Last month, a physician who serves as an ethics consultant told me about a growing concern in her hospital. Doctors and nurses “feel trapped,” she said, by the competing demands of administrators, insurance companies, lawyers, patients’ families and even one another. “And they are forced to compromise on what they believe is right for patients.” She called the problem “moral distress.” Since that discussion, I have not been able to stop noticing moral distress. Recently, for instance, I visited one of my closest friends, a brilliant and articulate nurse whom I’ll call Mary. During the years that we worked together, I learned that Mary’s assessments of different clinical situations were nearly always correct. But I also noticed that over time, she would often resort to enigmatic and noncommittal statements when expressing her opinions to doctors and supervisors. Soon after we met, for example, Mary began taking care of a transplant patient admitted with an infected abdominal hernia repair. By the time I became one of the residents on this patient’s surgical team, he had lived in the I.C.U. for a month and his abdominal wall, or what was left of it, had become a beehive of festering bacterial pockets. One morning, after yet another attempt in the operating room to clear the infected pockets, Mary pulled me aside. “How much can a person take?” she asked. Over the next few days, Mary posed the same question to the rest of the surgical team. When it finally became clear that no one on the team was acknowledging her concerns, Mary’s question changed. If a doctor asked her to prepare the patient for yet another trip to the O.R., she would ask back, “What do you want me to do?” Or she would reply, “Say that again?” Or she would walk away, her response trailing behind. “O – kay.” Eventually, Mary stopped answering at all. She simply went about her job in the most perfunctory of ways, and her usually bright patter turned flat. I finally asked her what was wrong. “If I say something, I get into trouble,” she explained, looking up from her charting work. “Doctors think I am out of line, and I get warnings from my superiors about being unprofessional. But if I don’t say anything, I’m afraid that the patient might suffer.” Her gaze drifted over to our patient. “What can I do?” she asked.
Moral distress — knowing what is ethically appropriate but being unable to act on it because of obstacles inherent in a situation — was first described in 1984 in a book on nursing ethics. Subsequent researchers focused primarily on the experiences of nurses and found that those who suffered from moral distress often became reluctant to interact with patients and other providers. In one recent study, 15 percent of nurses left their jobs because of moral distress. It now appears that doctors — caught between obligations to patients and the demands of insurance companies, administrators and even, occasionally, patients’ families — are feeling increasingly “trapped” and unable to do what they believe is ethically right.
Please click on the link below to read the complete New York Times article:
http://www.nytimes.com/2009/02/06/health/05chen.html?_r=2&partner=rss&emc=rss&pagewanted=all
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