Recently in Northern Ireland, a qualitative study was conducted in an intensive care unit to investigate the causes of moral distress in physicians and its’ consequences on making decisions affecting end-of-life patients.
As one of the first ethicists to study moral distress in nurses, in 1984, Dr. Andrew Jameton explains: “Moral distress arises when you know the right thing to do or the correct action to take …, but obstacles or organizational constraints prevent you from acting accordingly”.
The study published in the International Journal of Medicine states : “Decisions for end-of-life care are a source of moral distress. Among the patients admitted to critical care units (CCU), approximately 13 – 20% die as a result of decisions about non-escalation and/or withdrawal of life support. The patient’s advance directives are rarely known or made available; thus, the responsibility falls upon others to make decisions in the patients’ best interests. »
Based on patient case studies, 21 in-depth interviews with senior and junior doctors were examined. It was found that decisions are often made “under emotionally intense conditions, and are complicated by having life support administered, and the difficulty in predicting death.” The analysis determined two main themes: key moral distress triggers; and strategies and consequences.
- In young doctors, moral distress is triggered by a feeling of futility, lack of continuity, protracted decisions and failure to ensure a “good death”. Senior physicians appear to be less affected by moral distress probably because of a greater degree of “autonomy” in decision-making.
- The consequences of moral distress affect personal life, working relationships and career choice.
This UK study is the first to explore physicians’ moral distress in end-of-life decisions in intensive care. The results of this study have implications which need to be taken into account for physician education. The Covid-19 pandemic amply illustrated caregivers’ lack of preparation for death. In France, the decisions for “Limiting and Stopping Active Therapeutics” (LATA) for the sick and those at the end-of-life is regulated by the Leonetti Law enacted on April 22, 2005.
This study illustrates the potential misunderstandings about palliative care which can relieve symptoms to improve the patient’s quality of life during every phase of ill health. By using a comprehensive approach which takes the psychological, relational and spiritual dimensions into account, supportive palliative care can coexist harmoniously and simultaneously with treatment objectives. This study demonstrates the need of integrating palliative care into intensive care units and medical student education programs.
