Moral Distress: Insights From Stories in the PICU

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Moral Distress Insights From Stories in the PICU

• Daniel Garros, MD
• Associate Professor of Pediatrics
• The Dossetor Health Ethics Centre Univ. of
  Alberta,
• Attending Physician, PICU, Stollery Childrens
  Hospital
• Wendy Austin, RN, PhD
• Professor Emeritus
• Canada Research Chair (Relational Ethics in
  Health Care) 2003-2013
• The Dossetor Health Ethics Centre Univ. of
  Alberta
• Edmonton, Canada

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• Before I realized that she was going to die, I
  felt justified in doing all our little heroic
  things that we do, and theyre painful things.
  After I knew she was going to die, I felt badly
  doing those things. I felt badly that we were
  prolonging the pain for her.
• PICU Nurse in Davies et al., 1996, p. 502.

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Moral Distress

• 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, or
• is unable to act on ones moral choices.
• Nathaniel, A. (2006). Moral Reckoning in Nursing
  . Western Journal of Nursing Research, 28(4),
  419-438. Definition on p. 421.
• Nathaniel, A. (2003). A Grounded theory of moral
  reckoning in nursing. West Virginia University,
  p. 22.

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Moral Distress

• Arises when a person believes s/he knows the
  right thing to do
• But is unable to act on ones moral choices, due
  to
• Internal (personal) constraints
• Or because of external (contextual) barriers

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Moral Dilemma

• Practitioner Outcome 1
• Action 1 ?
• Outcome 2
• Action 2 ?

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Moral Distress

• Practitioner ---------///-------------- Outcome
• Action blocked

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Significance of Moral Distress

• May be an expression of sensitivity to the moral
  aspects of practice
• Appreciation of vulnerability of patients
• Embracing of values expressed in codes of ethics
• Acceptance of accountability and moral
  responsibility

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• The moral self is a self always haunted by the
  suspicion that it is not moral enough.
• (Bauman, Postmodern Ethics, p. 80)

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Moral Distress

• Moral residue
• George Webster
• François Baylis
• Crescendo Effect
• Elizabeth Epstein
• Ann Hamric

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Journal of Clinical Ethics
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PICUs

• The starkest of alternativeslife and death of
  children are focused in sharp relief in the
  PICU. 1

PICUs are high-tech, high-pressure
environments in which physicians (intensivists)
co-ordinate a multidisciplinary team 2
PICU teams include physicians, nurses,
respiratory therapists, social workers,
dieticians, pharmacists, physical therapists,
occupational therapists, psychologists clergy.
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1. DeMaso, D. Meyer, E. (1996). A psychiatric
   consultants survival guide to the pediatric
   intensive care unit. J AM Acad Child Adolesc
   Psychiatry, 35, 1411- 13.
2. Austin, W., Kelecevic, J., Goble, E. Mekechuk,
   J. (2009). An overview of moral distress and the
   PICU Team, Nursing Ethics, 16(1), 57-68.

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EnvironmentalAttributes

• High Tech Environment
• Multidisciplinary Teams
• End-of-Life
• Decision-Making

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Method Narrative InquiryThe power of stories
Their story, yours, mine - its what we all
carry with us on this trip we take, and we owe it
to each other to respect our stories and learn
from them. - William Carlos Williams
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Research Details

• Setting 6 Canadian PICUs
• Participants
• nurses, intensivists, dieticians, social workers,
  respiratory therapists, residents
• Story Gathering
• interviews, focus groups
• Analysis
• extraction of stories (63)
• creation of typology
• Dissemination
• Play Just Keep Breathing
• Website
• Presentations Publications
• Further research
• Secondary analysis re org influences
• Dissemination grant

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Research Activities
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Just Keep Breathing
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Movie presentation

• Part II

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Triggers of Moral Distress in PICUs

• Communication Breakdown
• Hierarchy Power differences
• our voice not heard (a team?)
• Multidisciplinary conflicts
• Conflicts with families
• dissimilar goals of therapy
• diverse views on disability
• Patient suffering

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Sources of Moral distress

• Clinical situations
• Unnecessary Treatment
• Prolonged dying aggressive treatment
• Inadequate inform consent
• Incompetence of colleagues
• Being in the middle

• Internal Factors
• Perceive powerless
• Lack of Knowledge
• Increased moral sensitivity
• Lack of FULL understanding of a situation
• Amric et al, The Pharos, 2006

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External triggers of MoD

• Institution culture/ constrains
• Lack of time
• Understaffing
• Lack of admin support
• Polices and priorities and conflict with care
  needs
• Pressure to reduce cost compromising care
• Reimbursement constrains
• Co-worker issues/ different professional
  perspectives
• Amric, A et al, The Faros, 2006

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Resolution Efforts
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Resolution Efforts

• Debriefing formal and informal
• Ethics consultation
• Ethics training develop tools for sense-making
  and coping
• Rounds learning from cases
• Interdisciplinary understanding and support
• Inclusive decision-making (including family)
• Time away from unit/situation
• Self-care exercise, spirituality, humour,
  journaling,
• Sharing with a colleague spouse

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Resolution Efforts

• Time away from unit/situation
• Self-care
• fitness strategies
• spiritual strategies (e.g., rituals)
• journaling
• humour

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Creating Morally Habitable Practice Environments

• This is not a place where I have the freedom
  to work ethically.

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Websites

• www.picumoraldistress.ualberta.ca
• www.justkeepbreathingfilm.com
• www.facebook.com/justkeepbreathingfilm