Something Doesn’t Feel Right:
A Case Study on Moral Distress
GRACE KELLY, BSN, RN-BC, CLIII
NURSING GRAND ROUNDS
DECEMBER 14, 2012
Abstract
 Health care professionals face a variety of
challenging situations throughout their careers.
 Occasionally, situations present themselves that have
severe ethical and moral implications.
 This presentation will focus on the phenomenon of
moral distress by examining a case study that
presented many moral and ethical challenges for the
health care team involved.
Abstract
 Moral distress occurs when a health practitioner
feels they know the ethically appropriate course of
action, but is unable to carry it out.
 This can leave a moral residue with feelings of
frustration, anxiety, compromised integrity, and a
variety of other feelings that will be examined
throughout the presentation.
 As this is a rarely discussed phenomenon, healing
can often come simply by the recognition of these
symptoms in a given situation.
Abstract
 While this hour will focus on nursing, it has
implications for physicians, physical and
occupational therapists, as well as the rest of the
interdisciplinary team.
Objectives
 Identify moral distress
and its causes
 Identify 3 strategies for
coping with moral
distress
Ethics 101
 Non-maleficence - the obligation to do no harm
 Beneficence - the moral obligation to act for the good
of others
 Autonomy - respecting the right of all people to make
choices and decisions based on their individual
beliefs and values
 Fidelity - faithfulness, particularly the duty to honor
commitments made to others
 Justice - all people deserve to be treated fairly and
available resources should be used equally
Ethics 101
Moral distress
Examples Include
 The psychological
 institutional constraints
 lack of power
 lack of resources and/or
disequilibrium that
occurs when a person
believes he/she knows
the right course of
action, but cannot
carry out that action
because of some
obstacle.




support
legal limits
when nurses disagree with a
course of action that has been
chosen
inability to complete basic
nursing function/role
conflict of use of resources,
violation of personal
morals/values, etc
3 Categories of Ethical Issues
Moral uncertainty
Moral dilemma
 Often the earliest response;
 When two or more
occurs when caregiver feels
something is not right or is
uncertain about a particular
course of action. May
manifest as questioning,
discomfort, tension, or
frustration
 The clinician does not know
the ethically correct choice,
but feels a nagging
uncertainty, a sense that
something is not quite right.
opposing actions can
be equally justified and
the agent, unable to
carry out both actions,
faces a dilemma in
choosing which ethical
course to follow.
Moral Distress
 Moral distress – the
clinician feels they know
the right course of action
but feels constrained
from acting out because
of some obstacle.
Why does this matter?
ANA Code of Ethics
 Provision 1: The nurse, in all professional
relationships, practices with compassion and respect
for the inherent dignity, worth, and uniqueness of
every individual, unrestricted by considerations of
social or economic status, personal attributes, or the
nature of health problems
 Provision 2: The nurse's primary commitment is to
the patient, whether an individual, family, group, or
community.
Why does this matter?
ANA Code of Ethics
 Provision 3: The nurse promotes, advocates for, and
strives to protect the health, safety, and rights of the
patient
 Provision 5: The nurse owes the same duties to self
as to others, including the responsibility to preserve
integrity and safety, to maintain competence, and to
continue personal and professional growth.
Case Study
 33 y/o male with multiple, long-term admissions to
the hospital for sepsis related to major stage 4
decubitus ulcers on his coccyx, sacrum, hips, and
bilateral lower extremities.
 Over the course of 4 years, CP would get admitted for
antibiotics and electrolytes, as well as placement
assistance.
 Due to his complex wound care needs, placement
was difficult and he eventually started refusing.
Case Study, Continued
 He would come into the hospital for several weeks,
become stable, and be discharged with home health
or something in place for his wound care.
 Readmissions were frequent due to repeat infections.
 Throughout his hospitalizations, several treatment
options were explored, including a radical
hemipelvectomy.
 He was determined to not be a candidate due to his
fragile health status.
Case Study, Continued
 In early admissions, he had good relationships with
the staff; he was energetic, friendly, and participated
in care.
 In the final few years of his life, he became
increasingly labile in his goals of care, attitude, and
treatment of staff.
 He became verbally abusive and demanding.
 His family would, at times, pose physical and verbal
threats to staff.
Case Study, Continued
 The care team established a clear care plan – with
nurse rotations, required care, and mutual respect
goals – to prevent burnout and abuse.
 Staff were to go into his room two-by-two, offer care
only once, and leave immediately if he refused or
became abusive.
Case Study, Continued
 He eventually developed a seizure disorder and
started becoming more receptive to the idea of
palliative care.
 The care team tentatively started discussing this idea
when he had another seizure that made him
incapacitated.
 As CP had not established an Advanced Directive or
POLST, medical decisions were deferred to his
mother.
 She had not been a frequent visitor throughout his
years in the hospital and had a known drug and
alcohol problem.
Case Study Continued
 The medical team was uncomfortable with her now




being the principle decision maker, however, the law
is clear in this category.
She insisted on full treatment.
CP had a former girlfriend who had been very
involved in his care from the beginning and was
realistic about his prognosis.
She was advocating for palliative care, but was not a
decision maker.
She continued to visit him throughout this stage and
was a valuable advocate for the medical staff.
Case Study, Continued
 Once CP awoke from his “trance”, he refused all care,
but no longer wanted to pursue palliative care.
 Staff became increasingly frustrated with providing
care for him.
 He was refusing all the treatments he was in the
hospital for, including basic hygiene and room
cleaning. We continued our care plan until his DC.
 C.P. eventually discharged back home; several
months after his final discharge, he was admitted to
Emanuel and passed away.
Our Concerns
 As nurses we faced much frustration about this case:
 Why
was he permitted to stay and receive care if he
was refusing everything we had to offer? Taking up
an expensive bed, using valuable staff?
 As nurses, our role is to provide care to those who
need it and want it; this patient desperately
needed it, but was refusing. We were unable to
fulfill our perceived duty as nurses, medical staff,
and interdisciplinary care givers.
Our Concerns
 What we did to ease our concerns:
 Ethics
consult
 Connections consult
 Debriefs when needed
 Pastoral care
Discussion
 What are the moral issues seen within the case?
 Interdisciplinary Perspectives
 Physicians
 Care
Management
 Rehab services
 Pharmacy
NOW WHAT??
Identification
Initial Moral Distress
Reactive Distress
 initial moral distress:
 reactive distress: this is
first encounters the
situation and senses
that "something is
wrong -- I shouldn't be
party to this”
what the clinician feels
about their inability or
failure to act on the
initial distress
Moral Residue
 Distressing feelings that linger after the situation if
the caregiver feels regret
Symptoms
Frustration
Anxiety
Guilt
Compromised
integrity
Psychological
disequilibrium
Admitting You have a Problem is the First Step
 Initial Steps in treatment
Recognition and naming moral distress
 Increase self-awareness of strengths and weaknesses
 SPEAK UP! Self advocacy – insist on a dialogue with
the other people involved
 Get the whole story

 Identify the Values in Conflict
Whose values?
 What is their relationship to the patient?

Solutions
 Talk about your concerns openly to help identify
them
 Offer safe, confidential debriefs whenever necessary
 “Time to Talk” – group debriefs with the care team
 Care conferences
Include the entire care team and patient
 Involve Pastoral Care

Solutions
 Seek an ethics consult when appropriate – in ethics
consults, if everyone is looking for the ethical
dilemma but the real issue is moral distress, it may
be misdiagnosed and the problem is not treated.
 At one point in his hospitalizations, nursing placed
an ethics consult; it was cancelled due to a lack of an
identifiable ethical dilemma.
 We did not know at the time we were feeling moral
distress.
Questions?
References
 Hamrick, A.B., Davis, W.S., & Childress, M.D., (2006).
Moral distress in health care professionals: What is it and
what can we do about it?. Pharos, 16-23.
 Choen, J. S., & Erickson, J. M. (2006). Ethical dilemmas
and moral distress in oncology nursing practice. Clinical
Journal of Oncology Nursing, 10(6), 775-780.
 Ferrell, B. R. (2006). Understanding the moral distress
of nurses witnessing medically futile care. Oncology
nursing forum, 33(5), 922-930.
 Beumer, C. M. (2008). Innovative solutions: The effect if
a workshop on reducing the experience of moral distress
in an intensive care unit setting. Dimensions of critical
care nursing, 27(6), 263-267.