Care for critically and terminally ill patients and moral distress of physicians and nurses in tertiary hospitals in South Korea: A qualitative study.

Physicians and nurses working in acute care settings, such as tertiary hospitals, are involved in various stages of critical and terminal care, ranging from diagnosis of life-threatening diseases to care for the dying. It is well known that critical and terminal care causes moral distress to healthcare professionals. This study aimed to explore moral distress in critical and terminal care in acute hospital settings by analyzing the experiences of physicians and nurses from various departments. Semi-structured in-depth interviews were conducted in two tertiary hospitals in South Korea. The collected data were analyzed using grounded theory. A total of 22 physicians and nurses who had experienced moral difficulties regarding critical and terminal care were recruited via purposive maximum variation sampling, and 21 reported moral distress. The following points were what participants believed to be right for the patients: minimizing meaningless interventions during the terminal stage, letting patients know of their poor prognosis, saving lives, offering palliative care, and providing care with compassion. However, family dominance, hierarchy, the clinical culture of avoiding the discussion of death, lack of support for the surviving patients, and intensive workload challenged what the participants were pursuing and frustrated them. As a result, the participants experienced stress, lack of enthusiasm, guilt, depression, and skepticism. This study revealed that healthcare professionals working in tertiary hospitals in South Korea experienced moral distress when taking care of critically and terminally ill patients, in similar ways to the medical staff working in other settings. On the other hand, the present study uniquely identified that the aspects of saving lives and the necessity of palliative care were reported as those valued by healthcare professionals. This study contributes to the literature by adding data collected from two tertiary hospitals in South Korea.

Introduction

Tertiary hospitals constitute a starting point of care for critically and terminally ill patients. Patients visit tertiary hospitals to seek treatment, cure, and recovery, but some patients with life-threatening diseases are categorized as being under life-or-death emergency situations. Some patients struggling with critical diseases are diagnosed to be at the terminal stage, while some at the stage die in the hospitals. Recent statistics support the current worldwide status of hospitals as places for dying. Half of the people in the United Kingdom (UK) and Australia die in hospitals [1]. Compared to some countries, such as the United States of America (USA), where the percentage of deaths that occurred in hospitals has decreased from 48.0% in 2000 to 35.1% in 2018 [2], in East Asian countries, the proportion of hospital deaths is more salient. In 2018, nearly 90% of the total deaths in Hong Kong, 80% in Japan, and 62.5% in Singapore occurred in hospitals [3]. Similarly, in South Korea, 76.2% of all deaths in 2017 occurred in hospitals [4].

Despite the large proportion of hospital deaths, only few tertiary hospitals in South Korea provide palliative and hospice care services for their outpatients and inpatients. For example, only 16 tertiary hospitals among 45 were equipped with palliative and hospice care wards or teams in 2017. The main goal of tertiary hospitals when dealing with terminal patients is to refer them to hospices or nursing homes; however, due to the insufficient number of hospices, physicians and nurses often fail to do so. [5]. In addition, until the introduction of advance directives (AD) and physician order for life-sustaining treatment (POLST) in 2018, withdrawal of life-sustaining treatment was not legally protected. The proportion of obtaining a Do-Not-Resuscitate order (DNR) from terminal stage patients had remained low and the DNR order was obtained too late in that 82.6% of patients died within 0–3 days after signing their DNR orders in 2006 [6]. Overall, in tertiary hospitals in Korea, adequate palliative care was not offered, referrals to hospices often failed, and there was no legal process to guarantee the end-of-life care that patients wanted.

Caring for critically and terminally ill patients is often challenging for physicians and nurses. In facing life-or-death matters, healthcare professionals hold moral beliefs in determining what is good for the patient. However, they simultaneously encounter various contradictory values and legal restrictions, and the practices are done customarily [7, 8]. Moral distress occurs when one knows the right thing to do but institutional constraints make it nearly impossible to pursue the right course of action [9]. Since the definition of Jameton, previous studies have explored the major elements and negative effects of moral distress, and discussed how to measure the severity of moral distress and how to reduce the occurrence of moral distress in clinical settings [10-13].

With a few exceptions [14], the literature focuses on a homogeneous group of healthcare professionals, such as nurses providing geriatric care, physician trainees, the intensive care unit (ICU) staff, and staff in the pediatric departments [11, 15–17]. Yet, a large-scale hospital is a setting where healthcare professionals in diverse departments work together with respective care goals and duty priorities under the complex interrelations of legal regulations and internal rules. Depending on their occupation (e.g., doctor or nurse) [18, 19], level of experience [11, 16, 20], and specialty (e.g., ICU or emergency medicine) [21, 22], healthcare professionals may encounter considerably different issues to which they respond in diverse ways [14]. In this context, institutional constraints are highly likely to preclude healthcare professionals from pursuing what they believe to be morally appropriate for patient care [23].

The aim of this study was to explore moral distress in the context of care for critically and terminally ill patients in tertiary hospitals by analyzing the experiences of physicians and nurses from various departments. In doing so, the present study sought to identify what healthcare professionals believe to be right, what institutional constraints hamper the values and beliefs they wish to pursue, and what consequences the resulting moral distress has on them.

Method

Design

Semi-structured in-depth interviews were conducted to explore healthcare professionals’ experiences of moral distress related to caring for critically and terminally ill patients.

Recruitment

Physicians and nurses who had previously provided care for critically and terminally ill patients and had experienced ethical challenges were recruited from two tertiary university hospitals in South Korea. These two hospitals had palliative care team and ethics consultation services. To obtain a diverse array of views and experiences, this study used purposive maximum variation sampling [24, 25]. A total of 22 participants were recruited through advertisements posted on bulletin boards in both hospitals and an online bulletin board in one of the hospitals. None of the participants were related to the research team. All participants were informed about the purpose and methods of the study as well as the constitution of the research team. Written consent was obtained prior to their participation.

All the interviews began with the question, “Could you describe the personal experience that may have prompted you to participate in our study upon seeing the advertisement?” By starting with such an episode, participants were able to freely explore the situations that had caused moral distress, the burdens they had experienced, how they had tried to resolve the incidents, and the root causes of the episodes. The interviews were recorded with the participants’ approval and transcribed. All identifying data were deleted from the transcripts. Theoretical saturation was reached when no new issues were addressed in the interviews. Consequently, recruitment was closed. One member of the research team (JK), who was an experienced ethnographic researcher and a medical anthropology doctoral candidate, conducted all interviews.

Data collection

In the research preparation stage, a list of questions was prepared to guide the semi-structured interviews (Table 1).

Table 1

Semi-structured interview questions.

1. Have you experienced ethical concerns or moral conflicts while caring for a critically and terminally ill patient?

1–1. What did you want to do for the patient?

1–2. Why did your ethical concerns or moral conflicts occur?

2. Did you feel any physical or psychological burden because of these moral conflicts?

3. How did you try to solve the problem?

4. What advice would you like to give someone who is experiencing a similar problem?

Analysis

The transcripts were analyzed according to grounded theory [26] using MAXQDA. The grounded theory approach was adopted as it is a useful analytic tool for research aiming to uncover problems faced by participants within a particular context. There is little research regarding how Korean health practitioners relate to moral distress when caring for critically and terminally ill patients in acute care institutions. Following a data-driven strategy [25], in the stage of open coding, two members of the research team (EC and JK) independently created the core categories and key themes with memos that emerged while they were iteratively reading the transcripts. The categories and themes that were addressed in previous interviews were redefined in subsequent interviews and informed further data collection. In the axical coding stage, EC and JK linked the emerged core categories and key themes to understand their causal relationships and subsequently developed a codebook. Another researcher (HYP) examined the transcripts and the codebook together. The drafting of the codebook was supervised by the entire research team and an external expert in nursing-related qualitative research in the selective coding stage. After three rounds of supervision, the final comprehensive code structure that explained the relationships between the core categories and themes was approved. Through multiple rounds, all members (seven women and one man) from diverse positions (medical student, doctoral candidate, and professor) and various backgrounds (medical anthropology, medicine history, nursing, palliative care, and oncology) examined the interview data in a reflexive manner, and this process contributed to minimizing biased interpretation.

Ethics

The ethics committees of the Seoul National University Hospital and the Seoul National University Bundang Hospital approved the study protocol and materials in December 2016 (No. 1612-071-813). This study was conducted in accordance with the Declaration of Helsinki.

Results

Nine physicians and 13 nurses participated in the study from February to June 2017. All interviews were conducted by a single researcher (JK) and lasted between 60 and 90 minutes each. The participants’ demographic characteristics are displayed in Table 2.

Table 2

Demographic characteristics of the study participants (n = 22).

	N	%
Sex
Female	18	81.81
Male	4	18.18
Age (years)
19–29	6	27.27
30–39	12	54.54
40–49	3	13.63
50–59	1	4.54
Profession
Doctor	9	40.9
Nurse	13	59.1
Years of employment
< 5	8	36.36
5 ≤ n < 10	7	31.81
10 ≤ n < 15	5	22.72
≥15	2	9.09
(Doctors) Specialty
Emergency medicine	1
Pediatrics	2
Neurology	3
Intensive care medicine	2
Family medicine	1
(Doctors) Level
Resident	4	44.44
Fellow	1	11.11
Professor	4	44.44
(Nurses) Department
Intensive care units	4	30.76
Wards	4	30.76
Outpatient departments	5	38.46

Among the 22 participants, 21 reported the experiences that conformed to the definition of moral distress, that is, they knew what was right for the patients but were unable to pursue their values and beliefs due to institutional constraints. One nurse working in the ICU addressed emotional distress caused by caring for the dying patients rather than moral distress, and this data was not considered in this study. The data analysis identified what the participants valued for the patients (Table 3).

Table 3

What participants valued for the patients.

Minimizing meaningless intervention at the terminal stage

Letting patients know of their bad prognosis

Saving lives

Necessity of palliative care

Care with compassion

Minimizing meaningless intervention

Once a patient was diagnosed to be at the terminal stage, participants valued minimizing tests or treatments that caused pain and discomfort to the patient. Participants did not see any benefit that could be gained from the interventions because these interventions did not contribute to the patient’s recovery or improve their quality of life. The scope of the meaningless interventions that participants addressed included not only aggressive life-sustaining treatments but also ordinary tests, such as arterial blood collection, and treatments (e.g., anti-cancer treatment).

“I needed to do a CO2 test to an elderly patient with pneumonia and stroke to see how bad his condition was. I collected arterial blood for it, and he was basically supposed to be stabbed in his arteries four times a day… I was like, ‘Do I have to do this to this dying man? Is it really for the good? I can’t see anything but harm resulting from it.’ But I was an intern and interns just do what is supposed to be done.” (ID 12. Resident, Family Medicine)

Although participants regarded these interventions as “treatments that only makes it harder for the patient,” they had to initiate or continue these interventions on their patients because of the hierarchy among healthcare professionals. Participants, as interns, residents, or nurses, could not challenge the orders of their supervisors. Nurses stated:

“I am not in the position to make any decision. It is the professors who make decisions. It is hard for me to say something when my patients ask about my opinion.” (ID 34. Nurse, Internal Medicine)

“I know this is not right and I know patients have hard times, but at times, I lose my motivation because I think ‘Oh, this seems meaningless,’ while doing my job. (ID 28. Nurse, EICU)

Residents and nurses were not the only participants who had to perform what they regarded as meaningless interventions. Attending physicians also reported that they considered the patients’ family members as the final decision-makers over patients themselves. All participants thought that family members take the ultimate responsibility as they would be able to file a lawsuit against the healthcare professionals.

“The opinions of the family members are important because the patients in ICUs are unconscious. Even if you have written a DNR, have expressed what you would want at the end of life, like, ‘I don’t want respirators, I don’t want CPR (cardiopulmonary resuscitation), I don’t want dialysis,’ your family members do not agree and ask me to do something, then I am supposed to do that.” (ID 16. Nurse, EICU)

“If a patient’s relatives assert that they can handle it, afford the treatment cost, and hire paid caregivers, we do it [hopeless life-sustaining treatment]. Even though the patient expressed her will not to receive life-sustaining treatment, we can’t help but do it because there is no legal protection for us.” (ID 21. Physician, Intensive Care Unit)

Letting patients know of the poor prognosis

Participants believed that the patients should know of the poor prognosis in advance so that the patients and their family members can prepare for their death, and accordingly consider decisions such as spending time with the family, enjoying their favorite food, having a chance to leave a will, and deciding whether to receive life-sustaining treatment. However, nurses were not allowed to talk to their patients about poor prognosis before the attending doctor and the family caregivers of the patient brought up the topic with the patients.

“Sometimes, patients call us and ask about their prognosis. I can’t say anything because the professor must have an idea but I don’t know what it would be, and my patients want to hear my opinion. I’m in a very awkward position.” (ID 1. Nurse, Outpatient Department)

Combined with their position on minimizing meaningless interventions, obtaining a DNR order from a patient at the terminal stage was an important means to initiate the end-of-life care plan discussion with the patient in advance. Simultaneously, however, all participants shared the idea that obtaining a DNR was regarded as giving up on the patient by healthcare professionals, patients, and their family members. Theoretically, a DNR order means no cardiopulmonary resuscitation, but in the acute care setting, all participants felt that a patient was abandoned once they signed their DNR. Consequently, residents whose practices were under evaluation were worried that obtaining a DNR order would be perceived as negligence even though they believed it was necessary for the patient to die with dignity. One resident said:

“I feel that obtaining a DNR order means no more treatment. If I try to get one from a patient, it will look like I don’t want to care for them. I was told by my senior that an internal medicine professor admonished residents for obtaining DNR orders, saying that they did it because they didn’t want to do their job. That means that professors regard a DNR order as abstaining from further treatment.” (ID 12. Resident, Family Medicine)

In addition, the prevailing clinical culture of avoiding the discussion of death frustrated participants. They thought the current timeframe for obtaining a DNR order is too late to give the patients time to prepare for their death. However, in circumstances where no one is expected to talk about end-of-life plans until “the death rattle appears,” participants could not break this tacit rule. Some participants shared fear with the patients’ relatives that the poor prognosis might frustrate the patient and hasten the patient’s death.

“When a doctor brings up the topic to the patient’s family members, they also put off the conversation, like ‘We need time.’ All the people know what is going to happen but wait until it happens.” (ID 19. Nurse, Oncology Ward)

“If you try to get a DNR from a patient with clear consciousness, you might frustrate the patient.” (ID 34. Nurse, Internal Medicine)

Saving lives

Some participants reported their experiences of situations where they wanted to fulfill the primary goal of medicine, which is to save lives, but could not do so despite their medical judgment or were unsure if they did the right thing. First, when a patient goes through an event at the terminal stage, physicians and nurses may ascertain that the patient can survive for a few more weeks and months through some interventions. However, the family members of the patient may regard this intervention as prolonging the patient’s suffering.

“An infant got brain damage and was expected to be bedridden. The parents were doctors. Maybe they knew the prognosis too well. They wanted to give up on the baby. There was nothing we could do. When the baby was discharged, she was okay except for the brain damage, and she died at home.” (ID 15. Nurse, NICU)

Second, participants from the neurology and pediatrics departments addressed the episodes in which the practices they employed to save the patients led to a bedridden state. According to the participants, with the advancement in medical knowledge and technologies, the survival rates of critically ill patients have increased, but in many cases, the “saved” patients have to depend on other people’s care for the rest of their lives. Participants acknowledged the situations where public resources to support these patients are not enough, and family caregivers are in charge of round-the-clock care for the patients.

“In the case of child patients, they live in that [bedridden] state from when they are a few months old. Their mothers have to take care of them all the time, without any promise of getting better… If your parents or grandparents are in the bedridden state, you are subsidized by the state and there are some institutions you can take your parents to. But if children are bedridden, it is only their mothers who take all of the care burden. I have some child patients who have survived for 10 and 20 years. Their mothers are getting older and depressed because they don’t have their own lives but are taking care of the sick children.” (ID 41. Physician, Pediatrics)

As participants had observed the family caregivers’ physical and psychological burnout and financial troubles, they were sometimes not sure if trying to save their patients was the best measure for everyone.

“Sometimes I think if my job is supposed to let children patients go [die], should I do everything for my child patients when CPR is needed or should I pretend to do something and just send the child to God and take the burden off the mother?” (ID 40. Physician, Pediatrics)

Necessity of palliative care

Participants acknowledged the necessity of special care for patients at the terminal stage, including pain management, comfort care, psychological care, and spiritual care. However, tertiary hospitals in Korea are not sufficiently prepared to provide palliative care services to all patients. Consequently, physicians and nurses who have not specialized in end-of-life care are put in charge of dying patients. For instance, a nurse working in an oncology ward said:

“I get irritated when physicians order pain control medications as if they are mechanically following the textbook. I wonder if they even think about how severe the pain is that the terminal cancer patients are experiencing. They just follow the textbook stating, ‘maintain four-hour interval, two-hour interval, dose according to body weight.’ … I got a patient, and he was like, ‘Please save me, please give me the painkillers,’ even as I was giving it to him. He was terrified about the pain that will come next time. So, I hang more painkillers next to the IV poll and assure them that I will give it to them whenever they can’t stand the pain. Patients remember how severe the pain is and they are very anxious. Time interval does not matter. How on earth can you stand cancer pain for four hours?” (ID 20. Nurse, Oncology Ward)

While this nurse addressed the lack of personnel resource in palliative medicine, another nurse working in the oncology ward mentioned about another issue in the ward. The recruitment hospital was equipped with a single-bed room that was reserved for a dying patient (whose death was expected within two to three days) in the oncology ward, but the nurse taking care of the dying patient in the single-bed room felt powerless and frustrated because she had no further end-of-life care options besides offering the room.

“We feel stressful, too. I have nothing that I can do for them [the patients in the single-bed room], but they are conscious, and the family members are there. I don’t know what to say to them. It is awkward to ask them, “Are you ok?” isn’t it?” (ID 19, Nurse, Oncology Ward)

Care with compassion

One theme that frequently emerged was the value of care with compassion and the frustration that it wrought. Participants weighed providing sincere care to their terminally and critically ill patients and their family members. However, the healthcare professionals working in tertiary hospitals reported pressure from hospital administrators to save time and beds.

“The problem is that these patients tend to stay for a long time, which generates ‘a traffic jam.’ The bedrooms in this hospital are not for them. You know, we have patients who got a heart surgery and they need the bedrooms. If you are taking care of the terminally-ill patient for months, then it would cause a huge problem to all people here.” (ID 40. Physician, Pediatrics)

According to the acute care logic, patients in the terminal stage are supposed to be moved to long-term care institutions so that patients with acute problems can be treated. The attending physicians, who had the responsibility of allocating the limited space to patients, felt that they were caught in between the acute care logic and their wish to provide quality care for terminally-ill patients.

In terms of pressure to save time, physicians reported that they had only five minutes to discuss the end-of-life care plan, including withdrawal of life-sustaining treatment; the workload of the nurses was too heavy for them to provide humane care to their patients. For example, one nurse said:

“I don’t have time to talk with a patient or their family members during working hours. I don’t even have time to pee for 12 hours.” (ID 34. Nurse, Internal Medicine)

In the work environment where the participants were sometimes unable to fulfill their own basic needs, they viewed their patients only as “work.” Detachment from their patients functioned as a coping strategy to deal with the emotional distress and heavy workload, but this strategy did not resolve the fundamental problem in that it made them feel guilty.

“Sometimes I feel callous, and this feeling causes internal conflict in me. You can’t respond as much as people expect you to when they are sick and dying. You can’t show your sympathy or console them and just say, ‘That’s how it is,’ and your response upsets people.” (ID 3. Nurse, Outpatient Department)

Since obtaining a DNR order, as mentioned above, means cessation of treatment, nurses experiencing intensive workload felt less burdened once a patient had signed one. This feeling, however, conflicted with their professional ethics, and they experienced guilt for feeling relieved by a patient’s death.

“You are busy working and you take care of your job mechanically. If you get the DNR form from a dying patient, you [the nurses and doctors] feel relieved because it is agreed by all that this patient is dying. Even if the patient’s pulse suddenly drops, it is okay because you have gotten the consent from the family members and it’s okay to see her die… Of course, I’m a little upset, but I’m a little relaxed. I feel less pressure.” (ID 27. Nurse, Hematology)

Outcomes of moral distress

Participants reported particular emotional responses and behavioral strategies used to handle problematic situations (Table 4).

Table 4

Consequences of moral distress.

Trying a family-centered round

Helplessness

Stress

Lack of enthusiasm

Guilt

Depression

Skepticism

Detachment from patients

Quitting jobs or changing specialty

One participant (Intensivist, Professor) reported her attempt to minimize moral distress situations in ICUs. Since withdrawing and withholding life-sustaining treatment is a crucial issue, and agreement among healthcare professionals, patients, and patients’ family members is the key to solving this without fear of lawsuit, she and her colleagues were trying a new mode of consultation: a family-centered ICU, which satisfied both the healthcare professionals and the patients’ family members, and contributed to reducing potential cases that could cause moral distress.

However, most of the participants did not have the resources or the power to challenge institutional constraints. Residents and nurses reported having no reliable sources of advice and approaching the hospital ethics committee was not regarded as an option. Stress, lack of enthusiasm, guilt, depression, and skepticism were reported, with some participants deciding to be detached from their patients for self-protection.

“I said to my colleague, ‘I think I will go to hell.’” (ID 11. Resident, ER)

“I am still looking for a good answer. But if someone asks my advice, I would say, ‘Do not work here for a long time.’” (ID 15. Nurse, NICU)

Three participants quit their job or changed their specialty to get away from the situations that generated conflicts between what they wanted to pursue and what hampered the same. For instance, a participant explained the reason for changing her specialty:

“I was like, ‘Should I do this [unnecessary exam] to dying patients?’ and I wanted to do something that prevents people contracting diseases, and I changed my way from internal medicine to family medicine.” (ID11. Resident, Family Medicine)

Discussion

The findings of this study are largely consistent with the themes and root causes reported in previous studies that were conducted in other countries and in non-acute care settings [14, 21, 27–31]. The values that participants in this study stated are in line with the studies conducted in nursing homes [10] and acute hospital settings in the UK [32], and among physician trainees in the USA [11]. Akin to many studies [10, 33, 34], nurses in this study have addressed the difficulties originating from the hierarchy among healthcare practitioners and the proximity with their patients. This supports the notion that nurses may be the first to recognize the patients’ worsening state but their lack of influence over critically and terminally ill patients causes moral distress. The physician trainees’ report regarding powerlessness while providing “futile” treatment is also aligned with previous studies [11].

The results of this study reconfirm the unique qualities of acute care settings that have been addressed in previous literature. In the acute care settings where patient groups mix and the work pace is hectic, care of dying patients is given a lower priority [33, 34]. This work environment hampers the healthcare practitioners’ efforts in providing sincere and humanistic care for critically and terminally ill patients and their families [7]. It is also seen that hospitals tend to pay less attention to palliative care services [33, 35, 36], as participants in this study wished to have more staff and facility resources for palliative and hospice care.

Even though the necessity of palliative care in acute care settings has been highlighted [37], in these medical institutions, where the palliative philosophy conflicts with biomedical culture that is heavily oriented toward cure and recovery, the initiation of palliative care tends to be seen as giving up on the patient [32], and consequently, end-of-life care discussions start too late [32]. Palliative care is still practiced according to the transitional model of care that sharply divides curative from palliative care and is inappropriately conducted in a fragmented way [38]. Further, this study also found that moral distress negatively affects healthcare professionals’ job retention [14, 28, 39, 40], to the extent that some participants considered leaving their departments or had changed their specialties.

Notably, two themes which have been rarely addressed in previous literature emerged in this study. First, this study found saving lives as one of the values in relation to end-of-life care. This theme was addressed among challenging cases of pediatrics and neurology departments survivors with significant disability. The doctors and nurses understood the lack of social support for these survivors and caregivers as a root cause of moral distress. This finding indicates that in order to reduce experiences of moral distress, public care infrastructure should be considered for survivors and their caregivers after medical interventions save them at the crossroads of life and death.

Second, it is also noteworthy that aggressive treatment was not the only issue for the physicians and nurses in acute care settings. Moral distress in end-of-life care tended to be discussed in relation to the meaninglessness of life-sustaining treatments for terminally ill patients [11, 28, 39, 41]. However, participants regarded the lack of comfort care after the patients entered the terminal stage and difficulties in transition from treatment for cure to palliative and hospice care, too, as crucial elements of moral distress. This finding suggests an apparent need for palliative care specialists, both for patients and medical staff, even in large-scale acute care settings, and that not only the prevention of futile life-sustaining treatment but also the facilitation of comfort care is an urgent needs.

Conclusion

Physicians and nurses working in acute care settings, such as tertiary hospitals, take care of critically and terminally ill patients and are involved in various stages of care, ranging from diagnosis of life-threatening diseases to care for the dying. Regardless of the multifaceted stages and situations of dying and death, and regardless of the large number of hospital deaths, tertiary hospitals in South Korea do not provide enough palliative care services to patients. The number of hospices remain insufficient to cover terminally ill patients. Given this context, the present study had aimed to identify the moral distress experienced by healthcare professionals working in the two large-scale tertiary hospitals, in relation to care for critically and terminally ill patients. Among the 22 participants, 21 reported experiences of moral distress. What the participants believed to be right for the patients included minimizing meaningless interventions during the terminal stage, letting patients know of their poor prognosis, saving lives, offering palliative care, and providing care with compassion.

However, family dominance, hierarchy, the clinical culture of avoiding the discussion of death, the lack of support for patients who survived, and the intensive workload challenged and frustrated what the participants were pursuing. As a result, the participants experienced stress, lack of enthusiasm, guilt, depression, and skepticism. The in-depth interviews in this study allowed the participants to freely and honestly explore what they had undergone, thought, and felt regarding critical and terminal care in the clinical field. Given that a large number of the previous studies have been conducted in North America and the UK, and in nursing homes and hospices, this study contributes to the dialogue by adding data collected from two tertiary hospitals in South Korea.

This study had some limitations. First, the experiences of the physicians and nurses that emerged from the interviews may have been influenced by cultural and contextual factors specific to the two institutions included in the study. Second, as only practitioners who had experienced moral distress volunteered to participate in this study, the cases reported here may not be representative of other medical professionals. Further studies are needed to compare moral distress between institutions and countries.

19 Nov 2020

PONE-D-20-27654

Imbalanced end-of-life care and moral distress in tertiary hospitals:

A qualitative study

PLOS ONE

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The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the opportunity to review this manuscript on the increasingly important topic of moral distress among clinicians.

The authors have presented the data well and it is well written especially as English is not their first language. Additionally, it is important to have data from different countries as the embedding of palliative care into clinical care differs in many settings.

The authors have highlighted important cultural differences in particular in both clinician and family views of the role of palliative care. It is disappointing that it is seen as "giving up" and that "nothing more can be done". This indicates the need for education both at a clinical and community level which the authors highlight in the Discussion.

The themes are well described however, the findings needed to be structured more around the Semi-structured interview questions. The responses to these questions do not appear in the manuscript at all. The paper is more focussed on the failings of providing end of life care rather than the moral distress that this causes.

I would also like to see a definition of critical incident techniques which was the theoretical basis of the analysis.

The Abstract needs to be stronger to reflect the findings and the conclusion needs to be more aligned with the question of moral distress - which is the theme of the study - hence the statement from the manuscript that "Medical practitioners experienced moral distress either when providing futile life-sustaining treatment or failing to provide comfort care”. This I see as the key message rather that a statement that the study demonstrated that end-of-life care is neglected in acute care settings or a listing of the ways end of life care has failed.

The study brings important insights, however it needs to be more focussed on the main question of the study.

Reviewer #2: Thank you for the opportunity to review your manuscript, ‘Imbalanced end-of-life care and moral distress in tertiary hospitals: A qualitative study’.

The topic is a worthy one and the study shines a light on the experiences of physicians and nurses in Korea in end of life care that causes them moral distress.

However, the manuscript requires attention in the following areas before it is ready for publication.

1. Title: should include participants, as it is not clear whose moral distress was examined.

2. Abstract:

a. Suggest you do not use the term ‘medical practitioners’ to describe the physician and nurse participants, as this term signifies physicians in many parts of the world. Suggest the terms ‘health professionals’ or ‘clinicians’ would be more universally correct.

b. The assertion that the study demonstrates that end of life care is neglected in Korean hospitals is too strong/too great a leap for a qualitative study of the perspectives of physicians and nurses. Please revise this statement so that it is more in keeping with the methods/objectives of your investigation.

3. Introduction:

a. Please explicitly define end of life care, as this is your key concept, and it can be interpreted differently. For example, in Australia end of life care is defined as that which aims to optimise quality of life for persons likely to die in the next 12 months by addressing suffering, promoting dignity and function, respecting their needs and preferences, and supporting their family, including into bereavement. Is this what you are referring to by end of life care?

b. Suggest you revise use of the term ‘a good death’ (page 3), as this concept differs from end of life care, and furthermore it is a loaded and variously interpreted term.

c. Suggest use of less euphemistic language than ‘meet their demise there’ (paragraph 2, page 3) e.g. ‘die there’.

d. Please provide a reference/s to substantiate the low level of satisfaction with end of life care in particular regions of the world (page 3).

e. The introduction should include information about the end of life care needs, services and health care policy in Korea, to communicate to the reader the context in which the study was conducted.

f. The last paragraph of the introduction (the aim of the study) contains two different and seemingly dissonant objectives. The first was to examine physicians’ and nurses’ subjective experiences of moral distress related to end of life care. The second was to identify the organisation and systemic barriers to EOL in the hospitals, which strikes me as being more suited to an objective assessment, and too great a leap from the first objective. Please re-consider the scope of examination of the topic that was possible using qualitative methods.

4. Methods:

a. The manuscript states that the COREQ reporting guideline informed the study methods. This statement is problematic for two reasons. Firstly, reporting guidelines are to guide study reporting, not study methods. Secondly, the study has not been reported according to the COREQ, as several items are missing. Rather than pointing each of these out individually, my suggestion is that you ensure that all items of the COREQ are reported in your revised manuscript.

b. Table 1 belongs in the results section, not the methods, as does the information about duration of the interviews.

c. Critical incident technique has a particular analytic method, whereas you used a grounded theory analysis approach. Currently, the reporting suggests an unsound hybrid qualitative approach, especially as the findings are not reported in line with critical incident technique. Please revise this section to justify why you used the hybrid approach.

d. Analysis: last line - what specific type of bias did you minimise? Also, because you have not reported your positions, backgrounds and reflexivity process (which the COREQ calls for), it is difficult for the reader to be convinced that you fully addressed the minimisation of researcher bias.

5. Findings:

a. An introductory paragraph, including the characteristics of participants and interview, and summary of the themes and sub-themes, is required. Also, I was left wondering what proportion of the sample experienced moral distress.

b. In reporting the findings, it is important not to over-generalise. For example, the statement that procedures and treatments were not provided in patients’ best interests (page 8) should be modified, as you are recounting health professionals’ subjective perspectives only.

c. The statement “Because obtaining a DNR order means cessation of treatment…” requires revision, as a DNR order means no cardiopulmonary resuscitation, not no treatment overall.

d. I believe that the lack of exemplar quotes in the reporting of the ‘Main contributing factors’ theme adversely affects the strength and trustworthiness of your interpretations. While they are available in the supplementary file, their absence in the narrative means that the findings are reported in a disjointed way. Please consider formatting the findings in a consistent way throughout, and provide exemplar quotes for each sub-theme.

6. Discussion:

a. The first paragraph of the discussion is clear and reflects the findings.

b. However, at times you introduced new findings in the discussion that were not earlier reported. For example, I can’t see anything that refers to patients’ pain in the findings, but it is referred to on page 13. Similarly, there were no data on participants wanting to leave their work, yet it is referred to on page 14. Only items reported in the findings should be discussed.

c. As per my earlier comments about there being too great a leap from investigating participants’ moral distress to interpretations about systems/macro level change, I suggest you rein in recommendations about macro-level transformation; or at least, provide more specific recommendations about required practice and system change.

d. Please provide a conclusion.

7. References: A key missing reference is: ‘Re-defining moral distress: A systematic review and critical re-appraisal of the argument-based bioethics literature’ https://journals.sagepub.com/doi/abs/10.1177/1477750919886088

8. Figure: I found it strange that moral distress of health professionals was the end point, whereas really it was your starting point. Also, it suggested to me a focus on health professionals’ well-being, rather than patients or their families, who are the primary focus of end of life care. I suggest that some more thinking is required about how to best convey the findings of your study diagrammatically.

I hope these suggestion are helpful in your revisions and wish you all the best in your ongoing work to improve end of life care in Korean hospitals.

Reviewer #3: Thank you for the opportunity review this paper, which explores end of life care and moral distress in tertiary hospitals in Korea. The authors have interesting data and raise important points, however, overall there are a number of methodological issues with the paper and overall, I find it quite confusing.

I think that this paper needs a bit of re-focussing and I wonder if authors are trying to do too much by exploring moral distress and imbalance of services. Regarding the latter, this feels a little bit tagged on and I wonder whether this would be a stronger paper I it focussed upon causes of moral distress in S Korean acute settings – using organization of services aspects as discussion. As currently written, I think the introduction needs to more clearly contextualise the paper in terms of: known causes of moral distress in the context of palliative care, and description of the South Korean health system – it is only in the results that palliative and hospice services are referred to. Methods also need improved description and justification of approach.

This is interesting work in need of improvement ahead of being publishable work – I have commented in more detail on specific sections below.

Introduction

The concept of moral distress is interesting, but it would be useful to have some examples here – what would be examples of the ‘diverse and even contradictory ethical and cultural values, as well as legal restrictions’ in which clinicians works in S Korea?

The claim that “tertiary hospitals serve as the starting points of end-of-life care” requires justification. You must forgive my lack of contextual knowledge of the S Korea healthcare system, but it would be useful to have some description of what other services/alternatives are available to the acute setting i.e. we learn that hospice is available in the results, is the suggestion that some people go to acute care when they more appropriately be under hospice care? Also, examples are given of western countries – many of which will have hospital palliative care teams (even if satisfaction remains low) – are any such services available in S Korea?

Overall, I don’t feel that the introduction justifies the aims. It feels more like you are focussing upon factors which contribute to moral distress in acute hospitals? The additional aim regarding organization of care feels a little tagged on and without improved description of the healthcare system overall, difficult to understand.

Methods

Most importantly, I am not satisfied that the authors use Grounded Theory, which is not something which can simply be applied as a mode of analysis. GT applies far earlier than the analysis stage an would also require continuing analysis, used to inform further data collection. The analysis process which the authors describe sounds entirely suitable and of due rigor, but is not GT and requires different description.

As for the sampling strategy, authors state that ‘purposive maximum variation’ sampling, but also that participants were recruited through open advert. Please make clear how this approach allowed a diverse range of views and also provide comment on how the sample size was agreed and its representation of the workforce within acute hospitals across departments.

Thank you for including the interview questions – I think they look good but also echo that organization of care was not a key aim.

Results

First line states that ‘overtreatment and a lack of care emerged from the interviews as issues causing the participants’ moral distress’. I feel that it needs to be established that participants did experience moral distress before making this claim. Did participants identify as having moral distress in interviews? Was this part of an inclusion/exclusion criteria? It is noted as a limitation that ‘all participants had ‘moral distress’ though I am not satisfied that this has been established – the recruitment poster only refers to inviting people who had provided terminal care.

Findings on Slow Code are heartbreaking, but require setting up better in the introduction to achieve full impact. In what circumstances do legal issues arise here to cause ‘fear of lawsuits?’ RE: DNRs, please clarify what is meant by ‘cessation of treatment’ – I would expect that people would continue to receive usual care in this circumstance, but would not be resuscitated.

In ‘Lack of end-of-life care resources,’ it’s stated that palliative and hospice care are marginalised in the hospital system, but this is the first suggestion that these services may be available at all! Please clarify.

Euthanasia is mentioned within ‘main results’ but this is the first use of the word in the manuscript. Is euthanasia practiced in S Korea?

I feel that more discussion is needed regarding the patient profile within an acute hospital in S Korea. Continuing life sustaining treatment can be a barrier to appropriate care, but all kinds of patients will be present in an acute setting, many of whom for which life sustaining therapy would be appropriate. Please comment on this issue and the prevalence of people with terminal illness in this setting.

Discussion

The Discussion as currently written is quite vague and a little confusing. E.g. the sentence “if a doctor does not believe that he or she will be supported by the hospital system when a patient’s relatives file a lawsuit, it is hard for the doctor to pursue the patient’s best interests or wishes.” Is somewhat alarming and poorly explained.

I would suggest that this section needs re-writing to both review the causes of moral distress and make clear its consequences. Description included within this section re: available services in acute settings, should come much earlier (introduction) so that Discussion can follow here.

“The six contributing factors that participants addressed are consistent with the themes and root causes reported in previous studies” – what are the contributing factors and what do they contribute to? – please refer to these factors or reference the figure earlier.

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6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #2: Yes: Annmarie Hosie

Reviewer #3: Yes: Dr Joseph Clark

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

21 Jan 2021

We all deeply appreciate your thorough and sincere reviews. All the comments helped us to improve the original manuscript. We have submitted Response to Reviews.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

1 Mar 2021

PONE-D-20-27654R1

Care for critically and terminally ill patients and moral distress of physicians and nurses in tertiary hospitals in South Korea: A qualitative study

PLOS ONE

Dear Dr. Park,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Thanks for the revision of the manuscript, that has improved the first version submitted. Yet, one of the reviewers has still major comments that I kindly ask to carefully consider and address. Please note that the final decision will be based upon this further revision.

Please submit your revised manuscript by Apr 15 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Sara Rubinelli

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: N/A

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: Thank you for the opportunity to comment on your revised manuscript, 'Care for critically and terminally ill patients and moral distress of physicians and nurses in tertiary hospitals in South Korea: A qualitative study'.

The revised version is much more coherent and well integrated, and you have addressed most of the reviewers' comments well.

However, there are a few important areas still needing attention before the manuscript is ready for publication, as follows:

Title/abstract/aim: The phrasing of what you examined is imprecise in these parts of the report. Moral distress is experienced by persons in specific situations, so a clearer and simpler way of expressing what you examined is exactly as you expressed it in the study design section i.e. ''...'health professionals' experience of moral distress related to caring for critically and terminally ill patients'. My advice is that you use this better phrasing at all times throughout the study report.

Introduction: Bravo - this is much more informative and focused. However, I suggest a final refinement of the first paragraph by rounding up the percentages to whole numbers and tying in similar findings e.g. 49.9% of hospital death in the UK and 50% of hospital deaths in Australia is basically the same proportion and could be expressed as 'Half of people in the UK and Australia die in hospital compared to more than three-quarters (76%) of people in Korea (and btw, is that figure for South Korea only or all of Korea?). Also, given much of the previous research related to your topic was likely conducted in the US, what are the US stats?

Aim statement (pages 4-5): is the first statement your aim and the second statement your objectives? As presently this reads as two somewhat different aims. Suggest revise this section for improved clarity.

Table 1: The red text indicates you revised this information, yet the wording appears exactly the same as the original version. Please would you explain this point? (especially as interview questions can't be changed retrospectively)

Analytic approach: I share Reviewer 3's concern that you have not fully applied grounded theory. I can see that you have used elements of grounded theory, so my recommendation to address this issue is that you state you used a qualitative approach based on grounded theory, and then state exactly what the applied aspects were. It is also important to state the rationale for your choice of analytical method. Given there were existing data on moral distress in health professionals in relation to care of people likely to die, a grounded theory approach seems inappropriate, unless you choose to use it because there were little existing data on this topic in South Korea.

Findings:

- This section is now more focused and clear, but there are many author statements made without the addition of supporting quotes. For your study findings to be trustworthy, every assertion you make about what participants said should be backed up by an exemplar quote. By doing this, you are also allowing the reader to hear the participants' voices, which provides a more compelling narrative.

- The quote from the paediatric physician indicated to me that he/she was tempted to or in fact had dissembled (or more bluntly, been dishonest) with others in the team or even the family of the critically ill child about their clinical interventions. It also suggests (although this may not be what they meant) that they took an active role in hastening the death of the child, which is euthanasia, unethical and unlawful. However, the participant may simply have meant that they allowed (or wished to allow) that the child die a natural death through the removal of life sustaining treatment, which is ethical and lawful IF done transparently, with supportive care, and with the consent of those who are the primary decision makers for the child, which is almost always their parents/family. Given that you understand the context in which this quote sits, and the importance of distinguishing clinicians' intentions in their care of people at the end of life, please provide more explanation of what the participant meant, and explicitly acknowledge its implications in the discussion. For example, if you discerned that participants were not always honest/transparent in their clinical communication and actions, what was driving this troubling issue? I realise that addressing findings that do not align with ethical practice is challenging, but am sure that you will be able to do this well in a way that maintains respect and compassion for the participants while honoring what is owed to patients and their families.

- Similarly, in the quote from the nurse about pain relief, what exactly did he/she mean? Did he/she mean that the pain relief should be individualised to the needs of the person? As it is entirely reasonable and good practice to order medication at standard regular intervals in palliative care contexts, as this is based on half-life of the drug. There are other avenues for responding to pain that is not controlled by regular doses of analgesia e.g. PRN dosing with close monitoring. This is another example of ambiguity of the participants' meaning that requires more explanation.

Discussion:

- More specific examples/details of similar/different findings from other studies is required, as the only one mentioned was about job retention.

- Second paragraph, page 16: here again the focus is attempting to be too broad. What is unique and interesting about your study is that it was set in in South Korea and has specific implications for the health care system there. Please revise this section so that it becomes more appropriately focused on the context within which the study was conducted.

- Please state limitations of your study at the end of the discussion.

Alignment with COREQ: Items 4,5,6,7,8,25, 28,29 and 30 have not been adequately addressed. I strongly encourage that you do so to ensure your study reporting is of the highest quality.

Reference 1 has a punctuation error.

I hope these suggestions are helpful and I look forward to seeing the next version of the report.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

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Reviewer #2: Yes: Annmarie Hosie

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

15 Apr 2021

We do appreciate your sincere and thorough feedbacks.

Submitted filename: Response to Reviewers1.docx

Click here for additional data file.

18 Jun 2021

PONE-D-20-27654R2

Care for critically and terminally ill patients and moral distress of physicians and nurses in tertiary hospitals in South Korea: A qualitative study

PLOS ONE

Dear Dr. Park,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

The paper has much improved after the revision. Yet, there are still some aspects to consider as two reviewers have highlighted. Specifically to the comments of the last reviewer, it would be good to state clearly (e.g. in the implications of the study) how the study addresses previous literature and provides innovative insight.

Please submit your revised manuscript by Aug 02 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Sara Rubinelli

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

Reviewer #4: All comments have been addressed

Reviewer #5: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

Reviewer #4: Yes

Reviewer #5: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: N/A

Reviewer #4: N/A

Reviewer #5: No

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: (No Response)

Reviewer #4: Yes

Reviewer #5: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

Reviewer #4: Yes

Reviewer #5: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: I congratulate the authors on a very well written and deeply moving account of the findings of their qualitative study, and wish them well in your ongoing work in this important area of patient care.

Reviewer #4: Thr revised artcile has addressed the outstanding concerns but would beneifit from a structured abstract with a more considered conclusion.

Reviewer #5: In this paper, a qualitative study describes the ethical conflicts of medical staff in Korean acute care hospitals. Qualitative research has been conducted by taking over the appropriate method, but I have some problems about the interpretation of the results.

1. The results of the interview are the five things shown in Table 3, but the conclusion is that 'As a result, the participants went through stress, lack of enthusiasm, guilt, depression, and skepticism.' are written and there is a leap in interpretation.

2. This study reveals much the same results as similar previous studies, as the authors have stated in their discussions. Therefore, I cannot find the strength or novelty of this research.I suggest that the author examine the results more deeply and consider the categorized list.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: Yes: Annmarie Hosie

Reviewer #4: Yes: Dr Jonathan Koffman

Reviewer #5: No

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1 Aug 2021

We appreciate the thorough and kind reviews. Your comments truly helped us to improve the manuscript. We have included Response to Reviewers file in this revision.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

9 Nov 2021

Care for critically and terminally ill patients and moral distress of physicians and nurses in tertiary hospitals in South Korea: A qualitative study

PONE-D-20-27654R3

Dear Dr. Park,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Sara Rubinelli

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

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Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: N/A

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Reviewer #2: No

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Reviewer #2: Yes

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Reviewer #2: Again I congratulate the authors on their well-written study report. I have no further suggestions to make.

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Reviewer #2: Yes: Annmarie Hosie

7 Dec 2021

PONE-D-20-27654R3

Care for critically and terminally ill patients and moral distress of physicians and nurses in tertiary hospitals in South Korea: A qualitative study

Dear Dr. Park:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Sara Rubinelli

Academic Editor

PLOS ONE