The Many Faces Of Moral Distress:     Maintaining Professionalism Among The IDTCynda H Rushton , PhD, RN, FAAN • Suzana Ma...
Overview What is moral distress? Delving into dissonance: lessons from the humanities Contemplation and resilience: pra...
Gratitude…    Joan Halifax Roshi    Tony Back, MD    Susan Bauer-Wu, PhD, RN,    FAAN    Gary Pasternak, MD    Barbara Dos...
What brings you to this work?Silent reflection
On Professionalism        8 elements of professionalism (from ABIM):   altruism,                   honor,   accountabil...
What gets in the way of Professionalism?
Moral distress: definitions“Moral distress is the pain or anguish affecting the mind,body or relationships in response to ...
Moral distress: definitions Moral distress is the psychological disequilibrium that  occurs when a person believes he or ...
"At times, I have acted against my conscience in                            providing treatment to children in my care.”  ...
Personal reflectionsColumbine Lake, San Juan Mountains, CO – Jack Brauer Photographer -www.widerange.org/photo/columbine-l...
Find a partnerShare your story –• what was at stake for you? • what supported you? • how have you made sense of it?
Moral distress: contributing factors Perceived powerlessness                   Lack of time Socialization to follow ord...
Moral distress: consequences Diminished professionalism Decreased patient/family satisfaction Potential decrease in qua...
Burnout & Compassion Fatigue
Acknowledging moral distressA sign of weakness   A sign of courage
“Simply” notice
On dissonance
On dissonance
On dissonanceMusic would not speak if it were devoid of dissonance.
Dissonance in practice 42 year old Syrian  immigrant with metastatic  non-small cell lung  cancer, intubated for post-  o...
Family•We know he’s dying, but he needs to stay for his son.Intensivist•He’s in multi-system organ failure. I know he’s yo...
Reflecting on moral distress
On curiosity
Leaning in to dissonance Cognitive dissonance  involves the ability of the  mind to hold two seemingly  opposite truths i...
Moral distress in the hospice IDT                                   Hospice                                    nurse      ...
Only people who are capable of loving stronglycan suffer great sorrow, but this same necessity ofloving serves to countera...
Contemplative practiceIntroduction to Metta
Antoine Lutz, Julie Brefczynski-Lewis, Tom Johnstone, Richard J. Davidson. Regulation of the Neural Circuitry of Emotion b...
Create a pause Anchor yourself in your       Ask questions  breath                                Get clarifications P...
Addressing Moral Distress Engage in contemplative  practices Cultivate moral sensitivity Modulate emotions Care for yo...
In Summary Moral distress – can occur in any clinician, it adds to risk  for compassion fatigue and burnout, but there ar...
GoetheIn breathing there are two kinds of grace:To draw air into, then out of, your space.The one presses down, the otherr...
Please Answer the Following Question:Sometimes I feel we are  saving patients who  should not be saved. Agree Uncertain...
Please Answer the Following Question:Sometimes I feel as though we  give up on patients too  soon. Agree Uncertain Disa...
Please Answer the Following Question:Sometimes I feel the  treatments I offer/provide  to patients are overly  burdensome....
Please Answer the Following Question:At times, I have acted against my   conscience in providing treatment   to patients i...
Moral distress: causes poor-quality and futile care, unsuccessful advocacy, and raising unrealistic hope               ...
New and Lingering Controversies in Pediatric End   of Life Care, Pediatrics, Oct 2005; 116: 872 - 883.                    ...
Definition: Burnout           •    A response to chronic, and                cumulative stress (often                relat...
Burnout: Selected DataBurnout shown to predict mood  disorders and poor general  health in physicians (Hillhouse et al.,  ...
Burnout: Impact 60% of practicing physicians report symptoms of  Burnout (Krasner, wt al, 2009 ) 50% of PICU attending w...
Burnout: Selected Data• 76% of medical resident  respondents reported  symptoms of burnout:    –   High depersonalization ...
Compassion Fatigue Is a form of secondary trauma characterized  by exhaustion, helplessness and dysfunction  as a result ...
How many agreed with this statement?"Sometimes I feel we are saving children whoshould not be saved,“                     ...
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Many Faces of Moral Distress: Maintaining Professionalism in the IDT - AAHPM2012

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Presentation at the AAHPM by Cynda Rushton and Suzana Makowski

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  • CR
  • CR – add your preferred definition here
  • SM - dyad
  • CR
  • CR
  • Burnout definition: A response to chronic, and cumulative stress (often related to work). Includes:Emotional exhaustionDepersonalizationDiminished personal accomplishmentBurnout shown to predict mood disorders and poor general health in physicians (Hillhouse et al., 2000)Burnout associated with: - increase in self-reported medical errors (West et al., 2006) - suboptimal patient care practices (Shanafelt et al., 2002) 60% of practicing physicians report symptoms of Burnout (Krasner, wt al, 2009 )50% of PICU attending were at risk or burned out (Fields, et al, 1995)38%-66% Nurses report symptoms of Burnout (Aiken et al, 2001; Laschinger, et al, 2006)Linked to poorer quality of careDecreased patient satisfactionIncreased Medical errors and lawsuitsDecreased ability to express empathy (Krasner, et al, 2009)76% of medical resident respondents reported symptoms of burnout: High depersonalization (e.g., “I’ve become more calloused towards people since I took this job.”)Emotional exhaustion (e.g., “I feel emotionally drained from my work.). Shanafelt, colleagues (2002)Half the residents who feel burned out suffer from depressive symptoms. Shanafelt, colleagues, (2002)it is not compassion that causes fatigue, and it is not compassion that becomes fatigued. Compassion is not a finite quantity that becomes consumed and depleted. Rather, fatigue that accompanies efforts to relieve suffering or to change a particular situation is more likely related to the inability to accept and understand that some suffering and pain is not fixable, no matter what the effort the outcome is not totally within anyone’s control.-even if one’s actions are motivated by laudable intentions. Fatigue that arises when there is attachment to a particular outcome (“we need to get the parents to agree to a DNR order”) and thus the term “attachment fatigue” may be more accurate. Is a form of secondary trauma characterized by exhaustion, helplessness and dysfunction as a result of prolonged exposure to compassion stress and trauma.Usually evolves in caring professionals who absorb the traumatic stress of those they help (Najjar et al , 2009).No uniform definitionMay be misnamed: Compassion cannot cause fatigue or that becomes fatigued
  • CR- Body scan - what's happening in you right now, what are you noticing?  These are important pieces of information to use to respond to rather than react with.
  • SM -‘‘‘All dramatic stories always involve conflict,’’writes Professor Ian Johnston in his introductorylecture on Shakespeare. ‘‘Typically, the dramaticnarrative opens with some sense of normal society[.] Then something unusual and often unexpected happens to upset that normality. [.]Creates confusion and conflict. [.] Attemptsto understand what is going on or to deal withit simply compound the conflict, accelerating itand intensifying it. Finally, the conflict is resolved.’’3But,the resolution is not always prettydresulting in forgiveness and reintegration of society and personhood; in fact, the most famous andcompelling plays end in alienation, death, andsorrow. Literature has the advantage of creatingcoherence, even in the presence of unspeakabletragedy; after the hero’s demise, there is often lament and ‘‘a reflection of the significance of thelife which has now ended.’
  • SM -As palliative care clinicians, when we remainwith a patient and his or her family as they struggle from tension to tension, we create room forthe possibility of catharsis. In doing so, we lendour strength, our curiosity about the possibilitythat their narrative will discover meaning, purpose, and harmony. By staying we don’t writethe ending but rather facilitate the potentialfor the protagonist to finish their ownstorydpreferably with less pain, distress, andloneliness. This we might call the harmony ofresolution, the narrative of hope, and the restoration of proportion and meaning.By developing a senseof curiosity toward dissonance we may discovera sense of wonder about the rich complexity ofthe human experience and develop mentalstability and courage.
  • SM -
  • Here there is no medical solution. This illustrates the needs to draw on interdisciplinary expertise to find a meaningful solution for all involved. So now that we can acknowlegde moral distress, we can start working on solutions to fix it, but it would be even better if we had the means to prevent it in the first place and in fact we do
  • To make matters even more challenging, the family Priest (they were Eastern Orthodox) was young – a year or two out of seminary. When he arrived in the ICU, he looked like a deer in the headlights with what seemed like the weight of the world on his shoulders.
  • This is where we present a case: SM provides the narrative of the case, CR guides the listeners through the reflective process – what comes up in the body, in the mind, etc?Guide people through the case where we get people start by noticing.- What memories come up, what thoughts come up, how is your body responding?Then to guide people through this exploration… Often the conversation goes quickly to "we shouldn't be doing this… this is futile… etc."Monitor our own responses 'they are making me to things I don't want to do…"  my role is to find compassion in their own situation… move away from judgement.Body scan - what's happening in you right now, what are you noticing?  These are important pieces of information to use to respond to rather than react with.
  • SM
  • SM -
  • SM - But resolution does not always happen. Stories don’t always end well. We all know stories whose endings are tragic, no matter how much we practice this form of presence. So – what do we do? We lean on each other. We turn inwards and find others to teach us resilience and remind us. Perhaps this is through meditation, prayer, a walk through nature, a ski in deep powder, a hour enveloped in Mahler or Brahms or whatever music helps you to remember.For some, we practice compassion.
  • CR
  • SM – on contemplative practice/reflection on burnout, etc.Research has shown that the development of brief meditation or reflection practices can reduce negative affect, depression, and anxiety for those experiencing stress (Wachholtz & Pargament, 2005, 2008). Other studies have shown that when clinicians develop skills in reflection practices or practice some form of contemplation of their experiences of suffering, they experience decreased burnout, compassion-fatigue (Holland & Neimeyer, 2005; Kearney, Weininger, Vachon, Harrison, & Mount, 2009) and moral distress (Austin, Lemermeyer, Goldberg, Bergum, & Johnson, 2005).
  • Rumi space between two notes
  • CR
  • it is not compassion that causes fatigue, and it is not compassion that becomes fatigued. Compassion is not a finite quantity that becomes consumed and depleted. Rather, fatigue that accompanies efforts to relieve suffering or to change a particular situation is more likely related to the inability to accept and understand that some suffering and pain is not fixable, no matter what the effort the outcome is not totally within anyone’s control.-even if one’s actions are motivated by laudable intentions. Fatigue that arises when there is attachment to a particular outcome (“we need to get the parents to agree to a DNR order”) and thus the term “attachment fatigue” may be more accurate. Is a form of secondary trauma characterized by exhaustion, helplessness and dysfunction as a result of prolonged exposure to compassion stress and trauma.Usually evolves in caring professionals who absorb the traumatic stress of those they help (Najjar et al , 2009).No uniform definitionMay be misnamed: Compassion cannot cause fatigue or that becomes fatigued
  • Many Faces of Moral Distress: Maintaining Professionalism in the IDT - AAHPM2012

    1. 1. The Many Faces Of Moral Distress: Maintaining Professionalism Among The IDTCynda H Rushton , PhD, RN, FAAN • Suzana Makowski, MD, MMM, FACP, FAAHPM
    2. 2. Overview What is moral distress? Delving into dissonance: lessons from the humanities Contemplation and resilience: practical tools
    3. 3. Gratitude… Joan Halifax Roshi Tony Back, MD Susan Bauer-Wu, PhD, RN, FAAN Gary Pasternak, MD Barbara Dossey, PhD, RN, FAAN Alisa Carse, PhD. Jon Kabat-Zinn, PhD. Christina Puchalski, MD Warren Reich, STD Saki Santorelli, EdD Monica Sharma, MD
    4. 4. What brings you to this work?Silent reflection
    5. 5. On Professionalism 8 elements of professionalism (from ABIM): altruism,  honor, accountability,  integrity and excellence,  respect for others duty, service,
    6. 6. What gets in the way of Professionalism?
    7. 7. Moral distress: definitions“Moral distress is the pain or anguish affecting the mind,body or relationships in response to a situation in which theperson is aware of a moral problem, acknowledges moral responsibility, and makes a moral judgment about the correct action;yet, as a result of real or perceived constraints, participatesin perceived moral wrongdoing” (ANA, 2002).
    8. 8. Moral distress: definitions Moral distress is the psychological disequilibrium that occurs when a person believes he or she knows the right course of action to take, but cannot carry out that action because of some obstacle, such as institutional constraints or lack of power.
    9. 9. "At times, I have acted against my conscience in providing treatment to children in my care.”  54% of house officers  48% of critical care nurses  38% of critical care attending physicians  38% of hematology/oncology nurses  25% of hematology/oncology attending physiciansMildred Z, Solomon et al. New and Lingering Controversies in Pediatric End of Life Care, Pediatrics, Oct 2005; 116: 872 - 883.
    10. 10. Personal reflectionsColumbine Lake, San Juan Mountains, CO – Jack Brauer Photographer -www.widerange.org/photo/columbine-lake-reflection/
    11. 11. Find a partnerShare your story –• what was at stake for you? • what supported you? • how have you made sense of it?
    12. 12. Moral distress: contributing factors Perceived powerlessness  Lack of time Socialization to follow orders  Inadequate staffing Hierarchies within the  Lack of collegial healthcare system relationships Lack of administrative  Policies/priorities in conflict support with care needs Compromised care due to  Fear of litigation pressure to reduce costs  Inadequate informed Providing prolonged, overly consent aggressive treatment  Increased moral sensitivity Ineffective communication among team membershttp://www.azbioethicsnetwork.org/wp-content/uploads/2011/05/Moral-Distress.pdf
    13. 13. Moral distress: consequences Diminished professionalism Decreased patient/family satisfaction Potential decrease in quality of care Increased organizational costs Burnouthttp://www.azbioethicsnetwork.org/ethics-cases/moral-distress/
    14. 14. Burnout & Compassion Fatigue
    15. 15. Acknowledging moral distressA sign of weakness A sign of courage
    16. 16. “Simply” notice
    17. 17. On dissonance
    18. 18. On dissonance
    19. 19. On dissonanceMusic would not speak if it were devoid of dissonance.
    20. 20. Dissonance in practice 42 year old Syrian immigrant with metastatic non-small cell lung cancer, intubated for post- obstructive pneumonia. Septic shock on maximal pressor support. Now with multiorgan failure. Diagnosed 6 months prior. Now has a 3 month old baby “Do everything.”
    21. 21. Family•We know he’s dying, but he needs to stay for his son.Intensivist•He’s in multi-system organ failure. I know he’s young, but he won’t survive. But we will keep him full code, since that’s what they want.Nurse•This feels like futile care. He’s not awake. He’s in isolation. His baby can’t even see him. I don’t know why we’re doing what we are.
    22. 22. Reflecting on moral distress
    23. 23. On curiosity
    24. 24. Leaning in to dissonance Cognitive dissonance involves the ability of the mind to hold two seemingly opposite truths in a moment  “We know he’s dying, but we need him to stay for his son.”  “He doesn’t want to die, but he doesn’t want to suffer either.”  “As the family Priest, I should give them advice and support, but I am afraid of this suffering as well.” Being curious  How else might he be able to linger?
    25. 25. Moral distress in the hospice IDT Hospice nurse Hospice Volunteer Physician Patient & Home health family Attending Physician aide Social Chaplain Worker
    26. 26. Only people who are capable of loving stronglycan suffer great sorrow, but this same necessity ofloving serves to counteract their grief and healsthem.Tolstoy
    27. 27. Contemplative practiceIntroduction to Metta
    28. 28. Antoine Lutz, Julie Brefczynski-Lewis, Tom Johnstone, Richard J. Davidson. Regulation of the Neural Circuitry of Emotion byCompassion Meditation: Effects of Meditative Expertise. PLoS ONE, 2008; 3 (3): e1897 DOI: 10.1371/journal.pone.0001897 This is not just to make you feel good A. Voxel-wise analysis of the Group by State by Valence (negative versus positive sounds) interaction in insula (Ins.) (z = 2, corrected, colors code: orange, p<5.10ˆ-2, yellow, p<2.10ˆ-2, 15 experts (red) and 15 novices (blue)). B. Average response in Ins. from rest to compassion for experts (red) and novices (blue) for negative and positive sounds. C–D. Voxel-wise analysis of BOLD response to emotional sounds during during poor vs. good blocks of compassion, as verbally reported. C. Main effect for verbal report in insula (Ins.) (z = 13, corrected, colors: orange, p<10ˆ-3, yellow, p<5.10ˆ-4, 12 experts and 10 novices). D. Average response in (Ins.) for experts (red) and novices (blue). doi:info:doi/10.1371/journal.pone.0001897.g002
    29. 29. Create a pause Anchor yourself in your  Ask questions breath  Get clarifications Pause  Be open to new possibilities Be transparent  Let go of outcomes Monitor your mindset  Become a witness, rather Explore personal responses than an actor
    30. 30. Addressing Moral Distress Engage in contemplative practices Cultivate moral sensitivity Modulate emotions Care for yourself so you can care for others Reconnect to meaning Build your “resilience muscle” Be generous and kind to self and others Develop institutional systems
    31. 31. In Summary Moral distress – can occur in any clinician, it adds to risk for compassion fatigue and burnout, but there are things we can do Reflective practices Learning to watch
    32. 32. GoetheIn breathing there are two kinds of grace:To draw air into, then out of, your space.The one presses down, the otherrefreshes;Thus marvelously lifes web intermeshes.You thank God whenever he hems youin,And thank him whenever he frees youagain.
    33. 33. Please Answer the Following Question:Sometimes I feel we are saving patients who should not be saved. Agree Uncertain Disagree
    34. 34. Please Answer the Following Question:Sometimes I feel as though we give up on patients too soon. Agree Uncertain Disagree
    35. 35. Please Answer the Following Question:Sometimes I feel the treatments I offer/provide to patients are overly burdensome. Agree Uncertain Disagree
    36. 36. Please Answer the Following Question:At times, I have acted against my conscience in providing treatment to patients in my care. Agree Uncertain Disagree
    37. 37. Moral distress: causes poor-quality and futile care, unsuccessful advocacy, and raising unrealistic hope Schulter et al (2008)
    38. 38. New and Lingering Controversies in Pediatric End of Life Care, Pediatrics, Oct 2005; 116: 872 - 883. Survey of 781 clinicians at 7 institutionsMildred Z. Solomon, Deborah E. Sellers, Karen S. Heller, Deborah L.  209 attending physicians Dokken, Marcia Levetown, Cynda Rushton, Robert D.Truog,  116 house officers and Alan R. Fleischman  456 nurses.
    39. 39. Definition: Burnout • A response to chronic, and cumulative stress (often related to work). Includes: – Emotional exhaustion – Depersonalization – Diminished personal accomplishment (Maslach C, Jackson SE: Maslach Burnout Inventory Palo Alto, California:Consulting Psychologists Press; 1986.)
    40. 40. Burnout: Selected DataBurnout shown to predict mood disorders and poor general health in physicians (Hillhouse et al., 2000)Burnout associated with: - increase in self-reported medical errors (West et al., 2006) - suboptimal patient care practices (Shanafelt et al., 2002)
    41. 41. Burnout: Impact 60% of practicing physicians report symptoms of Burnout (Krasner, wt al, 2009 ) 50% of PICU attending were at risk or burned out (Fields, et al, 1995) 38%-66% Nurses report symptoms of Burnout (Aiken et al, 2001; Laschinger, et al, 2006) Linked to poorer quality of care  Decreased patient satisfaction  Increased Medical errors and lawsuits  Decreased ability to express empathy (Krasner, et al, 2009)
    42. 42. Burnout: Selected Data• 76% of medical resident respondents reported symptoms of burnout: – High depersonalization (e.g., “I’ve become more calloused towards people since I took this job.”) – Emotional exhaustion (e.g., “I feel emotionally drained from my work.). Shanafelt, colleagues (2002)• Half the residents who feel burned out suffer from depressive symptoms. Shanafelt, colleagues, (2002)
    43. 43. Compassion Fatigue Is a form of secondary trauma characterized by exhaustion, helplessness and dysfunction as a result of prolonged exposure to compassion stress and trauma. Usually evolves in caring professionals who absorb the traumatic stress of those they help (Najjar et al , 2009). No uniform definition May be misnamed: Compassion cannot cause fatigue or that becomes fatigued
    44. 44. How many agreed with this statement?"Sometimes I feel we are saving children whoshould not be saved,“ and"Sometimes I feel we give up on children too soon." 20 times more nurses agreed with 1 than with 2 15 times more house officers, 10 times more attending physicians Mildred Z. Solomon et al Pediatrics 116: 872 - 883

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