Monday, October 19, 2015

Moral distress among residents: the hidden price of futility

Crash cart.  Courtesy Wikimedia.
by: Alex Smith, @AlexSmithMD

Have you ever had that experience when you think what you're doing is futile, and that thought goes through your mind:

"Why am I doing this?"

"I'm torturing him."

"This feels wrong."

For those of us that are physicians, think back to your internship and residency training.  I think we can all remember at least one of these situations, if not more.

I remember being in the ICU as a 3rd year internal medicine resident, being sent a man with advanced cancer on blood thinners from the emergency department who was losing liters of blood through his nose.  He was DNR, but his code status had been reversed in the ED by his family to treat this unexpected event.  This decision was not unreasonable, and yet the family looked terribly distressed by the blood spurting everywhere and frenzy of activity around him .  The patient was thin, bordering on emaciated.

Blood started oozing out of his nose again, and his blood pressure plummeted.  We squeezed hard on the packing in his nose.  He started to code and we brought out the pads to shock him.  The nurses and I looked at each other and we were thinking the same thing: "This doesn't feel right."

Liz Dzeng, a physician-researcher at UCSF, now brings a fresh perspective and insights into moral distress felt by resident trainees in providing futile care near the end of life.  Liz completed this research while a Gen Med Fellow at Hopkins and concurrently a PhD candidate in sociology at Cambridge, in England.

Liz interviewed 22 residents at 3 American internal medicine programs.  She found high degrees of moral distress among housestaff.  The quotes speak for themselves:
It felt horrible, like I was torturing him. He was telling us we were torturing him. I did not think we were doing the right things
A lot of traumatic things happen when you’re a resident. There was this tiny 90-year-old lady. We had to code her and it was one of the worst experiences of my life
You know there’s no good outcome. You just continue to code them and at some point they’re going to die. You’ve wasted time and resources and you’ve just provided futile care and tortured somebody for however much more time. Then there’s the whole disassociation where you want what’s best, but what you can do? And what do you have ability to affect? You just do your job
There are definitely patients that disturb the nursing staff because they are the ones who have to carry out the doctor’s orders and who are at bedside seeing the effects of our treatment—seeing patients suffer.
We do a lot of terrible things to critically ill patients and at the end of life. It’s routine care, and I feel pretty numb to having done those things 

Liz poignantly weaves these quotes together into themes that tell a story of outrage, powerlessness, and dehumanization.  The single ray of hope came from a hospital that routinely encouraged debriefing and discussions that normalized the emotional pain of treating someone when you feel it's torture, not care.

But this study is just scratching the surface .  The nursing literature is replete with research on moral distress.  The medical literature...not so much.  There is so much pain in this paper.  It brings me back to some very hard and emotional experiences in my training.

For our bleeding man with advanced cancer, I brought the family into the patient's ICU room during the code.  I called out for a dose of epinephrine to be administered, and his daughter said, "Will any of this help?"  I said it almost certainly would not, and they asked us to please stop.  We ended up with mixed emotions - sad that we had done so much that felt like "torture" to this man, yet pleased that the family ultimately agreed to stop.

Most times though, it doesn't stop so neatly.

Issues with the term and meaning of futility aside, let's face the reality here.  These are our future physicians who are morally scarred, who become numb, inured to the moral pain, and unable to empathize.

We have to ask ourselves, is this how you would want your doctor trained?  Is this hidden moral cost to young physicians worth the choice we give people to make such decisions? 


Janice Reynolds said...

I am a nurse (albeit retired) and during my nursing career spoke on Moral Distress in Conferences and taught in some classes. Perhaps if these thing were incorporated more often in med school as well as conferences and staff meetings, physicians might become more comfortable with medically futile care and as well as moral distress. I believe it is improving but there is still discomfort with dying and death among physicians (possibly because hey see it as a failure rather than a part of life. One time I always remember; I came on to my shift and in report was told this 80+ year old gentleman had an episode of severe shortness of breathe (he was a COPDer as well). This was a newer nurse and she had elected give a morphine upneb (which are seldom effective) and had left the furosemide and steroid for me. I quickly drew them up and went into the room. The patient was for all intents and purposes had died; he was agonal breathing (a breath maybe once a minute. I explained what was happening to the family and called the physician. He asked if I had given the medication, I explained what had happened and no I had not because the patient had died. The physician said, "I don' think the family is ready for that yet." I reiterated I would not give medication to a dead man (he was a DNR), I had him speak to the family and he later thanked me. An ED doc later when he heard I refused to give the meds was very angry I did not follow orders no matter what. So education in medically futile care as well as dying seems to me to be imperative for physicians from the start.

Camille Dillard, DO, MPH said...

The problem with futility in medicine has much to do with the futile thinking about the personhood of physicians, both fully certified and in training, as well as other members of the health care community.

Contrary to the educational and financial structures in health care, health care is guided and administered by people who care for people.
Medical training, at its core, admires the personhood of its applicants then quickly forgets about their personhood in the curriculum; both didactic and practicum. I recall how some of my fellow medical students had a difficult time spiritually and emotionally processing the expectation of dissecting a deceased human. There was no preparation, no process made available to help medical students through this transition.

The problem, of course precedes and is greater than medicine/health care. We know at the core, we reside in a society that has not made dying a part of living. We deny our spiritual being as become more technologically advanced. We are compelled to check our spiritual and religious orientation at the door of our houses as we leave to execute our duties in the work place.

The end result is predictable, we reduce ourselves to mere technicians and the patients to inanimate objects to have things done to them.

Until we learn to embrace the humanity of the physician, other members of the health care team as well as that of our patients, we will remain in the state of futility.

Camille Dillard, DO, MPH
Preventive and Family Medicine