Moral Distress In NursingRegister Today!
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.by TheCommuter Asst. Admin Jul 11, '12
Moral distress occurs when an individual judges that they know the right action in a particular situation, but internal or external constraints prohibit taking action (Volpe, 2011). Nurses are routinely placed in the difficult situation of being expected to stand behind the care decisions made by physicians and family members, even if we know that their choices may result in prolonged suffering. Nurses are expected to help patients and address their physical pain, but at the same time, we might participate in very painful interventions that seem to offer little in the way of help. This leads to a moral conflict that can mentally rip apart the strongest members of our ranks.
Moral distress can be discouraging, especially when the interventions are carried out at the whim of unrealistic family members. For instance, a 96-year-old female with end-stage dementia ends up on the acute rehabilitation unit at a specialty hospital where she must endure three hours per day of physical, occupational, and speech therapy after undergoing a bilateral total knee replacement. Her eldest son, the medical power of attorney, insisted that the patient have this major surgery despite the risks and the fact that she has not walked in nearly two years. When she stopped eating approximately one year ago, her son refused a consult for hospice, and instead, ensured that she had a feeding tube inserted.
After one month of various therapies at the rehab hospital that proved to be unsuccessful, the patient was discharged back to the skilled nursing facility where she had been residing prior to the surgery. She never regained the ability to walk, frequently wails in pain, never gets out of bed, stares at the wall inside her room all day, and pulls her feeding tube out at least once per month. The attending physician at the facility recently informed her son that the patient would now need hemodialysis. The son said, "Do whatever it takes. I want everything done for my mother." The staff at the nursing home cringed because they must continue to provide heroic measures for a patient with a terminal disease process.
Nurses have used unhealthy methods to deal with moral distress such as resentment, anger, job-hopping, casting blame on themselves and others, reducing hours to part-time, leaving the bedside for a position that involves no direct patient care, or leaving the profession altogether. However, more adaptive techniques exist. First of all, the most important thing we can do is speak up and identify the distressing situation, although this might be discouraged in certain settings. Since moral distress is not solely a nursing issue, the other disciplines need to be involved, especially social work and medicine. Management needs to support floor nurses by openly allowing dialogue regarding moral distress and conducting support groups. If possible, get the ethics committee involved. Also, a supportive network outside of the workplace is of great value to nurses who grapple with moral distress.
Most importantly, education is the key. We must educate patients and families about the inevitable end of life. By insisting that 'everything be done' for someone with a terminal prognosis, well-meaning family members are unwittingly reducing the patients' quality of life while prolonging the inevitable outcome. The circle of life naturally ends with death, and this is an outcome that no one will ever escape.Last edit by Joe V on Jul 11, '12
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TheCommuter is a moderator of allnurses.com and has varied workplace experiences upon which to draw for her articles. She was an LPN/LVN for four years prior to earning RN licensure
APA Style Citation
TheCommuter. (Jul 11, '12). Moral Distress In Nursing. Retrieved Sunday, May 19, 2013, from http://allnurses.com/showthread.php?t=755791
- Jul 11, '12 by Pepper The CatI think the Medical profession as a whole also has to say "No. This will not be done. " The ortho sugeon should refused to operate. The Gastro doc should refused to insert the g-tube. As long as we continue to bow to the wishes of the family, they will push for more.
- Jul 11, '12 by classicdamebut we do not want to be in the position where someone, ANYONE, has the right to determine who lives or dies. The above scenario probably would not exist in real life since the patient would not meet rehab goals. I do agree that education for the family, and maybe counseling, should be resources since family may feel guilty about making the wrong decision. This is not an easy call.
- Jul 11, '12 by imintroubleWhen death becomes an acceptable end to life, the end of life choices will change.
- Jul 11, '12 by TheCommuterQuote from classicdameThe above scenario has existed in real life many times.The above scenario probably would not exist in real life since the patient would not meet rehab goals.
I've taken care of demented 90+ year-old patients whose children insisted that they undergo a bilateral knee replacement. I have seen many of these types of patients in acute rehab hospitals, rehab wings of nursing homes, and so forth. Their Medicare dollars are milked for 100 days, and then they are discharged with no restoration in function.
- Jul 11, '12 by LovinLife28This post hits home for me. We had my 86 yr old grandmother removed from the ventilator this past tuesday. There was no hope for her, it was her time to go. First of all she never really recovered from a CVA she previously had. She was in a SNF where she developed a kidney infection. She was rushed to the hospital that Friday. She had renal failure, she had a MI, and she had pneumonia. Her lungs were so full of fluid. She was hooked up to about 12 different IVs and had a blood transfusion. Some of my family members did not want to take the tube out. Me being a nursing student understood the process a little better than them and I tried to explain to them that she cannot recover from this and to let her go. She was passing very little urine in 3 days so she was just swelling up with fluids. When they removed the tube, she lasted about 5 minutes before she passed away. Now the family members that did not want the tube removed are upset at those that had it removed.:uhoh21:
- Jul 11, '12 by johnny depp23I 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.
- Jul 11, '12 by DizzyLizzyNurseLovinLife28 I'm very sorry to hear about your grandmother.
I used to work rehab and another place where my unit was next to the rehab unit. People who are inappropriate for rehab have surgery and get sent to rehab ALL the time.
- Jul 11, '12 by anotheroneQuote from johnny depp23Accommodating how? Moral distress/compasion fatigue are big issues in nursing/health care that almost every nurse deals with and they are RARELY discussed never heard it mentioned outside of on here and in school. You need to know the bad things and the good. As has been mentioned a billion times before many nurses come on here to vent. There have been posts on the good parts of nursing, not out fault if they do not become the epic threads.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 Ithink 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.
- Jul 11, '12 by TheCommuterQuote from LovinLife28I'm so very sorry about your loss.This post hits home for me. We had my 86 yr old grandmother removed from the ventilator this past tuesday