Moral distress, moral residue, and the crescendo effect

Journal of Clinical Ethics

Volumn 20, Issue 4, 2009, Pages 330-342

  Epstein, Elizabeth Gingell ^a   Hamric, Ann Baile ^a  

^a UNIVERSITY OF VIRGINIA   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; CONFLICT; CONSCIENCE; DECISION MAKING; ETHICS; HUMAN; INTENSIVE CARE; LONG TERM CARE; MENTAL STRESS; MORALITY; PEDIATRICS; VERBAL COMMUNICATION;

CHOICE BEHAVIOR; CONFLICT (PSYCHOLOGY); CONSCIENCE; DECISION MAKING; HUMANS; INTENSIVE CARE; LIFE SUPPORT CARE; MORAL OBLIGATIONS; NARRATION; PEDIATRICS; STRESS, PSYCHOLOGICAL;

EID: 77649213935     PISSN: 10467890     EISSN: None     Source Type: Journal    
DOI: None     Document Type: Article

References (113)

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2. P.W. Chen, "When nurses and doctors can't do the right thing," New York Times, 5 February 2009, http://www.nytimes.com/2009/02/06/health/ 05chen. html, accessed 6 February 2009.
3. A.B.Hamric and L.J. Blackhall, "Nurse-Physician Perspectives on the Care of Dying Patients in Intensive Care Units: Collaboration, Moral Distress, and Ethical Climate," Critical Care Medicine 35, no.2 (2007): 422-9;
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9. E. Epstein, "End-of-Life Experiences of Parents, Nurses, and Physicians in the Newborn Intensive Care Unit," (PhD dissertation, University of Virginia, 2007): abstract number AAT3286595; please contact the author to obtain these data at meg4u@virgin/a.edu.
10. Jameton, see note 4 above.
11. Adapted from A.B. Hamric, W. Davis, and M.D. Childress, "Moral Distress in Health-Care Providers: What Is It and What Can We Do About It?" Pharos of Alpha Omega Alpha Honor Society 69 (2006): 16-23; Jameton, see note 1 above.
12. J.M. Wilkinson, "Moral Distress in Nursing Practice: Experience and Effect," Nursing Forum 23, no.1 (1988): 16-29;
13. E.H. Elpern, B. Covert, and R. Kleinpell, "Moral Distress of Staff Nurses in a Medical Intensive Care Unit," American Journal of Critical Care 14 (2005): 523-530
14. J. McCarthy and R. Deady, "Moral Distress Reconsidered," Nursing Ethics 15, no.2 (2008): 254-262
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18. E. Gordon and A.B. Hamric, "The Courage to Stand Up: The Cultural Politics of Nurses' Access to Ethics Consultation," The Journal of Clinical Ethics 17, no.3 (2006): 231-54;
19. Epstein, see note 5 above.
20. M.Z. Solomon et al., "New and Lingering Controversies in Pediatric End-of-Life Care," Pediatrics 116, no.4 (2005): 872-873
21. Hamric, Davis, and Childress, see note 7 above;
22. G. Webster and F. Bayliss, "Moral Residue," in Margin of Error: The Ethics of Mistakes in the Practice of Medicine, ed. S. Rubin and L. Zoloth, (Hagerstown, Md.: University Publishing Group, 2000).
23. This comment was made by a reviewer of a previous draft of this manuscript and was believed important and relevant enough to be incorporated into the current text.
24. M.C. Corley, "Moral Distress of Critical Care Nurses," American Journal of Critical Care 4 (1995): 280-5;
25. Epstein, see note 5 above;
26. Wilkinson, see note 8 above;
27. Elpern, see note 8 above.
28. Several studies have found that nurses feel they "know" what the outcome will be before the family and sometimes even the physicians know. In a study by Frick, Uehlinger, and Zuercher Zenklusen, nurse participants were more accurate than physicians in prognosticating death. Unfortunately, they were also overly pessimistic and predicted that some patients would die who actually did not die (and some of those who survived went on to describe their quality of life as "good"). Nurses, therefore, do not have the corner on prognostication, and their views are not necessarily morally better. However, nurses do have the advantage of being at the bedside day after day and witnessing subtle clinical changes which could aid in prognostication. This perspective too often goes unappreciated. There are other moral values at stake as well in these situations. In pediatrics, for instance, there is great and unspoken aversion to letting children die. Cultural and religious beliefs can influence family and healthcare provider values and consequent understandings of obligations to continue aggressive care.
29. S. Frick, D.E. Uehlinger, and R.M. Zuercher Zenklusen, "Predicting Outcome of Intensive Care Unit Patients by Nurses and Doctors A Prospective Comparative Study," Critical Care Medicine 31, no.2 (2003): 658-64;
30. Corley, see note 16 above;
31. Elpern, Covert, and Kleinpell, see note 8 above;
32. Epstein, see note 5 above;
33. Hamric and Blackhall, see note 3 above;
34. L. Meltzer and L. Huckabay. "Critical Care Nurses' Perceptions of Futile Care and Its Effect on Burnout," American Journal of Critical Care 13 (2004): 202-8;
35. Schweitzer and Wang, see note 3 above.
36. Hamric and Blackhall, see note 3 above;
37. Schwenzer and Wang, see note 3 above.
38. Sporrong, see note 3 above.
39. Austin, Rankel, and Kagan, see note 3 above.
40. Webster and Bayliss, see note 14 above, p. 208.
41. Jameton, see note 4 above, p. 544.
42. Elpern, Covert, and Kleinpell, see note 8 above;
43. K.M. Gutierrez, "Critical Care Nurses' Perceptions of and Responses to Moral Distress," Dimensions of Critical Care Nursing 24 (2005): 229-41;
44. L.B. Hardingham, "Integrity and Moral Residue: Nurses as Participants in a Moral Community," Nursing Philosophy 5, no.2 (2004): 127-34;
45. Meltzer and Huckabay, see note 17 above;
46. Wilkinson, see note 8 above.
47. Epstein, see note 5 above.
48. Ibid.
49. Ibid.
50. Ibid.
51. Ibid.
52. Ibid.
53. K.D. Lomis, R.O. Carpenter, and B.M. Miller, "Moral Distress in the Third Year of Medical School: A Descriptive Review of Student Case Reflections," American Journal of Surgery 197 (2009): 107-112
54. American Journal of Surgery, Ibid., 109.
55. Epstein, see note 5 above.
56. Ibid., 214.
57. Ibid.
58. Ibid.
59. Ibid., 215.
60. Ibid., 198.
61. Ibid.
62. C.R. Figley, ed., Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder in Those who Treated the Traumatized (New York: Burnner/Mazel, 1995); M.T. Rourke, "Compassion Fatigue in Pediatric Palliative Care Providers," Pediatric Clinical of North America 54 (2007): 631-644 (Pubitemid 47542520)
63. No studies have yet compared moral residue and compassion fatigue. Their emotional characteristics appear to be different enough to say that these are different concepts. In general, it does not appear that compassion fatigue involves threats to one's moral integrity, but instead poses an emotional "cost of caring."
64. Figley, see note 39 above, p. 7.
65. Talking to families about withdrawal of life-sustaining treatment has been found to be a difficult enterprise in many studies. A highly experienced attending physician in Epstein's study stated, " 'Let's go tell mom all the settings, the dopamine, you know. I'm not going to tell them that this is worthless. She's never going to recover, she's going to die. She's not going home." Fear of litigation as well as societal expectations play a role in the avoidance of open discussion with families.
66. Epstein, see note 5 above.
67. Ibid., 208.
68. Wilkinson, see note 8 above.
69. Ibid., 25.
70. Gordon and Hamric, see note 12 above.
71. Ibid., 205.
72. Hamric and Blackhall, see note 3 above.
73. M.C. Corley, R.K. Elswick, M. Gorman, and T. Clor, "Development and Evaluation of a Moral Distress Scale," Journal of Advanced Nursing 33, no.2 (2001): 250-256
74. Hamric and Blackhall, unpublished data.
75. Elpern, Covert, and Kleinpell, "Moral Distress of Staff Nurses in a Medical Intensive Care Unit," see note 8 above.
76. Corley, Elswick, Gorman, and Clor, see note 49 above.
77. D. Chambliss, .Beyond Caring: Hospitals, Nurses, and the Social Organization of Ethics (Chicago: University of Chicago Press, 1996);
78. Wilkinson, see note 8 above; Gutierrez, see note 23 above.
79. A. Catlin et al., "Conscientious Objection: A Potential Neonatal Nursing Response to Care Orders that Cause Suffering at the End of Life? Study of a Concept," Neonatal Network 27, no.2 (2008): 101-108
80. W. Osier, The Master World in Medicine, Aequanimitas, With Other Addresses to Medical Students, Nurses and Practitioners of Medicine (Philadelphia: P Blakiston's Son & Co., 1925), chap. 18;
81. A. Vergherse, "The Calling," New England Journal of Medicine 352, no.18 (2005): 1844-7;
82. C. Andrew, "Optimizing the Human Experience: Nursing the Families of People Who Die in Intensive Care," Intensive and Critical Care Nursing 14, no. 2 (1998): 59-65;
83. M.K. Maeve, "Weaving a Fabric of Moral Meaning: How Nurses Live with Suffering and Death," Journal of Advanced Nursing 17 (1998): 1136-1142
84. Corley, see note 16 above;
85. Meltzer and Huckabay, "Critical Care Nurses' Perceptions of Futile Care and Its Effect on Burnout," see note 17 above.
86. The medical literature has not yet incorporated the terms "moral distress" or "moral residue" into its repertoire of research concepts, but similarity of causes of burnout reflect moral distress as found in Valent. P. Valent, "Diagnosis and Treatment of Helper Stresses, Traumas, and Illnesses," in Treating Compassion Fatigue, ed. C.R. Figley (New York: Brunner-Routledge, 2002): 17-27.
87. Meltzer and Huckabay, see note 17 above.
88. Hamric and Blackhall, see note 3 above.
89. Schwenzer and Wang, see note 3 above.
90. M.K. Kearney et al., "Self-Care of Physicians Caring for Patients at the End of Life," Journal of the American Medical Association, 30, no.11 (2009): 1155-1164
91. Gordon and Hamric, see note 17 above;
92. Epstein, see note 12 above.
93. Chambliss, see note 53 above.
94. Epstein, see note 5 above;
95. Hamric and Blackhall, see note 3 above;
96. Schwenzer and Wang, see note 3 above;
97. Sporrong, see note 3 above;
98. Austin, Rankel and Kagan, see note 3 above.
99. Hamric, Davis, and Childress, see note 14 above.
100. American Association of Critical Care Nurses, "AACN Standards for Establishing and Sustaining Healthy Work environments," 2005, http://www. aacn.org/WD/HWE/Content/hwehome.pcms menu= Community, accessed 20 October 2009;
101. Hamric, Davis, and Childress, see note 9 above;
102. W. Austin, "Moral Distress in Healthcare Practice: The Situation of Nurses," HECForum 17 (2005): 33-48;
103. C.H. Rushton, "Defining and addressing moral distress: Tools for critical care nursing leaders," AACN Advances in Critical Care 17, no.2 (2006): 161-8;
104. C.M. Lilly et al., "An Intensive Communication Intervention for the Critically Ill," American Journal of Medicine 109, no. 6 (2000): 469-75;
105. K.A. Puntillo and J.L. McAdam, "Communication Between Physicians and Nurses as a Target for Improving Endof-Life Care in the Intensive Care Unit: Challenges and Opportunities for Moving Forward," Critical Care Medicine 34, no. 11 (supp. 2006): S332-40.
106. American Association of Critical Care Nurses, see note 65 above.
107. American Association of Critical Care Nurses, 4 A's to Rise Above Moral Distress Toolkit (Aliso Viejo, Calif.: AACN, 2006).
108. C.M. Beumer, "The Effect of a Workshop on Reducing the Experience of Moral Distress in and ICU Setting," Dimensions in Critical Care Nursing 27, no.6 (2008): 263-267
109. Hamric, Davis, and Childress, see note 14 above
110. P.E. Morris and K. Dracup, "Time for a Tool to Measure Moral Distress?" American Journal of Critical Care 17, no.5 (2008): 398-401.
111. Corley, Elswick, Gorman, and Clor, see note 49 above.
112. W. Bartholome, "Moral distress. Medical College of Wisconsin Bioethics Discussion," online discussion, 10 December 1998,
113. quoted in A.B. Hamric, "Moral Distress in Every Day Bioethics," Nursing Outlooks, no.5 (September-October 2000): 199-201.