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.
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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.
