Moral distress common in physicians treating patients with surrogate decision-makers

Many physicians treating older patients who require surrogate decision-makers experience moral distress, according to research recently published in the Journal of General Internal Medicine.

The prospective study surveyed 154 physicians who were treating 362 patients requiring surrogate decision-makers. Physicians rated their moral distress about the care of each patient on a scale of 0 to 10. Results showed that physicians experienced moral distress while caring for 42% of the patients.

Researchers also found that physicians were more likely to experience moral distress with older patients (OR = 1.06; 95% CI, 1.02– 1.10) and when making a decision on life-sustaining treatment (OR = 3.58; 95% CI, 1.54–8.32). Meanwhile, they found physicians were less likely to experience moral distress when caring for patients living in nursing homes (OR = 0.4; 95% CI, 0.23–0.69) and for those who had previously talked about their care preferences (OR = 0.56; 95% CI, 0.35–0.90).

Two of the study authors, Alexia Torke, MD, MS, a research scientist at the Regenstrief Institute and an associate professor and the Indiana University School of Medicine, and Lucia D. Wocial, PhD, RN, FAAN, a nurse ethicist at Fairbanks Center for Medical Ethics at Indiana University Health and an adjunct assistant professor at the Indiana University School of Nursing, told Healio Primary Care more about the study and the implications of moral distress on the lives of both patients and physicians. – by Erin Michael

Q: Why was this study needed?

Wocial: There are many studies demonstrating moral distress in nurses, yet few studies address the physician experience of moral distress. In my role as a health care clinical ethics consultant, the most frequent reason clinicians seek assistance from an ethics consultation service has to do with cases around end-of-life care, especially when a surrogate is being asked to make decisions about what treatments to pursue when the patient has not in the past and, in the moment, cannot provide input into the decisions. Better understanding of physician moral distress means we can better support them and, in some cases, identify situations that are more likely to contribute to the experience of moral distress.

Q: What is moral distress, and what causes it?

Wocial: Despite the fact that moral distress has been identified as a significant phenomenon for decades, a precise definition of moral distress remains elusive. For the purposes of our research, we defined moral distress as the experience of believing you know the correct thing to do, but something or someone restricts your ability to pursue the right course of action. Individuals who experience moral distress feel distress because they feel the situation in some way compromises their integrity as an ethical practitioner. Moral distress is more than just feeling distressed in a difficult situation. It is the health care provider’s moral judgment about the rightness or wrongness inherent in a situation that leads to the emotional response. There are many things that can cause moral distress. In our study we found, for example, when physicians preferred a more comfort-focused plan than the patient was receiving, they had significantly higher moral distress. Physicians are responsible for making recommendations for treatment and when a patient has a treatment plan inconsistent with recommendations, physicians may feel they have not met their ethical obligation to patients. Moral distress is not a sign of weakness in physicians. It is more likely a sign that physicians are sensitive to the ethical complexity inherent in today’s health care environment.

Q: How can moral distress negatively impact patients and physicians?

Wocial: Moral distress has been correlated with secondary traumatic stress, burnout, intent to leave a position and depressive symptoms. According to the National Academies of Science, Engineering and Medicine, we are facing an epidemic of physician burnout. When health care providers have higher levels of moral distress, they may distance themselves from patients. Patients may suffer due to lack of continuity of care that is essential for high-quality patient care. Because moral distress is often associated with poor communication, it is often a sign of a problem within the health care environment.

Q: The study found that physicians caring for patients in nursing homes were less likely to experience moral distress. Why is that?

Torke: Unfortunately, our study does not tell us why patients in nursing homes led to less moral distress. We know that patients who are long-term residents of nursing homes tend to have poor health, and it may have been the case that there was more agreement to avoid life-sustaining treatments for those patients. Future research is needed to prove this.

Q: What interventions are needed to reduce moral distress?

Torke: We found that moral distress is lower when patients have discussed their own wishes for future treatment, a process called advanced care planning. Dr. Wocial and I are currently collaborating on an [National Institute on Aging]-funded study in which nurses will visit a patient in the home and conduct an in-depth advance care planning discussion. We are studying whether this discussion will help older adults get the care they prefer, even when they cannot make their own decisions. Improving this process may also improve the moral distress of the clinicians taking care of older adults in the hospital.

Reference:

Wocial LD, et al. J Gen Intern Med. 2020;doi:10.1007/s11606-020-05652-1.

Disclosures: The authors report no relevant financial disclosures.