Investigators recently discovered 42% of physicians experienced moral distress when caring for patients with surrogate decision-makers.1

“At the time the study was conducted, there was much less research documenting moral distress beyond nurses,” says Lucia D. Wocial, PhD, RN, FAAN, HEC-C, a nurse ethicist at Fairbanks Center for Medical Ethics at Indiana University Health.

Wocial and colleagues suspected physicians also experienced moral distress. To find out for sure, they surveyed 154 physicians caring for patients age 65 years and older as well as 362 patients admitted to ICUs and their surrogate decision-makers. Physician moral distress occurred more often when the clinician was male, the patient was older, and the decision had to be made about life-sustaining treatments.

Notably, there was no difference in moral distress in cases where the physician and the surrogate disagreed on the plan of care. There was discordance between physicians and surrogates more than 50% of the time.

Physicians preferred more comfort than surrogates preferred in 26.2% of cases. For example, in some cases, the family declined a feeding tube for a stroke patient despite the potential for partial recovery. Physician preference for more aggressive treatment than what surrogates preferred occurred more often (31.3% of cases). This conflicted with the researchers’ own clinical experience. “As a member of an ethics consultation service, we are more frequently contacted when the medical team feels a patient is receiving more aggressive treatment than can benefit the patient,” Wocial explains.

Physician moral distress occurred less often when patients had discussed their care preferences already. This suggest ethicists should redouble efforts to encourage discussions about end-of-life values and preferences before there is a medical crisis. “If you are sick enough to be in the hospital, especially during COVID, you should have a conversation about end-of-life preferences and, at the very least, name a surrogate,” Wocial suggests.

Really, it is never too early for such discussions. “We need to normalize it, and help providers make it a part of everyday conversations, not just when the writing is on the wall,” Wocial says.

Clinicians might also consider the wording they use when engaging in these conversations. Wocial suggests this wording: “Tell me what is important to you so we can make a plan consistent with your values and with what is possible with modern medicine.” Otherwise, says Wocial, “we get stuck in asking people what they want, without consideration for what is medically possible.”

Connie M. Ulrich, PhD, MSN, RN, FAAN, says it is important to anticipate issues that might arise in a patient’s care early. “Patients and families often rely on nurses to help clarify information that they might not understand or need help interpreting,” says Ulrich, professor of bioethics and nursing at the University of Pennsylvania School of Nursing.

Nurses might listen to patients and families ask questions about their care, preferences, and goals. Then, nurses can translate these conversations to physicians. Some patients and families are going to demand care that is perceived to be nonbeneficial or even harmful. “Ethicists can be called to address conflicts early on and to talk through possible scenarios of the situation,” Ulrich says.

Only about one-third of Americans have created advance directives that would let others know their preferences regarding life-sustaining measures.2 “Nurses and others experience moral distress when there is conflict related to end of life,” Ulrich observes.

To prevent this, Ulrich says patients should discuss their preferences and goals with their families before they are hospitalized. This is especially important at a time when many patients are presenting to EDs with possible COVID-19 symptoms. “Although this might not be the best setting to discuss end-of-life issues, we do need to have these conversations,” Ulrich stresses.

It is the only way for clinicians to understand what patients want should they need respiratory support or other invasive treatments. “Early and transparent communication helps everyone and ethically respects patients and families,” Ulrich adds.


  1. Wocial LD, Slaven JE, Montz K, et al. Factors associated with physician moral distress caring for hospitalized elderly patients needing a surrogate decision-maker: A prospective study. J Gen Intern Med 2020;35:1405-1412.
  2. Yadav KN, Gabler NB, Cooney E, et al. Approximately one in three US adults completes any type of advance directive for end-of-life care. Health Aff (Millwood) 2017;36:1244-1251.