Moral distress occurs in situations in which you feel that you are powerless or constrained from acting in a manner which you believe to be ethically correct or consistent with your core values. Everyone in healthcare has experienced moral distress, but it often feels that moral distress is something that we’re not supposed to talk about, particularly when we’re in training.
Neonatal intensive care units often come to mind when moral distress is mentioned, because so many of the patients cared for are at the edge of viability and/or have complicated, often devastating malformations.
I was therefore interested to see the article about moral distress in neonatology by Dr. Trisha Prentice and colleagues at the University of Melbourne and Université de Montréal, which is being early released this week by Pediatrics (10.1542/peds.2020-031864). They specifically looked at the dynamic nature of moral distress when caring for an infant during NICU hospitalization. They surveyed nurses, residents, fellows, and attending neonatologists on periodic days during that infant’s hospitalization about the degree of moral distress being experienced that day regarding that specific patient. If the survey indicated that the level of their moral distress was high, the respondent was asked to describe why.
There is a great deal of information in the results. Briefly, moral distress was described in 15% of the survey responses. The level of moral distress was variable – it tended to be highest at the beginning of the hospitalization and then declined, presumably as the infant’s condition stabilized. Neonatologists tended to describe lower levels of moral distress than trainees or nurses. Common reasons for moral distress centered around aggressive interventions that were not perceived to be in the best interest of the infant. Often families requested the desire for these aggressive interventions, and when this conflicted with the clinicians’ recommendation for comfort care, moral distress was universally described by the clinicians.
In an invited commentary, (10.1542/peds.2021-051029) Dr. Manisha Mills and Dr. DonnaMaria Cortezzo from Cincinnati Children’s note that experiences of moral distress are likely altered by the newer emphasis on shared decision-making, in which parents may have more voice in management decisions. The process of shared decision-making often provides the medical team with a better understanding of the family’s values and viewpoints, and this may reduce moral distress.
This article and the accompanying commentary have many insights that are important for all of us who care for patients. Additionally, improved understanding of the dynamic and complex nature of moral distress is important as we all work to reduce the negative impact of feeling powerless or constrained in difficult clinical situations.