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Many Faces of Moral Distress: Maintaining Professionalism in the IDT - AAHPM2012
1. The Many Faces Of Moral Distress:
Maintaining Professionalism Among The IDT
Cynda H Rushton , PhD, RN, FAAN • Suzana Makowski, MD, MMM, FACP, FAAHPM
2. Overview
What is moral distress?
Delving into dissonance: lessons from the humanities
Contemplation and resilience: practical tools
3. Gratitude…
Joan Halifax Roshi
Tony Back, MD
Susan Bauer-Wu, PhD, RN,
FAAN
Gary Pasternak, MD
Barbara Dossey, PhD, RN,
FAAN
Alisa Carse, PhD.
Jon Kabat-Zinn, PhD.
Christina Puchalski, MD
Warren Reich, STD
Saki Santorelli, EdD
Monica Sharma, MD
7. Moral distress: definitions
“Moral distress is the pain or anguish affecting the mind,
body or relationships in response to a situation in which the
person is
aware of a moral problem,
acknowledges moral responsibility,
and makes a moral judgment about the correct action;
yet, as a result of real or perceived constraints, participates
in perceived moral wrongdoing” (ANA, 2002).
8. Moral distress: definitions
Moral distress is the psychological disequilibrium that
occurs when a person believes he or she knows the right
course of action to take, but cannot carry out that
action because of some obstacle, such as institutional
constraints or lack of power.
9. "At times, I have acted against my conscience in
providing treatment to children in my care.”
54% of house officers
48% of critical care nurses
38% of critical care attending physicians
38% of hematology/oncology nurses
25% of hematology/oncology attending
physicians
Mildred Z, Solomon et al. New and Lingering Controversies in Pediatric End of Life Care, Pediatrics, Oct 2005; 116: 872 - 883.
11. Find a partner
Share your story –
• what was at stake for you? • what supported you? • how have you made sense of it?
12. Moral distress: contributing factors
Perceived powerlessness Lack of time
Socialization to follow orders Inadequate staffing
Hierarchies within the Lack of collegial
healthcare system relationships
Lack of administrative Policies/priorities in conflict
support with care needs
Compromised care due to Fear of litigation
pressure to reduce costs
Inadequate informed
Providing prolonged, overly consent
aggressive treatment
Increased moral sensitivity
Ineffective communication
among team members
http://www.azbioethicsnetwork.org/wp-content/uploads/2011/05/Moral-Distress.pdf
13. Moral distress: consequences
Diminished professionalism
Decreased patient/family satisfaction
Potential decrease in quality of care
Increased organizational costs
Burnout
http://www.azbioethicsnetwork.org/ethics-cases/moral-distress/
20. Dissonance in practice
42 year old Syrian
immigrant with metastatic
non-small cell lung
cancer, intubated for post-
obstructive pneumonia.
Septic shock on maximal
pressor support. Now with
multiorgan failure.
Diagnosed 6 months prior.
Now has a 3 month old
baby
“Do everything.”
21. Family
•We know he’s dying, but he needs to stay for his son.
Intensivist
•He’s in multi-system organ failure. I know he’s young, but he won’t survive. But
we will keep him full code, since that’s what they want.
Nurse
•This feels like futile care. He’s not awake. He’s in isolation. His baby can’t even
see him. I don’t know why we’re doing what we are.
24. Leaning in to dissonance
Cognitive dissonance
involves the ability of the
mind to hold two seemingly
opposite truths in a moment
“We know he’s dying, but we
need him to stay for his son.”
“He doesn’t want to die, but
he doesn’t want to suffer
either.”
“As the family Priest, I should
give them advice and
support, but I am afraid of
this suffering as well.”
Being curious
How else might he be able to
linger?
25. Moral distress in the hospice IDT
Hospice
nurse
Hospice
Volunteer
Physician
Patient
&
Home
health family Attending
Physician
aide
Social
Chaplain
Worker
26. Only people who are capable of loving strongly
can suffer great sorrow, but this same necessity of
loving serves to counteract their grief and heals
them.
Tolstoy
28. Antoine Lutz, Julie Brefczynski-Lewis, Tom Johnstone, Richard J. Davidson. Regulation of the Neural Circuitry of Emotion by
Compassion Meditation: Effects of Meditative Expertise. PLoS ONE, 2008; 3 (3): e1897 DOI: 10.1371/journal.pone.0001897
This is not just to make you feel good
A. Voxel-wise analysis of the Group by State by Valence (negative
versus positive sounds) interaction in insula (Ins.) (z = 2, corrected, colors
code: orange, p<5.10ˆ-2, yellow, p<2.10ˆ-2, 15 experts (red) and 15
novices (blue)). B. Average response in Ins. from rest to compassion for
experts (red) and novices (blue) for negative and positive sounds. C–D.
Voxel-wise analysis of BOLD response to emotional sounds during during
poor vs. good blocks of compassion, as verbally reported. C. Main
effect for verbal report in insula (Ins.) (z = 13, corrected, colors: orange,
p<10ˆ-3, yellow, p<5.10ˆ-4, 12 experts and 10 novices). D. Average
response in (Ins.) for experts (red) and novices (blue).
doi:info:doi/10.1371/journal.pone.0001897.g002
29. Create a pause
Anchor yourself in your Ask questions
breath
Get clarifications
Pause
Be open to new possibilities
Be transparent
Let go of outcomes
Monitor your mindset
Become a witness, rather
Explore personal responses than an actor
30. Addressing Moral Distress
Engage in contemplative
practices
Cultivate moral sensitivity
Modulate emotions
Care for yourself so you can care
for others
Reconnect to meaning
Build your “resilience muscle”
Be generous and kind to self and
others
Develop institutional systems
31. In Summary
Moral distress – can occur in any clinician, it adds to risk
for compassion fatigue and burnout, but there are things
we can do
Reflective practices
Learning to watch
32. Goethe
In breathing there are two kinds of grace:
To draw air into, then out of, your space.
The one presses down, the other
refreshes;
Thus marvelously life's web intermeshes.
You thank God whenever he hems you
in,
And thank him whenever he frees you
again.
33. Please Answer the Following Question:
Sometimes I feel we are
saving patients who
should not be saved.
Agree
Uncertain
Disagree
34. Please Answer the Following Question:
Sometimes I feel as though we
give up on patients too
soon.
Agree
Uncertain
Disagree
35. Please Answer the Following Question:
Sometimes I feel the
treatments I offer/provide
to patients are overly
burdensome.
Agree
Uncertain
Disagree
36. Please Answer the Following Question:
At times, I have acted against my
conscience in providing treatment
to patients in my care.
Agree
Uncertain
Disagree
37. Moral distress: causes
poor-quality and futile care,
unsuccessful advocacy,
and raising unrealistic hope
Schulter et al (2008)
38. New and Lingering Controversies in Pediatric End
of Life Care, Pediatrics, Oct 2005; 116: 872 - 883.
Survey of 781 clinicians at 7
institutions
Mildred Z. Solomon, Deborah E.
Sellers, Karen S. Heller, Deborah L. 209 attending physicians
Dokken, Marcia Levetown,
Cynda Rushton, Robert D.Truog, 116 house officers
and Alan R. Fleischman
456 nurses.
39. Definition: Burnout
• A response to chronic, and
cumulative stress (often
related to work). Includes:
– Emotional exhaustion
– Depersonalization
– Diminished personal
accomplishment
(Maslach C, Jackson SE: Maslach Burnout Inventory Palo
Alto, California:Consulting Psychologists Press;
1986.)
40. Burnout: Selected Data
Burnout shown to predict mood
disorders and poor general
health in physicians (Hillhouse et al.,
2000)
Burnout associated with:
- increase in self-reported
medical errors (West et al., 2006)
- suboptimal patient care
practices (Shanafelt et al., 2002)
41. Burnout: Impact
60% of practicing physicians report symptoms of
Burnout (Krasner, wt al, 2009 )
50% of PICU attending were at risk or burned out
(Fields, et al, 1995)
38%-66% Nurses report symptoms of Burnout (Aiken et al, 2001;
Laschinger, et al, 2006)
Linked to poorer quality of care
Decreased patient satisfaction
Increased Medical errors and lawsuits
Decreased ability to express empathy (Krasner, et al, 2009)
42. Burnout: Selected Data
• 76% of medical resident
respondents reported
symptoms of burnout:
– High depersonalization
(e.g., “I’ve become more
calloused towards
people since I took this
job.”)
– Emotional exhaustion
(e.g., “I feel emotionally
drained from my work.).
Shanafelt, colleagues (2002)
• Half the residents who feel
burned out suffer from
depressive symptoms. Shanafelt,
colleagues, (2002)
43. Compassion Fatigue
Is a form of secondary trauma characterized
by exhaustion, helplessness and dysfunction
as a result of prolonged exposure to
compassion stress and trauma.
Usually evolves in caring professionals who
absorb the traumatic stress of those they
help (Najjar et al , 2009).
No uniform definition
May be misnamed: Compassion cannot
cause fatigue or that becomes fatigued
44. How many agreed with this statement?
"Sometimes I feel we are saving children who
should not be saved,“
and
"Sometimes I feel we give up on children too soon."
20 times more nurses agreed with 1 than with 2
15 times more house officers,
10 times more attending physicians
Mildred Z. Solomon et al
Pediatrics 116: 872 - 883
Notas do Editor
CR
CR – add your preferred definition here
SM - dyad
CR
CR
Burnout definition: A response to chronic, and cumulative stress (often related to work). Includes:Emotional exhaustionDepersonalizationDiminished personal accomplishmentBurnout shown to predict mood disorders and poor general health in physicians (Hillhouse et al., 2000)Burnout associated with: - increase in self-reported medical errors (West et al., 2006) - suboptimal patient care practices (Shanafelt et al., 2002) 60% of practicing physicians report symptoms of Burnout (Krasner, wt al, 2009 )50% of PICU attending were at risk or burned out (Fields, et al, 1995)38%-66% Nurses report symptoms of Burnout (Aiken et al, 2001; Laschinger, et al, 2006)Linked to poorer quality of careDecreased patient satisfactionIncreased Medical errors and lawsuitsDecreased ability to express empathy (Krasner, et al, 2009)76% of medical resident respondents reported symptoms of burnout: High depersonalization (e.g., “I’ve become more calloused towards people since I took this job.”)Emotional exhaustion (e.g., “I feel emotionally drained from my work.). Shanafelt, colleagues (2002)Half the residents who feel burned out suffer from depressive symptoms. Shanafelt, colleagues, (2002)it is not compassion that causes fatigue, and it is not compassion that becomes fatigued. Compassion is not a finite quantity that becomes consumed and depleted. Rather, fatigue that accompanies efforts to relieve suffering or to change a particular situation is more likely related to the inability to accept and understand that some suffering and pain is not fixable, no matter what the effort the outcome is not totally within anyone’s control.-even if one’s actions are motivated by laudable intentions. Fatigue that arises when there is attachment to a particular outcome (“we need to get the parents to agree to a DNR order”) and thus the term “attachment fatigue” may be more accurate. Is a form of secondary trauma characterized by exhaustion, helplessness and dysfunction as a result of prolonged exposure to compassion stress and trauma.Usually evolves in caring professionals who absorb the traumatic stress of those they help (Najjar et al , 2009).No uniform definitionMay be misnamed: Compassion cannot cause fatigue or that becomes fatigued
CR- Body scan - what's happening in you right now, what are you noticing? These are important pieces of information to use to respond to rather than react with.
SM -‘‘‘All dramatic stories always involve conflict,’’writes Professor Ian Johnston in his introductorylecture on Shakespeare. ‘‘Typically, the dramaticnarrative opens with some sense of normal society[.] Then something unusual and often unexpected happens to upset that normality. [.]Creates confusion and conflict. [.] Attemptsto understand what is going on or to deal withit simply compound the conflict, accelerating itand intensifying it. Finally, the conflict is resolved.’’3But,the resolution is not always prettydresulting in forgiveness and reintegration of society and personhood; in fact, the most famous andcompelling plays end in alienation, death, andsorrow. Literature has the advantage of creatingcoherence, even in the presence of unspeakabletragedy; after the hero’s demise, there is often lament and ‘‘a reflection of the significance of thelife which has now ended.’
SM -As palliative care clinicians, when we remainwith a patient and his or her family as they struggle from tension to tension, we create room forthe possibility of catharsis. In doing so, we lendour strength, our curiosity about the possibilitythat their narrative will discover meaning, purpose, and harmony. By staying we don’t writethe ending but rather facilitate the potentialfor the protagonist to finish their ownstorydpreferably with less pain, distress, andloneliness. This we might call the harmony ofresolution, the narrative of hope, and the restoration of proportion and meaning.By developing a senseof curiosity toward dissonance we may discovera sense of wonder about the rich complexity ofthe human experience and develop mentalstability and courage.
SM -
Here there is no medical solution. This illustrates the needs to draw on interdisciplinary expertise to find a meaningful solution for all involved. So now that we can acknowlegde moral distress, we can start working on solutions to fix it, but it would be even better if we had the means to prevent it in the first place and in fact we do
To make matters even more challenging, the family Priest (they were Eastern Orthodox) was young – a year or two out of seminary. When he arrived in the ICU, he looked like a deer in the headlights with what seemed like the weight of the world on his shoulders.
This is where we present a case: SM provides the narrative of the case, CR guides the listeners through the reflective process – what comes up in the body, in the mind, etc?Guide people through the case where we get people start by noticing.- What memories come up, what thoughts come up, how is your body responding?Then to guide people through this exploration… Often the conversation goes quickly to "we shouldn't be doing this… this is futile… etc."Monitor our own responses 'they are making me to things I don't want to do…" my role is to find compassion in their own situation… move away from judgement.Body scan - what's happening in you right now, what are you noticing? These are important pieces of information to use to respond to rather than react with.
SM
SM -
SM - But resolution does not always happen. Stories don’t always end well. We all know stories whose endings are tragic, no matter how much we practice this form of presence. So – what do we do? We lean on each other. We turn inwards and find others to teach us resilience and remind us. Perhaps this is through meditation, prayer, a walk through nature, a ski in deep powder, a hour enveloped in Mahler or Brahms or whatever music helps you to remember.For some, we practice compassion.
CR
SM – on contemplative practice/reflection on burnout, etc.Research has shown that the development of brief meditation or reflection practices can reduce negative affect, depression, and anxiety for those experiencing stress (Wachholtz & Pargament, 2005, 2008). Other studies have shown that when clinicians develop skills in reflection practices or practice some form of contemplation of their experiences of suffering, they experience decreased burnout, compassion-fatigue (Holland & Neimeyer, 2005; Kearney, Weininger, Vachon, Harrison, & Mount, 2009) and moral distress (Austin, Lemermeyer, Goldberg, Bergum, & Johnson, 2005).
Rumi space between two notes
CR
it is not compassion that causes fatigue, and it is not compassion that becomes fatigued. Compassion is not a finite quantity that becomes consumed and depleted. Rather, fatigue that accompanies efforts to relieve suffering or to change a particular situation is more likely related to the inability to accept and understand that some suffering and pain is not fixable, no matter what the effort the outcome is not totally within anyone’s control.-even if one’s actions are motivated by laudable intentions. Fatigue that arises when there is attachment to a particular outcome (“we need to get the parents to agree to a DNR order”) and thus the term “attachment fatigue” may be more accurate. Is a form of secondary trauma characterized by exhaustion, helplessness and dysfunction as a result of prolonged exposure to compassion stress and trauma.Usually evolves in caring professionals who absorb the traumatic stress of those they help (Najjar et al , 2009).No uniform definitionMay be misnamed: Compassion cannot cause fatigue or that becomes fatigued