Hello. In this talk today, I will be discussing moral distress and moral injury in the ICU. My name is Beth Epstein, and I'm a professor and associate dean for academic programs at the University of Virginia School of Nursing. I'm also on the faculty of the UVA Center for Health, Humanities, and Ethics, and I'm an adjunct faculty member of the UVA Jewish Studies Department. I currently direct our Health Systems Moral Distress Consult Service, and I'm the lead on a national group, the Moral Distress Consultation Collaborative. I have no conflicts to disclose. The objectives for this talk include defining moral distress and moral injury, identifying common sources of moral distress and consequences of repeated moral distress, describing interventions to mitigate moral distress, and reviewing measures of moral distress and moral injury. The work that health care providers do in critical care is ethically grounded. When encountering a challenging situation in the ICU setting, it's important to know what is happening from an ethics stance in order to be able to manage it effectively. So welcome to the moral farm. Many animals live here, and each is distinct from the others. They all have ears, and many have fur, but the moral uncertainty chicken is very different from the moral distress calf. Are you dealing with an ethical dilemma sheep? That calls for a different action than if you're dealing with a compassion fatigue pig. You might actually be standing in the pasture with an ornery ethical dilemma sheep and an upset moral distress cow. You'll have to deal with both, but how you deal with them will be different. There's a lot of literature on moral distress now and how it should be defined. Some have conflated events that have a moral component and that are also emotionally distressing as moral distress, but this really is not correct. Moral distress is a term of art and has a fairly narrow definition. Moral distress occurs when clinicians are constrained from taking what they believe to be ethically appropriate actions or are forced to take actions that are ethically inappropriate based on their professional obligations and resulting in a sense of complicity in wrongdoing. Please note that the three elements that are really key to moral distress are constraint from taking action, the sense that a professional obligation, not a personal value, is being violated, such as the obligation to minimize suffering or to tell a patient the truth. And the third element is a sense of acting wrongly. There's a sense of violating your own professional obligations and have done something that is unethical. Moral injury has its own definition. First identified in military personnel, moral injury involves a sense of betrayal of what is morally right by someone who holds a legitimate place of authority in a high-stakes situation. Recent literature translates this military concept to health care, but it has not been an easy transition or a clear one. There is a bit of work going on now to really distinguish moral injury from other concepts in health care that are ethically relevant and including moral distress. I'd like to briefly describe two measures of moral distress and two measures of moral injury and highlight the differences between them. The moral distress thermometer measures in-the-moment moral distress. So you could ask, what is your level of moral distress today? Or what is your level of moral distress related to patient X? Or what is your level of moral distress related to the staffing crisis? The measure of moral distress for health care professionals measures moral distress over time, six months or 12 months or even a whole career. This measure has 27 items, and they address causes of moral distress at the patient level, such as aggressive treatment even though it's not in the best interest of the patient, the unit level or team level, such as watching patient care suffer because of a lack of provider continuity, or at the systems level, such as being required to care for more patients than I can safely care for. Moral distress does have three categories of sources, the patient level, the team level, and the system level. There are at least two measures of moral injury. The moral injury questionnaire addresses moral injury that occurs amongst military personnel, such as I saw or was involved in the deaths of children or other items like this. The moral injury symptom scale for health care providers addresses moral injury that is believed to exist in the health care field. I feel betrayed by other health professionals whom I once trusted, and likewise. You can see the differences potentially between moral injury items where they're a reflection of the internal response to events, as opposed to the moral distress measure, which identifies the sources within the system or within the everyday working conditions of the health care providers. I'd like to highlight a few interventions for moral distress. First, naming moral distress and recognizing it as real and not a fault of the health care provider is actually very helpful, especially in the beginning when moral distress is new to people, it's a new concept to people. Speaking up and insisting on being heard, finding avenues for escalation of issues, but also really building support networks, finding ally groups, that can be very helpful because there's more, there's power in numbers. Some people, an element of moral distress is often with the sense of powerlessness, and so one person may feel fairly powerless, but along with many colleagues or several colleagues at least, you can advance problems quite far. Starting with baby steps is actually very, very helpful, and then continuing to think about the three levels of moral distress, patient, unit, and organization can be helpful. There's a link here if you have access to these slides. The Moral Distress Consultation Collaborative has some resources on it for you if that would be helpful. Moral distress consultation is another intervention for moral distress. Moral distress consultation is generally system-wide. It's offered and available to all healthcare providers and professionals across an entire health system, but that's not the only way it could be implemented. It could be implemented for critical care, depending on who would be interested in implementing it and how they would do that. The idea is to identify moral distress as it's happening, and to identify, help teams to figure out where the barriers are to them doing the right thing, and then developing strategies to address those barriers so that it's not simply recognizing moral distress, which in itself is helpful, but also identifying where the causes are and addressing those causes. I'd like to just describe a study that we're just finishing up now that used moral distress consultation summaries from two different organizations that have moral distress consult services. We focused specifically on situations of potentially inappropriate treatment in the ICU. We collected all of the summaries from both institutions for 2006 through 2021. We redacted them all and isolated the potentially inappropriate treatment situations. We imported the data into a qualitative data analysis software called deduce to help us code and identify common sources of moral distress. We aligned or networked those causes, sources of moral distress with the barriers that participants in the summaries identified. And then we also aligned those barriers and common sources with the strategies that the teams came up with. And then we created a strategy network to address the common causes. So for example, overly aggressive treatment, some of the barriers were poor team communication or unclear goals of care or lack of training. And strategies were in-services for staff, targeted in-services for nurses or physicians or respiratory therapists, addressing education in nursing and medicine and during residency programs. For unclear goals of care, often palliative care consultation and ethics consultation were highlighted as strategies to address those. Poor team communication was often one of the key strategies was to devise scheduled team meetings and scheduled family meetings for particular patients for whom this poor team communication and poor continuity of care was occurring for. And then team rotation and nurse staffing changes, nominating leaders and identifying a primary team came up as very common strategies. So the goal of this was to create this kind of a network so that anyone encountering potentially inappropriate treatment situations could look at this network, identify which barriers they're encountering and then identify what strategies, get some hints as to what strategies might work for them. These are my references. I'm also happy to talk further, so please feel free to contact me. Thank you.

moral distress

moral injury

ICU

ethics

interventions