Moral distress has been described as “as a phenomenon in which one knows the right action to take but is constrained from taking it.”1 Continuous exposure to moral distress leads to moral injury. The term “moral injury” was first described in combat soldiers who were forced to commit, witness or participate in acts that conflicted with their moral beliefs, and, as such, caused long-term psychological or spiritual injury.2 If the moral injury is sufficiently severe, it resembles post-traumatic stress disorder.
As the U.S. healthcare system takes on the worst pandemic in recent history, there exists the possibility that many physicians may be deputized to take care of sick patients with COVID-19. In a worst-case scenario, up to 60% of the U.S. population may be infected. If we assume even a more modest 40% rate of infection, a 12-month transmission curve and the freeing up of 50% of currently occupied hospital b eds for COVID-19 patients, we can expect more than 20 million Americans to require hospitalization and 4.4 million to require intensive care.3 Should we be called into service during this pandemic, we must face the real possibility of exposure to moral distress.
Despite the existence of institutional guidelines designed to facilitate challenging ethical decision-making, physicians, nurses and other healthcare workers may confront intense pressure to make difficult decisions that contribute to moral distress and injury.4
Such decisions that need to be made in a crisis include: Who do we treat? Who do we admit to the hospital or to the precious intensive care units? How do we decide? With constraints on resources, we may be forced or persuaded to provide care that does not meet our standards for quality or safety.
There is a relationship between burnout and quality of care. One compilation of several studies showed an inverse relationship between a high level of burnout, and quality of care and safety for patients.5 While burnout is multifactorial, moral injury can be a major contributor to burnout in physicians.6
Physicians and surgeons who face moral distress on a regular basis begin to display the classic symptoms of burnout. They become cynical, depersonalize their patients and lose enthusiasm for their profession. Vascular surgery is documented as being a high-risk specialty for burnout. Yet, if given the chance, three out of four would choose to be a surgeon again.
Vascular surgeons are put in distress in many ways separate from the current pandemic. A few years ago, I—Bhagwan Satiani—was called to treat a blind 80-year-old African American woman with severe back pain, hypotension and a few comorbidities. A computerized tomography (CT) in the emergency room confirmed a ruptured abdominal aortic aneurysm (AAA). This was early in the era of the institutional monitoring of physician complication rates and the start of the cost-constraint era. After explaining the choices to the woman and her daughter, the thought occurred to me about the high mortality rate in this type of patient—but only briefly. The daughter seemed to be leaning towards comfort care when the patient spoke up and advocated for herself, saying she was functioning relatively well. I chose to operate on her. She was extubated one day after surgery and discharged about six days later with no complications.
We all have examples like this. This type of moral distress is short-lived in my opinion and prolonged only if extraneous factors are inserted into patient care. As surgeons, the patient-centered, ethical, internal decision-making process we utilize is a fundamental part of our training—and a fundamental part of our professional identity.
Today, great pressure is placed on surgeons, who are given score cards by young MBA and MHA graduates with graphics listing not only mortality and complications rates, but color-coded symbols of length of stay (i.e., institutional cost). Undoubtedly, there is purely internal financial data generated about us that is then not shared with
us. Subsequently, the moral distress is amplified significantly due to extraneous factors largely unrelated to direct patient care itself, both in terms of quality and safety. Yes, end-of-life care— or difficult decisions about life and limb in our specialty—do wear us down over time. And, yes,
we do understand the national healthcare resources wasted on the elderly at the end of their lives. But our true north is to give our patients and their families the optimum service and quality of care that they deserve. Period.
Physicians are awash with headlines about burnout. We blame ourselves thinking we are not resilient enough to handle patient care, taking resiliency training in order to ameliorate burnout.
However, the cynicism ascribed to surgeons in surveys may be more related to the healthcare system itself. This has reduced our autonomy, demanded that we keep silent when we should be speaking out and limited the insurance coverage for the tests and procedures our patients need. Rather than resiliency training, perhaps we should be talking more about the moral distress we confront on a daily basis.
While physical exhaustion or issues related to direct patient care are contributory, burnout from moral distress is real. The moral distress comes in large part, not from caring for our patients, but coping with what the healthcare system has become.
This is accompanied by our inability to get ordinary people the care they deserve in a way that also fits our values. Keep this message in mind as you are called into service in this COVID-19 crisis. We chose to become healers. As the American writer Dale Carnegie put it, “Our fatigue is often caused not by work, but by worry, frustration and resentment.” Let us remember that as we go on to care for our patients. They are not the problem.
- Jameton, A. (1984). “Nursing practice: The ethical issues.” Englewood Cliffs, NJ: Prentice-Hall.
- https://www.sciencedirect.com/science/article/abs/pii/ S0272735809000920
Bhagwan Satiani, MD, is professor of clinical surgery in the division of vascular diseases and surgery, the department of surgery, in the Ohio State College of Medicine at the Ohio State University in Columbus. He is an associate medical editor of Vascular Specialist. David P. Way, MEd, is an educational resource specialist with 27 years of experience in medical education and interests in measurement and performance assessment. He is in the department of emergency medicine at the Ohio State University Wexner Medical Center.