Compromised professional integrity, which correlates with burnout and depression, is often experienced by doctors treating older, cognitively-impaired adults who have surrogate decision-makers, a US study found.
As defined in the study, moral distress is an emotional experience in which an individual feels constrained from acting on deeply held beliefs, resulting in the sense of compromising one's professional integrity. Moral distress has been correlated with traumatic stress, burnout, depression and even intent to leave a position or profession.
When hospitalised older adults have impaired cognition, family members or other surrogates communicate with clinicians to provide information about the patient and to make medical decisions for them. When working with these surrogate decision makers, physicians often encounter ethical challenges — such as whether to continue life support or not – that may cause them to experience moral distress with its potential negative consequences.
"Making decisions for patients who can't participate in the decision-making process is hard for everyone and has a significant likelihood of causing physicians to experience moral distress," said study senior author Dr Alexia Torke, associate professor of medicine at IU School of Medicine and Regenstrief Institute research scientist. "About half of older adults rely upon surrogate decision makers, so our findings that 42% of these doctors experience moral distress is a large and concerning number which, unless we address the issue, will likely grow as our population ages."
The study reported that physician moral distress occurred more frequently when (1) the physician was male; (2) the physician was an intern or other junior level doctor; (3) the patient was older; or (4) decisions were required about life-sustaining treatments. The authors found that physicians were less likely to experience moral distress when (1) caring for patients residing in a nursing home; (2) the physician or family members had discussed care preferences with the patient before that individual became unable to make his or her own decisions; (3) the surrogate decision maker felt emotionally supported by the physician and other clinicians, and (4) whether or not the physician and surrogate decision maker agreed on the course of treatment.
"We learned that communication is clearly key to diminishing physician moral distress," said study corresponding author Dr Lucia Wocial, a nurse ethicist. "Physician moral distress was lower when the patient had expressed his or her preferences through an advance medical directive or even orally to someone — a clinician, the surrogate or other family member or friend – before the patient was cognitively impaired and these preferences were made known to the treating physician." Wocial co-chairs the IU Health Ethics Consultation Service and is a faculty member of the Charles Warren Fairbanks Centre for Medical Ethics at IU Health.
Torke added, "Since physician moral distress diminished when the patient's surrogate decision maker felt supported, efforts to forestall or decrease physician moral distress can focus on working with surrogates as well as the physicians themselves."
A total of 362 surrogate decision makers of older adult patients who lacked decisional capacity and 152 physicians carrying for these patients were surveyed for the study. The researchers found that a significant cause of physician moral distress was related to the feeling that the care plan included more life-sustaining treatment for the patient than the physician believed was appropriate.
This study was funded by the Research in Palliative and End-of Life Communication and Training (RESPECT) Signature Centre at IUPUI, the Greenwall Foundation and the National Institutes of Health's National Institute on Aging.
Abstract
Background: When working with surrogate decision-makers, physicians often encounter ethical challenges that may cause moral distress which can have negative consequences for physicians.
Objective: To determine frequency of and factors associated with physicians’ moral distress caring for patients requiring a surrogate.
Design: Prospective survey.
Participants: Physicians (n = 154) caring for patients aged 65 years and older and their surrogate decision-makers (n = 362 patient/surrogate dyads). Patients were admitted to medicine or medical intensive care services, lacked decisional capacity and had an identified surrogate.
Main Measures: Moral distress thermometer.
Key Results: Physicians experienced moral distress in the care of 152 of 362 patients (42.0%). In analyses adjusted for physician, patient, and surrogate characteristics, physician/surrogate discordance in preferences for the plan of care was not significantly associated with moral distress. Physicians were more likely to experience moral distress when caring for older patients (1.06, 1.02–1.10), and facing a decision about life-sustaining treatment (3.58, 1.54–8.32). Physicians were less likely to experience moral distress when caring for patients residing in a nursing home (0.40, 0.23–0.69), patients who previously discussed care preferences (0.56, 0.35–0.90), and higher surrogate ratings of emotional support from clinicians (0.94, 0.89–0.99). Physicians’ internal discordance when they prefer a more comfort-focused plan than the patient is receiving was associated with significantly higher moral distress (2.22, 1.33–3.70) after adjusting for patient, surrogate, and physician characteristics.
Conclusions: Physician moral distress occurs more frequently when the physician is male, the patient is older or requires decisions about life-sustaining treatments. These findings may help target interventions to support physicians. Prior discussions about patient wishes is associated with lower distress and may be a target for patient-centered interventions.
Authors
Lucia D Wocial, James E Slaven, Kianna Montz, Patrick O Monahan, Susan E Hickman, Christopher M Callahan, Paul R Helft, Greg A Sachs, Lev Inger, Emily S Burke, Alexia M Torke
[link url="https://www.regenstrief.org/article/physicians-moral-distress-study/"]Regenstrief Institute material[/link]
[link url="https://link.springer.com/article/10.1007/s11606-020-05652-1"]Journal of General Internal Medicine abstract[/link]