3/3/2010 Laying the Groundwork Addressing Moral Distress in � What is Moral Distress? � Why do we Care? Caregiving at the End of Life � Common scenarios of internal conflict Health Ethics Week � What might we do to manage moral John Dossetor Health Ethics Centre distress? Eric Wasylenko MD March 2, 2010 � Reflections eric.wasylenko@albertahealthservices.ca What is Moral Distress What is Moral Distress � Many definitions used: � Recognizing that various options for action are available, where the values, � The experience of feeling incapable of b li f beliefs or sense of rightness and f i ht d doing what one believes one ought to do wrongness underlying the choices are because of some barrier… (Jim Read) competing and not easily reconciled. What is Moral Distress What is Moral Distress � Moral Distress occurs when: � Do these definitions encompass the � Know the ethically appropriate action, but scope of moral distress for you… cannot act upon it � Act contrary to personal and professional � Act contrary to personal and professional values, undermining integrity and authenticity (American Assoc. of Critical Care Nurses, from A. Jameton) 1
3/3/2010 What is Moral Distress What is Moral Distress � In some circumstances, our own � After moral deliberation, on balance the competing values make us uncertain chosen action may seem right. But other about what the right choice is. g treasured values may necessarily be t d l il b � In some circumstances, competing subjugated in order to carry out the values between persons make us action. uncertain about what the right choice is. Scenarios of Internal Conflict Scenarios of Internal Conflict � A woman asks you to approve a travel � A person asks you to not provide food authorization for treatment in a clinic in and liquids so that she can die more M Mexico, motivated by a belief that a i ti t d b b li f th t quickly when you know you can likely i kl h k lik l miracle may happen. You worry that she provide reasonable quality for many will die while there, away from her young months if given the opportunity. family and support systems. Scenarios of Internal Conflict Scenarios of Internal Conflict � A person’s family demands life � A dying person’s family won’t allow you prolonging interventions on behalf of to discuss with him what is happening their mother who cannot speak for p because of cultural belief religious because of cultural belief, religious herself, in a situation in which you know imperative, or personal fear. you cannot likely prevent substantial � Yet you believe firmly in the importance pain. of including him fully. 2
3/3/2010 Scenarios of Internal Conflict Scenarios of Internal Conflict � A person’s family asks you to carry on � The resources needed to provide with life prolonging interventions for their reasonably safe, secure care for an dying, comatose brother despite what d i t b th d it h t elderly, dying widow in her home are not ld l d i id i h h t you believe is irreversible major able to be secured, necessitating a deterioration. placement in LTC, against her wishes. Scenarios of Internal Conflict Scenarios of Internal Conflict � You are a Resident. The Attending does � You care for a homeless person with terminal esophageal cancer, who is not want to speak openly with a person gruffly appreciative of what your team about her terminal oncologic condition has been providing in hospital, but who has been providing in hospital but who f for fear of taking away hope. Yet you f f t ki h Y t desperately seeks return to the street are aware this person has a need to where he is unconfined and back with his prepare her family for her inevitable people. death. Scenarios of Internal Conflict Scenarios of Internal Conflict � You believe the direction of care and � You care for a person at home who interventions for a person you are caring requires the use of opioids for pain for are wrong, maybe even control. But you learn some of her t l B t l f h d h dehumanizing. But you are compelled to i i B t ll d t follow the orders written into the care supply is being diverted by a nephew plan and feel you have no power to who lives with her. change them or question them. 3
3/3/2010 Scenarios of Internal Conflict Scenarios of Internal Conflict � You care for a person whose daughter � The family of a terminally ill man you are insists on avoidance of opioids for her caring for is accusing you of withdrawing mother, since she believes they make , y lif life sustaining fluids and PEG feeding t i i fl id d PEG f di her confused. Yet the patient is just so that he will die sooner and you obviously in considerable pain. Her can free up a bed. daughter is the agent. Scenarios of Internal Conflict Scenarios of Internal Conflict � A person you are caring for seems to be � A dying person on your unit whose family pleading with his eyes for you to relieve never visits desperately needs someone his distress. But due to the complexity of to just be present with her. But you are his pathology you don’t feel able to sort hi th l d ’t f l bl t t run off your feet with meds to draw up out his pain diagnosis or know how best and deliver, and the family in room 6 is to assist him, and there is no one else to very demanding of your time. help. Scenarios of Internal Conflict Commonalities � Your colleague has just experienced the � What are some common threads that run death of her own brother, and is back at through all these examples? work. Today she is caring for a similarly y g y aged person dying of the same disease as her brother, and you don’t know how best to support her. 4
3/3/2010 Scenarios of Internal Conflict Limited view � You are asked/compelled to provide or � Some authors categorize the range of avoid certain acts, and the compulsion circumstances producing moral distress runs counter to what you believe is right as: � You wish to minister to those who � You wish to minister to those who depend on you, but you cannot due to � Arising from a distressing situation limitations outside of your control � Arising from a unit practice or behavior � Competing principles and values result in � Arising from power imbalances decisional conflict for you That is too constrained… or � There can be � There are individual circumstances � an accumulation of single distressing events leading to episodic moral distress � recognition that single events will re occur � recognition that single events will re-occur � this can resolve or linger hi l li � a sense that all we do will simply not be enough, outside of major events Stress versus Dis-stress Stress versus Dis-stress � Moral distress, on the other hand, is � Moral stress can be seen as positive disempowering tension , that does not tension , creating space for moral keep us integral, and that leads to p g , reflection individually or as a team, in fl ti i di id ll t i internal conflict that is not resolved, order to determine ideal care decisions despite what may be seen by others as while maintaining moral balance correct or acceptable actions. 5
3/3/2010 Balancing Continuum � Many difficult decisions lay on points of � Most of our actions require a balance the continuum between being beneficent between competing imperatives. When and not causing harm. the scales on competing sides are nearly p g y � There are no universal ways to balanced, we have increased the risk of determine if it is better to seek maximum doing the wrong thing. benefit for those we serve, or to avoid major harm. � That worries us. Human nature The nature of end of life care � Yet it is likely human nature that we tend � Reduce suffering to impart more weight to what we feel we � Optimize function cannot ideally provide – where we feel � So that people can accomplish aims, live � So that people can accomplish aims live we have failed – than to what we do h f il d th t h t d right. until they die, and prepare themselves � This is especially true in a conflicted and their loved ones. situation where we have to choose. The nature of end of life care Tension generators � Where do tensions arise: � Pall = to cloak � Personal drive for excellence � We feel a driving need to envelope with loving care, to � Genuine caring shield from suffering. � Professional duty Professional duty � But how do we know this is what patients want � Fear of recrimination (professional sanction, universally? reputational, lawsuit, self-berating, lack of � Does suffering mean the same thing to each of us as it appreciation, negative response from does to each of our patients? patients and families) � Desire for moral wholeness (integrity) 6
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