Una St Ledger1, Joanne Reid2, Ann Begley3, Peter Dodek4, Daniel F McAuley5, Lindsay Prior6, Bronagh Blackwood7. 1. Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University of Belfast, Belfast, UK; Belfast Health and Social Care Trust, Belfast, UK. Electronic address: una.stledger@belfasttrust.hscni.net. 2. The School of Nursing and Midwifery, Queen's University of Belfast, Belfast, UK. Electronic address: j.reid@qub.ac.uk. 3. Freelance Ethicist, School House, Macken, Co Fermanagh, UK. Electronic address: a.begleyschoolhouse@gmail.com. 4. Division of Critical Care and Center for Health Evaluation and Outcome Sciences, Faculty of Medicine, University of British Columbia, Vancouver, Canada. Electronic address: peter.dodek@ubc.ca. 5. Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University of Belfast, Belfast, UK; Belfast Health and Social Care Trust, Belfast, UK. Electronic address: d.f.mcauley@qub.ac.uk. 6. The School of Public Health, Queen's University of Belfast, Belfast, UK. Electronic address: l.prior@qub.ac.uk. 7. Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University of Belfast, Belfast, UK. Electronic address: b.blackwood@qub.ac.uk.
Abstract
PURPOSE: The purpose is to explore triggers for moral distress, constraints preventing physicians from doing the right thing and ensuing consequences in making decisions for patients approaching end of life in intensive care. MATERIALS AND METHODS: The qualitative study was undertaken in a tertiary referral intensive care unit in Northern Ireland in the United Kingdom. Drawing upon patient case studies of decisions about non escalation and/or withdrawal of life support, we undertook indepth interviews with senior and junior physicians. Interviews were transcribed verbatim and narratively analysed. RESULTS: Eighteen senior and junior physicians involved in 21 patient case studies were interviewed. Analysis determined two predominant themes: key moral distress triggers; and strategies and consequences. Junior residents reported most instances of moral distress, triggered by perceived futility, lack of continuity, protracted decisions and failure to ensure 'good death'. Senior physicians' triggers included constraint of clinical autonomy. Moral distress was far reaching, affecting personal life, working relationships and career choice. CONCLUSION: This study is the first to explore physicians' moral distress in end-of-life decisions in intensive care via a narrative inquiry approach using case studies. Results have implications for the education, recruitment and retention of physicians, relevant in the Covid 19 pandemic.
PURPOSE: The purpose is to explore triggers for moral distress, constraints preventing physicians from doing the right thing and ensuing consequences in making decisions for patients approaching end of life in intensive care. MATERIALS AND METHODS: The qualitative study was undertaken in a tertiary referral intensive care unit in Northern Ireland in the United Kingdom. Drawing upon patient case studies of decisions about non escalation and/or withdrawal of life support, we undertook indepth interviews with senior and junior physicians. Interviews were transcribed verbatim and narratively analysed. RESULTS: Eighteen senior and junior physicians involved in 21 patient case studies were interviewed. Analysis determined two predominant themes: key moral distress triggers; and strategies and consequences. Junior residents reported most instances of moral distress, triggered by perceived futility, lack of continuity, protracted decisions and failure to ensure 'good death'. Senior physicians' triggers included constraint of clinical autonomy. Moral distress was far reaching, affecting personal life, working relationships and career choice. CONCLUSION: This study is the first to explore physicians' moral distress in end-of-life decisions in intensive care via a narrative inquiry approach using case studies. Results have implications for the education, recruitment and retention of physicians, relevant in the Covid 19 pandemic.
Authors: Elizabeth M Viglianti; Jennifer N Ervin; Chad A Newton; Jacqueline M Kruser; Theodore J Iwashyna; Thomas S Valley Journal: BMJ Open Date: 2022-04-04 Impact factor: 2.692