Since 2006, staff at Charlottesville, VA-based UVA Health have been able to request a consult specifically for moral distress.1 “We have learned so much in the last 10 or 20 years about what moral distress is, and why it’s important to recognize and intervene,” says Beth Epstein, PhD, RN, HEC-C, FAAN, associate professor and interim director of academic programs at UVA School of Nursing and UVA Center for Health Humanities & Ethics.

To date, ethicists have conducted 115 consults. To obtain data on the usefulness of the Moral Distress Consultation Service, Epstein and colleagues recently analyzed 21 consults and interviewed the participants.2 “We hoped that our study would give others some ideas about addressing moral distress, and perhaps even [about] developing a similar service,” Epstein says.

Only a small decrease in moral distress was found after consults. This finding was unexpected and somewhat disappointing. “But when we looked carefully at the quantitative and qualitative data, there were two reasons why we didn’t see a big change,” Epstein reports.

First, moral distress levels for some consult attendees were fairly low at presentation. “After spending an hour discussing the case, they realized how truly morally distressing the situation actually was, and left with higher levels of moral distress,” Epstein says.

Others entered the consult with already-high levels of moral distress. After realizing colleagues shared similar concerns, and identifying some coping tactics, these participants reported lower levels of moral distress.

Second, at the end of the consult, the morally distressing situation remained ongoing. “The group has identified some actions to resolve the situation, but they haven’t acted yet,” Epstein notes.

Overall, participants found the consult service to be valuable as a way to figure out how to resolve difficult cases as a team. Participants also believed it was a demonstration that the organization values them. “We frequently get feedback from those who’ve attended consults that this is the case,” Epstein says. “The consult service is a good mechanism for empowering clinicians to speak and act.” One participant mentioned “no retribution or fear of other people thinking poorly of you.”

The consult service seemed to affect the ICU more than non-ICU settings. “There could be several reasons for this,” Epstein says.

One possibility is the causes of moral distress differ, depending on the setting. In the ICU, the issue often is prolonged aggressive treatment the clinical team believes is not in the patient’s best interests. “The team can work on strategies that address that specific instance,” Epstein offers.

In non-ICU settings, the issues tend to more broadly involve unit and system factors. Some of those consults focused on managing patients with aggressive behavioral issues. Trying to improve the way such cases are managed cannot happen without involvement from outside areas: security, behavioral medicine, or psychiatry. This adds complexity to the process. “When clinicians are already time-constrained, fixing the problem can seem too big a task,” Epstein observes.

Addressing moral distress is different than addressing ethical challenges, according to Epstein. She says awareness of these differences is important. Ethical challenges involve specifying the justifiable paths that could be taken, and a process to decide which is the “best right path.” Moral distress challenges involve violations of professional obligations and constraints that inhibit healthcare providers from taking the right action.

During moral distress consults, ethical issues might arise. For instance, some consults involve a fully capable patient with metastatic cancer who requested no further treatment and wants to go home with hospice care. The patient’s adult children demand she continue treatment, refuse to take her home, and threaten to call a lawyer if the team does not comply with their demands.

In this situation, the team may coax the patient to continue treatment, and the patient unenthusiastically complies. “She has tried to speak up for herself, but has not been heard,” Epstein says. “During this consult, the ethical issue of respecting a patient’s wishes arises.” For this issue, an ethics consult would be appropriate.

Ethicists who want to pursue this at their own organizations can consult with the recently formed Moral Distress Consultation Collaborative. This is a group of 10 ethicists at six organizations who practice some form of moral distress consultation. “The goal is to conduct research and develop educational materials and competencies for clinical ethicists interested in addressing moral distress at their institutions,” Epstein says. 

REFERENCES

  1. Hamric AB, Epstein EG. A health system-wide moral distress consultation service: Development and evaluation. HEC Forum 2017;29:127-143.
  2. Epstein EG, Shah R, Marshall MF. Effect of a moral distress consultation service on moral distress, empowerment, and a healthy work environment. HEC Forum 2021; Apr 3. doi: 10.1007/s10730-021-09449-5. [Online ahead of print].