Coping with moral distress

Dr. Leena Amin, an internal medicine physician at the Grey Nuns Community Hospital, is well aware of the inner turmoil she’s experiencing due to the COVID-19 pandemic.

She is used to shaking hands with her patients and their family members or displaying physical empathy by placing her hand on her patients, especially when she has to deliver bad news.

But because of strict guidelines and protocols about using personal protective equipment (PPE) to minimize the risk and spread of the virus, Leena has to refrain from her natural response to those under her care.

“It takes away from the compassion and warmth you want to convey to others. No one can see you smile now that you’re wearing a mask.”

This is one of several instances of moral distress that physicians are now facing. In fact, Leena says that moral distress is something she and her fellow physicians are discussing a lot right now. “It’s a conversation all of us are having.”

Moral distress occurs when one knows the ethically correct action to take but feels constrained in some way from taking that action. It is prevalent in health care and happens when clinicians know the right thing to do but are prevented from doing it and therefore feel powerless.

“We’ve heard expressions of moral distress across the board,” says Eleanor Stewart, a clinical ethicist with Covenant Health who regularly consults with physicians, staff and families in situations where there is conflict or uncertainty about doing the right thing.

She adds that anybody working in health care is vulnerable, and while the concept of moral distress was first identified in nursing, researchers have been studying moral distress experienced at the clinical, administrative and organizational levels for three decades.

Though moral distress is inherent in the medical profession, it has become more prevalent during the pandemic.

Eleanor says that visitation restrictions for patients and residents in hospitals and care facilities, in particular, have been hard on everyone. While there are exceptions to the rule — the latest public health orders allow residents at long-term care facilities that are COVID-free to enjoy outdoor visits with a designated essential visitor and one other person and also permit end-of-life care patients to receive up to two visitors in the two weeks prior to death — most people are still having to make compromises about the ease with which they were able to visit their loved ones before the pandemic.

Eleanor echoes Leena’s sentiments about PPE, saying that it changes the practice of many healthcare practitioners.

“Nurses and healthcare aides are there because they want to take care of people. This weighs on clinicians,” says Eleanor.

The question about one’s mortality during the pandemic is something that Leena shares as also being a source of distress at this time, and it’s one she’s never experienced before in quite this way.

“Driving to work involves a very clear and present understanding of your own mortality. It’s not about how ‘they’ are the sick but that we could easily become infected too by virtue of coming here. The virus is a clear and present danger that can happen during any patient encounter — it’s not accrued over time.”

Yet Leena's call to serve compels her to show up for work to treat patients. She’s seen a “tremendous number of patients” with influenza-like illness, and some may ultimately test positive for COVID. “It’s about balancing duty to our calling, knowing there’s a risk of acquiring infection and potentially purveying it to our loved ones,” she adds.

The challenges of moral distress may be daunting, but they can be mitigated. “It’s difficult to resolve, but moral distress can be countered by moral resilience, which includes engaging in practices of reflection and being part of a moral community with shared experiences,” says Eleanor.

She explains that people who have been successful at overcoming the effects of moral distress are those who have made it a practice to reflect. They also tend to have a way to put meaning to their experience and have a holistic view of complex situations and problem-solving skills.

She adds that organizations also have a role to play in that they can mitigate moral distress by promoting a culture of ethical practice. “People are talking about ethical issues perhaps now more than ever.”

For Leena, reflection is a coping mechanism. “I think about how I’ve navigated difficult circumstances before, how my mentors guided me and how I found solace. Difficult conversations and situations are not new to physicians; we’re just experiencing them now in a different way, with more frequency, on a larger scale and with more acuity.”

Leena also practices gratitude and cites the Grey Nuns as a place where everyone is united. She adds that having open conversations about how other staff — not just physicians — are coping during the pandemic has humbled her and given her a clearer perspective.

Lastly, Leena stays morally resilient by reminding herself why she decided to go into medicine. “Finding meaning as to why I’m doing this has helped me shore through this. What have also helped are my personal support system and faith observance, which have been tremendous sources of strength.”

Eleanor says that regardless of personal values, faith and support systems, people will be better equipped when they recognize their triggers for moral distress and find ways to cope with it in the future.

“Moral distress is the harm that you can’t see, but it’s something that people have a very difficult experience with. It can cause them to develop compassion fatigue and stop caring or leave the profession altogether.”