As part of a quality improvement initiative in the cardiothoracic ICU at Columbia University Medical Center in New York City, clinicians convened a multidisciplinary group of surgeons, ICU nurses, and ICU attendings to discuss the possibility of implementing palliative care triggers. During these meetings, it became clear the surgeons better understood the need for palliative care involvement after hearing how ICU staff struggle with moral distress and moral injury when caring for some patients undergoing mechanical circulatory support. “I was somewhat surprised, and realized that we needed to raise attention to this problem,” says May Hua, MD, an assistant professor of anesthesiology at Columbia University Medical Center.

Hua and colleagues surveyed 102 ICU clinicians (67 nurses, 28 physicians, seven advanced practice providers) and found those caring for patients receiving mechanical circulatory support reported high levels of moral distress.1 “Levels of moral distress reported by clinicians in our study was quite high overall,” Hua says.

However, clinicians did not report experiencing frequent moral distress when caring for patients undergoing mechanical circulatory support in comparison to other types of critically ill patients requiring life-sustaining therapies (e.g., chronic critically ill patients or patients with multisystem organ failure). “This is a hypothesis-generating result that needs further examination to better understand if it is a true finding,” Hua reports.

Clinicians were most likely to report frequent moral distress when caring for patients with chronic illness or multisystem organ failure, but were more likely to report frequent moral distress when caring for patients receiving mechanical circulatory support (26.5%) than when caring for patients needing routine care (10.8%). Moral distress was significantly higher among registered nurses (vs. physicians or advanced practice providers), clinicians reporting burnout (vs. those who did not), and clinicians considering leaving (vs. those who were not).

Clinicians pointed to palliative care and ethics consults as ways to mitigate moral distress. “We need to better understand how to support and help clinicians who experience moral distress,” Hua says.

During the COVID-19 pandemic, there was a surge in the application of extracorporeal membrane oxygenation (ECMO) for younger patients in acute respiratory failure caused by COVID-19 viral pneumonia, reports Edward Dunn, MD, medical director of palliative care for Louisville, KY-based Norton Healthcare.

In the first wave of the pandemic, some patients in acute respiratory distress were placed on ECMO in the later stages of their acute illness. These patients often failed to improve on ECMO support and expired. “We have learned that ECMO must be applied to these patients within one week from the onset of their symptoms to achieve clinical improvement and a higher likelihood for their survival,” Dunn observes.

However, even under ideal conditions, COVID-19 patients on ECMO recorded a high mortality rate. “The moral distress for ICU nurses occurs when the patient fails to improve on ECMO and continues to have complications like bleeding from a tracheostomy site or GI tract, inability to ventilate the patient, and progressive central nervous system deterioration,” Dunn says.

From experience, the nurse knows the patient likely will not survive. A disconnect in expectations of patient outcome between the medical teams caring for the patient and family members exacerbates this stress.

Despite the best efforts in communicating the realities of the patient’s critical condition by medical teams and nursing staff, the message may not be getting through to family members due to their grief state from anticipatory loss of their loved one. “The ethics consultant, if requested to become involved with such a patient, has the difficult task of bridging this communication divide among all parties who are witnessing the patient’s clinical deterioration,” Dunn says.


  1. Emple A, Fonseca L, Nakagawa S, et al. Moral distress in clinicians caring for critically ill patients who require mechanical circulatory support. Am J Crit Care 2021;30:356-362.