OPINION: Advocating for Patients, Facing Personal Moral Distress
Thursday, October 10, 2019
Posted by: Roy Muyinza
By: Shawn L. Boyd, MSN, APRN, AGPCNP-BC
Throughout the years, I have faced many situations where I experienced moral distress associated with end-of-life decision making, particularly futile treatments. In fact, these situations contributed to my leaving front line critical care nursing. Since then, I have served as a clinical and didactic instructor for a university and have recently returned to school for a post master’s certificate so I can become a nurse practitioner.
During my first NP clinical rotation, I was placed with a Certified Nurse Specialist (CNS) preceptor in palliative care at a level-one trauma center. My preceptor primarily provided care for patients suffering from serious traumatic brain injury (TBI) with tenuous outcomes. She supports families as they make crucial care decisions and collaborates with neurosurgeons.
In this rotation, I realized my moral distress in end-of-life situations stemmed from three driving forces.
One, neurosurgeons subscribe to a curative model, so they often only communicate the gravity of the situation to family members when patients are clinically brain dead. Before then, a patient’s condition is not considered terminal and irreversible, so doctors avoid quality of life discussions with families. Second, within the caring model that nurses use, nurses follow the neurosurgery team’s plan of care, which may not consider quality of life. And third, in some facilities with religious origins, religious views dictate that life-sustaining measures are necessary, regardless of quality of life.
When starting my rotation, I was surprised to see that the combination of the caring model, religious belief system and the curative medical model perpetuate life-sustaining measures as opposed to early prognostic decision making with informed family involvement.
In practice, facilities vary widely regarding early end-of-life discussions for TBI patients. Level I trauma centers had the lowest number of early “Do No Attempt Resuscitation (DNAR)” for patients, and Level IV the highest.
My own vision of caring is to avoid suffering and prioritize quality of life over quantity. For TBI patients to spend their remaining days with bouts of pneumonia, constantly being readmitted, was ultimately deleterious to the patients’ wellbeing, regardless of the good intentions.
When NPs are faced with external forces inhibiting them from doing what they think is morally correct, they experience moral distress, self-doubt and disappointment in themselves. When NPs find a way to resolve moral conflicts without compromising their integrity, they do not experience moral distress. Importantly, challenging our moral compass can result in building moral strengths.
To reconcile my moral distress, I reached out to my preceptor and the director of palliative care. The response I received was positive, and the palliative care team agreed with my interpretation of the situation. The team is now shifting the culture toward earlier prognostic conversations with families on a case-by-case basis for select TBI patients. I hope other nurses in moral distress can follow a similar path, and I am hopeful this intervention will result in a sense of empowerment for patients, their families and the nursing community as a whole.
Boyd is studying adult-gerontology primary care at the University of Texas at Arlington nurse practitioner program. With nearly 20 years of critical care experience in a variety of settings including cardiovascular, neurological, surgical and medical intensive care units, Boyd is now a clinical associate professor at Texas State University. She earned a Master of Science in Nursing degree from the University of Texas Health Science Center San Antonio, holds advanced cardiac life support certification and is a certified nurse educator.
 Dean, D., Martinez, M. S., & Newgard, C. D. (2014). Variability in Early Do Not Attempt Resuscitation Orders Among Patients With Serious Traumatic Brain Injury. Academic Emergency Medicine, 22(1), 54–60. doi: 10.1111/acem.12555
 Laabs, C. A. (2007). Primary Care Nurse Practitioners Integrity When Faced With Moral Conflict. Nursing Ethics, 14(6), 795–809. doi: 10.1177/0969733007082120