matter how mad they are. My grandmother will NOT go on a feeding tube or a ventilator, when its her time she will go, peacefully and in LEAST pain as possible.

As nurses/nursing students it is NOT our job to "play god" but its our job to ensure comfort for end of life care, and be advocates for our suffering patients!

Maremma

78 Posts

This is such a heart breaking subject. Another one of course that I do not fully comprehend. Now that I am in nursing and am seeing some of the insanity up front on top of my personal experience, I better understand why my father said and did what he did.

My dad was not in the medical profession. He was terrified of Dr.'s and hospitals. He watched his father die in agony from colon cancer when he was 15 years old and it haunted him all his life.

I knew something was very wrong with my father and tried many many times to get him to let me take him to the Dr. He would lie to me and tell me he was losing weight on purpose because of his high blood pressure. He would lie to me and tell me his sinuses were "acting up" that he would be sleeping so much more. He knew I knew it was far more serious than that.

One day I was really after him about his failing health.He was only 65. He said to me, "When I am ready to die I will let you take me to the hospital" I tried to talk to him about a living will.He told me "No I will not have one of the drawn up. YOU are my living will. He finally "confessed" "maybe I have what my father had". I knew right then my dad was dying of some form of cancer and did not want treatment. He did not want ANY measures to extend his suffering nor would he even seek a Dr for "comfort measures".

My dad told me "A living will is a useless piece of paper to anyone that still has any living family. The bottom line will still always be what the living say they want for the dying person". I didn't really comprehend what my father was saying. I was "convinced" that a living will is legally binding and ties the hands of anyone that tries to "undue" what the person had written in their living will. Still I respected my dad and knew he was asking me to "protect him" from any insanity that others would try to impose on him when he no longer had a voice.

A few weeks later on my regular stops to see my parents I heard a thumping noise upstairs and went to see what it was. My father had fallen and was laying on the floor next to his bed. He was unable to get up on his own. He looked at me with the most heartbreaking pleading eyes. It ripped through me.

My dad was a "giant mighty oak tree" in life. He was a power lifter in his youth and remained a very large and powerful man up until the last few months of his life. He was my best friend. My parents did not get along for many many years.My sister had done so many selfish things my father was bitter against her too. My dad was a shy man with very few friends. He often told me I was is favorite person in the whole world and me and is dogs were all he had left.

Dad said to me "I hit my head. Call an ambulance. Take me to the hospital. It's time". His previous word haunted me. "take me to the hospital" rang in my ears over and over. As the EMT's rolled my father over to be able to get him on the stretcher I was frozen in shock. My dad had also been hiding his body with large loose clothing any time I had seen him before this. There was a MASSIVE bulge in his left upper quadrant.He was so thin otherwise it looked like he had a basketball under her skin, Both EMT's also saw it and both quickly looked up at each other with knowing eyes but were unable to say what they knew.

The EMT's told us they had to take him to a further away hospital because after examining him they realized he had a severe head trauma. I raced behind them to meet them at the ER. My sister and mother right behind me.

By the time we got there dad's speech was beginning to slur. He still was able to speak, looked right at my estranged sister and FINALLY told her he loves her. I silently prayed and thanked God for that. It was far to many years that things were bad between them.

dad had a subdural hematoma from the fall. They were unable to stop the bleed due to the leukemia. The cells were going into his spleen but couldn't get back out. His spleen was ten times the size it was suppose to be and what was causing the severe bulge in is upper left quadrant. One nurse would come in and talk about his lymphoma, the next his leukemia, the next his hematoma.

We had a "meeting" with all us family and all the hospital staff doctors involved. It was all to surreal to me. What does he have? Leukemia? Lymphoma? Why are they using these terms interchangeably? They could not remove the spleen because he would bleed to death on the table. They were giving him bags of platelets one right after the other and they would just stay trapped in his spleen. None of the people in the meeting would give us direct answers. They explained that "Dad is struggling to breath, if they would put a tube in him to help him breathe, he would no longer be able to talk to us". "help him breath" not BREATHE FOR HIM. "Dad is no longer able to eat by himself, they would have to put a feeding tube through his nose to keep him from starving to death" Not "If we put a feeding tube in him we can increase his suffering a bit longer and force food into a system that is already shutting down" They were so vague in their responses.We were more confused after the meeting than before! What I DID understand was that they asked about DNI, DNR feeding tubes etc. I tell them that dad doesn't want all those things stuck in him and he doesn't want to be brought back to suffer more once he dies.

I had to run home to take care of my pets and get showered. I go back to find my dad has a feeding tube and is intubated! He kept trying to pull them out for himself and so they tied his hand fast to the bed! Dad was no longer able to speak but he was still able to respond to me by squeezing my hand. I asked him to squeeze my hand once for yes and twice for no. I explained to him that there was a tube in his throat that was breathing for him now. Did he change his mind? "No" Do you WANT this tube in you? "No"

I was so confused what happened and why. I went out to find his nurse. My mom had authorized these things! I asked the nurse if something had changed? Was there a new development that would now allow my father to get better and come home for a while? No. There is nothing else that can be done to help him get better. He will never be able to come home. She was very direct and kept it simple. I had to question my mother. She did not REALIZE what she was doing when she authorized these things! She thought she was easing his suffering by "helping him breath" and "not starving him to death"! The way the hospital staff worded things in that meeting guilt ed my mom into going against my dad's wishes. I went to the NURSE'S for help. My mom finally said to them "Just do whatever she says to do. He talked to her the most about all these things any way. I don't want him to haunt me after he is gone"

Another nurse was coming on shift and explained that if they took the tube out dad was going to begin struggling to breath. If that does happen they can give him medicine to ease his breathing. (morphine) I told them he doesn't want it you have to take it out. It KILLED me to see him struggling for breath but he squeezed my hand with a look in his eye that said "thank you". They gave him the morphine that thank God worked quickly. Dad passed peacefully in his sleep 12 hours later.

jadelpn, LPN, EMT-B

9 Articles; 4,800 Posts

The nurse who leaves his/her moral compass at the door is typically the same type of person who might be lacking in ethics or empathy.

Would you be okay with the patient with stage 4 metastatic cancer who writhes in intractable pain because her son (the POA) only wants her to have one regular strength Tylenol Q6h and nothing else? I cared for a patient like this several years ago. She screamed in agony and begged to go home to "be with the Lord" because the pain was so bad. BTW, she had 9 pressure ulcers in various spots on her body. She died 6 weeks later. Those final 6 weeks were filled with torture.

Creating Workplace Environments that Support Moral Courage

Again, one needs to be really, really mindful of who they choose to be their POA/HCP. And in this instance, no I would not want to see this, I think it is awful and sad and beyond unthinkable. But as advocates, then is it not time to get Social Work, Palliative care, and the Doctor involved in the obvious untreated pain of this patient? You bet. My point was that our own moral compass may not be the same moral compass as our patients or their POA/HCP. So we need to treat the patient, as opposed to our own thoughts on morality. IE: Patient actively dying and are religiously against blood transfusions. Religion prevents proper treatment. Patient has one little spark of awareness, and in go the tubes wires and whistles.For myself, I am empathetic and ethical to a fault. And I strive hard to get a patient what they need to be comfortable and at peace, that is the goal. By my ethical thoughts are not always the same as my patients, therefore, one needs to focus on what they can do, as opposed to how horrible it is what is not being done.

TheCommuter, BSN, RN

102 Articles; 27,612 Posts

Specializes in Case mgmt., rehab, (CRRN), LTC & psych.
I don't understand some of these posts/threads.? It's like ALL of them just want the 'new' people who are thinking about nursing to stay away. I think we should be more accommodating to our young ones. Teach and let others know the good things about nursing and how you can have a successful career if you stick with it.

We do have a very inspiring forum called Success Stories In Nursing. It is filled with posts where people share their successes, triumphs, joys, and love of the nursing profession. Click on the link below to get there:

Success Stories in Nursing

kdbuckley1

4 Posts

If a pt has a very clearly written living will and the health care surrogate wants to override the living will, since they are both legal documents, can the hospital override the healthcare surrogate? I just turned a case like very similar over to Risk earlier today. The patients wishes are CLEARLY layed out in his living will. He is mentally intact, but has a progressive disease that has taken his ability to communicate. Nursing staff and case management are trying our hardest to advocate for this patient. Just curious.

TheCommuter, BSN, RN

102 Articles; 27,612 Posts

Specializes in Case mgmt., rehab, (CRRN), LTC & psych.
If a pt has a very clearly written living will and the health care surrogate wants to override the living will, since they are both legal documents, can the hospital override the healthcare surrogate? I just turned a case like very similar over to Risk earlier today. The patients wishes are CLEARLY layed out in his living will. He is mentally intact, but has a progressive disease that has taken his ability to communicate. Nursing staff and case management are trying our hardest to advocate for this patient. Just curious.
In the state where I live, two physicians can sign an out-of-hospital DNR order if they feel it is in the best interest of the patient, even if other entities are demanding a full code status.