Addressing Moral Distress: Application of a Framework to Palliative Care Practice

Abstract

Background:

Moral distress is a pervasive reality of palliative care practice. An existing framework for understanding it has been proposed as a way to begin to address moral distress's detrimental effects on clinicians.

Objective:

The objective was to illustrate the application of this adapted conceptual framework to a clinical case and to offer recommendations for enlarging the professional repertoire for responding to challenging cases involving moral distress.

Analysis:

In the clinical case, clinicians are expected to respond to the patient's suffering based on four factors: empathy (emotional attunement), perspective taking (cognitive attunement), memory (personal experience), and moral sensitivity (ethical attunement). Each of these interrelated and iterative factors may become activated as clinicians care for patients with life-limiting conditions. This creates the foundations for clinicians' responses. When responses risk becoming aversive in the face of moral dilemmas, strategies are needed to foster principled compassion instead of unregulated moral outrage. A number of cognitive, attentional, affective, and somatic approaches derived from contemplative traditions are consistent with the framework. Combined with a systems-focused approach that incorporates organizational factors, they offer a means of improving professional repertoires for responding to difficult situations.

Conclusion:

Application of the proposed framework to a clinical case provides opportunities for understanding mechanisms of response that may be amenable to intervention and for suggesting appropriate alternative strategies and practices. A full understanding of the process can help to mitigate or to avoid the progression of distress and concurrently to appraise the situation that leads to moral distress or moral outrage.

Introduction

Moral distress is a clinical reality.^1–10 This paper applies a framework for understanding moral distress¹¹ to a case study and offers recommendations for enlarging the professional repertoire. Batson's¹² empathy model and Eisenberg's (2002)¹³ elaboration provide an important framework for identifying responses to situations causing moral distress for clinicians. We extend their work to include the ethical dimensions involving conflicting moral values, commitments, or perspectives. In addition to emotional attunement (empathy), cognitive attunement (perspective taking), and memory, responses to morally distressing events also include moral sensitivity. A proposed Framework for Understanding Moral Distress¹¹ outlines these four interrelated processes that create the preconditions for how one processes a triggering event instigated by a perceived ethical conflict or dilemma. Within this model there are two pathways: one leading to personal and moral distress, and one leading to principled compassion.

A Framework for Understanding Moral Distress

The proposed framework¹¹ (see Figure 1) addresses the effects of moral distress on clinicians. To illustrate this framework we relate it to a clinical case (see Table 1) and postulate how components might unfold in clinical practice. Using the case of Maria, we theorize how clinicians might respond to her suffering based on four antecedent factors: empathy (emotional attunement), perspective taking (cognitive attunement), memory (personal experience), and moral sensitivity (ethical attunement).¹¹ Although the process may appear linear, these aspects of appraisal are seen as interrelated and iterative, each triggering event initiating another response chain. An imbalance in any could cause destabilization and lead to self-focused behaviors, such as moral outrage, avoidance/abandonment, or numbness. Each of these factors can be activated as clinicians care for patients with life limiting conditions, creating the bases for adverse reactions. This framework will be applied to Maria's case, with recommendations on how it can be used to reduce the detrimental effects of moral distress.

FIG. 1.

A framework for addressing moral distress.¹¹

Table 1.

Case Application

Maria, 45 years old, was diagnosed with end stage liver failure and received a liver transplant. Since the transplant she experienced numerous complications including (1) recurrent pneumonia, respiratory failure, and chronic dependence on mechanical ventilation; (2) chronic renal failure requiring dialysis; (3) multiple drug resistant infections; (4) thrombosis with subsequent ischemia to fingers, toes, and lower extremity; (5) multiple wounds including a sacral decubitus ulcer; and (6) recurrent pain, anxiety, and depression. Her decision making capacity was intermittent. Her husband, Tom, was her health care agent. She had a young son and daughter who were significantly affected by limited access to their mother during her prolonged hospitalization, with disruption in family life, declining school performance, and behavior problems.

During Maria's extended hospitalization there was progressive conflict with her husband regarding her care. Tom was hopeful that she would survive, despite the long and complicated course. The surgeon caring for Maria supported his optimism and was perceived by others on the team as unwilling to discuss limitations of aggressive treatment. Many members of the ICU team questioned the continuation of aggressive treatment, claiming that their efforts were “futile.” Pain management emerged as an area of particular concern. Tom requested that her pain medications be limited to avoid sedation, because he believed that the sedation was undermining her progress. Maria's face consistently appeared distressed; she mouthed words that were interpreted as indications of her suffering, including requests to discontinue aggressive treatment. The nurses caring for her perceived routine care, dressing changes, and constant procedures were causing disproportionate pain and suffering. They reported that it was difficult to watch her responses and to participate in treatments they perceived as having no benefit and causing harm. Several refused to care for her; others reported distressing physical symptoms, nightmares, and other symptoms of stress.

Based on a clinical case; identifying data altered to protect privacy.

Empathy

Empathy, an affective process, was likely aroused in relation to Maria's suffering. Caring for her physiologic, emotional, and spiritual needs may be motivated by an intention to realize a balance between short-term burdens and the longer-term goal of survival with a desirable quality of life. Actions to care for Maria likely arose from the clinicians' empathic concern for her well-being and their professional commitment to alleviate suffering. Healthy modulated affective arousal from witnessing Maria's responses to treatment may have allowed empathic concern to arise. At such a juncture, care could be provided with integrity if there was congruence and understanding about care, goals, and treatment plan.

Central to cultivating modulated empathy and principled compassion is the capacity to differentiate self from other.¹⁴ When clinicians see Maria's suffering as separate from their own they can regulate their arousal so it remains in a zone of resilience, rather than becoming overwhelming.^15,16 When there is a clear recognition that the patient's suffering is not their own, and there is empathic resonance, clinicians may be able to enter Maria's world and remain personally and professionally grounded.¹⁷

As Maria's condition deteriorated, however, clinicians may have questioned actions that they perceive as causing harm.¹⁸ For example, a nurse may not be able to witness Maria's suffering with healthy empathy. Despite cognitively understanding the patient's and family's goals, a nurse may find it challenging to respond with balanced emotional attunement; this internal processing can be exacerbated by cumulative stress associated with Maria's care; the depletion of physical, emotional, and spiritual resources over the patient's long hospitalization; and the moral dissonance associated with competing values and commitments.^18,19

No longer able to see Maria's suffering as justified, clinicians may have shifted to a self-focused response based on a negative appraisal of the situation and characterized by empathic overarousal and aversion,¹⁷ thus turning away from the patient in response to their own distress. Increasing reports of physical symptoms such as headaches, nausea, and generalized feelings of fatigue and overall depletion, particularly by nurses, may reflect autonomic arousal and give clues about the negative impact of moral distress. Refusing to provide care, not wanting to go into the patient's room; expressing revulsion at participating in treatments perceived as harmful; and feelings of numbness, despair, and regret—all can be indicators of the aversion often born of empathic overarousal typical of clinicians who find themselves in a moral bind or dilemma.^18,20,21

When the boundaries between self and other blur it becomes difficult to separate the suffering of the other from one's own. As Maria's condition worsened, the integrity of her body began to erode; and decubitus ulcers, nonhealing wounds, and ischemia gave evidence of her decline. Coupled with the facial expressions, body language, mute cries, and mouthed requests to relieve her pain, the physical decline may have ignited an attunement between her suffering and feelings of despair, personal distress, and moral outrage in some of the clinicians caring for Maria.^17,18,21

Perspective taking

Perspective taking or cognitive attunement involves the ability to understand and appreciate the unique vantage points of others. Aggressive interventions to treat Maria's physiologic and emotional needs may have been motivated by the patient, family, and health care team's alignment about the goals of care and the values informing decisions. This attunement would have allowed the team to perceive their efforts as aimed at an achievable and ethically based goal to preserve life when recovery was possible. The congruence between the team's goals and those of the patient and family may have contributed to compassion-based responses.

As Maria's condition declined, no longer was there congruence in goals and values between patient, family, and team. First, Maria's husband Tom, as the patient's health care agent, prioritized doing “everything possible” to sustain her life as the primary goal of her care, despite mounting complications and diminished quality of life. Clinicians may have interpreted Maria's condition as irreversible, and perceived their efforts to sustain her life as unjustifiably burdensome, causing undue pain and suffering, and prolonging an inevitable death. There may have been differing interpretations of Maria's preferences for treatment, quality of life, or end-of-life care. Clinicians likely experienced dissonance between scientific evidence, assessments of prognosis, and her husband's request to continue despite the progression of Maria's disease process.¹⁹

Second, Tom believed that the best way to support Maria's progress was by minimizing sedation, maximizing mobility, and enhancing awareness and engagement with her family. For Tom, Maria's suffering was justified as facilitating her relational capacity and recovery. This may have widened the gap in alignment of goals between the husband and the health care team. Clinicians who did not agree with his perspective may have reasoned that the most compassionate action would be to alleviate her pain and suffering to the fullest extent possible.^22,23 This, coupled with their primary ethical mandate to “first do no harm,” may have fueled their moral distress.

Third, Maria's decisional capacity was uncertain, making it difficult to determine what she would have chosen had she been able to speak for herself. Prior to surgery Maria was clear that she wanted to live as long as possible, independently, with better quality of life. As her health declined, clinicians interpreted her physical expressions of pain and suffering, coupled with attempts to mouth words suggesting that she did not want to live in her current condition, as evidence that continued treatment was not in her best interest. The situation was complicated by a diagnosis of depression, and Tom's perspective on the impact on Maria's will to live and her ability to engage of clinical strategies for managing pain and anxiety.²⁴ Guided by a commitment to honor patient autonomy, clinicians may have perceived that their actions were disrespectful of Maria's choices. As her capacity to communicate and discern became intermittent, the gap between what her husband was requesting and what the team understood to be morally correct widened, contributing to cumulative moral distress.

Finally, the perspectives of various team members are also morally relevant. Nurses providing direct and round-the-clock care for Maria were likely different from the physicians who provided intermittent care. The surgeon who initiated the transplant may have experienced a heightened level of responsibility for the outcome and perceived an imperative to give her “every chance to live.”^25,26 In contrast, the nurses may have perceived their efforts as more harmful than beneficial, undermining their ethical mandate to relieve suffering.^8,27 Lack of understanding of differing perspectives and efforts can contribute to an exacerbation of both personal and moral distress. These and other factors may have contributed to the incongruence in goals and erosion of client and team relationships.^21,28

Memory

Conscious and unconscious memories inform a clinician's responses in cases like Maria's. Memory includes personal and professional experiences, cultural or societal experiences, and differences in physiologic and emotional responses.²⁹ Core values, personal and familial history, and professional culture also impact what individuals bring to caregiving. If memories are positive and prior professional experiences have led to a sense of self-efficacy, arousal may evoke a positive emotional response, resulting in regulated altruistic behavior³⁰ and leading to compassionate and integrity-preserving action. Clinicians who are able to maintain a state of emotional neutrality and/or positive orientation may be less likely to experience a high intensity of moral distress, even if they perceive a conflict in values or do not agree with the treatment plan.³¹

In contrast, clinicians who have had repeated professional experiences with cases like Maria's may have developed negative or unconscious response patterns influencing how they appraise and act. Unrecognized or unprocessed grief, or unconscious identification with the patient's situation because of age or contextual features, can impact one's appraisal and response to the case. Maria's disease progression may have reminded a clinician of similar experiences with other patients or family members, arousing grief or regrets about how these situations were handled.²⁹ Repeated unresolved or negative experiences with similar cases involving situations of “futility,” moral distress, or moral dilemmas that were refractory to negotiation or mediation can contribute to negative appraisal.^8,20 Eisenberg³² suggests that if unconscious negative memory is overly activated, responses to the situation are more likely to be self-focused, causing empathic overarousal, vicarious or secondary stress, or personal distress. The cumulative impact of repeated experiences of moral distress may leave a “moral residue” that alters the ability of clinicians to return to a baseline of well-being and stability and creates a “crescendo” effect with each subsequent exposure.⁹

Moral sensitivity

Being ethically attuned is foundational to recognizing ethical conflicts and the obligation to respond to them. Becoming aware of an ethical problem involves both conscious and unconscious processes. Being aware of and trusting one's intuition in the face of conflicting ethical commitments or unethical behavior can cultivate moral sensitivity. The ability to locate and articulate the source of internal discontent helps the clinician imagine possible courses of action and their consequences. When a clinician recognizes that a patient is in distress, a regulated empathic response may create the awareness of an ethical obligation to alleviate the patient's distress through a process of ethical appraisal and discernment. Similarly, recognizing the source of ethical unease or conflict can help to inform the appraisal and discernment process.

In Maria's case, clinicians may have experienced feelings such as empathy, tenderness, sadness, guilt, remorse, shame, frustration, or anger in response to perceived conflicts in values, interpersonal disagreements, and institutional constraints. These have been identified as key elements in the experience of moral distress and can either provide support or intensify the distress.^10,33,34 Although the proposed dynamic framework¹¹ focuses on the responses of individual clinicians to moral distress, it is also integral to creating a healthy work environment supporting clinicians to practice with integrity.³⁵

The ethical dilemmas in Maria's case escalated, as the perception of conflicting values and commitments and team disintegration grew. Some clinicians may have concluded it was unconscionable to participate in actions that caused disproportionate suffering and pursue goals perceived as unattainable.³⁶ Clinicians struggling to address the dissonance between what they are doing and their professional roles¹⁴ often express this conflict as a lament of “Why are we doing this?” Coupled with an experience of injustice on behalf of the patient and/or broader society, this conflict can lead to unhealthy emotional arousal and moral distress.¹⁴ Acting against informed moral judgment creates a conflict of conscience by abandoning, consciously or unconsciously, convictions, ethical values or norms, and/or personal integrity.³⁷ Conflicts of conscience are common among clinicians, particularly involving the care of patients at the end of life.^38,39

Emotion regulation

Clinicians caring for Maria are likely to have experienced an initial empathic response, potentially experienced later as aversion. Being fixated on a particular appraisal of the situation, unable to reappraise it from a different perspective, can result in emotion disregulation.⁴⁰ The lack of awareness of the perspectives of others may lead to inaccurate conclusions. For example, some clinicians may have concluded that Tom was in denial about the possible outcome for his wife—and that his request to continue aggressive treatments and limit certain therapies to treat pain was unreflected or uninformed.^41,42 Similarly, Tom may not have been aware of the level of the clinician's moral distress, and may have concluded that they were uncaring. Members of the interdisciplinary team could also react to the responses of their colleagues from an uninformed perspective.

The past experiences of family members and clinicians may create distress and negative responses to Maria's situation.¹⁹ If not stabilized, these emotional responses may exacerbate feelings of distress and instigate a focus upon one's own pain instead of Maria's suffering. In these instances, a clinician may try to convince the patient and family that their appraisals are inaccurate, or that they should accept the clinician's recommendations to forgo life-sustaining therapies.⁴³ Family members may adopt a defensive stance to protect the patient from a perceived threat of abandonment by the health care team. The result is often an intractable power struggle, where neither party is able to maintain a therapeutic relationship, and where isolation, conflict, and distrust grow.

Strategies for Addressing Moral Distress

After months of pursuing various options, the team caring for Maria requested ethics consultation in response to their moral distress, which was negatively impacting their ability to function well, individually and as a group. The consultation involved a series of meetings with the team and Maria's husband, where aspects of the framework were applied. Empathy and perspective taking were highlighted when Tom spoke about his fears and concerns about Maria's recovery and his acknowledgement of her impending death. This gave the clinicians an opportunity to attune to his situation and for some to shift to a more empathic response. Similarly, when nurses described their distress in how their actions were adding to Maria's suffering, both the physicians and Tom were able to acknowledge the intensity of the exposure to witnessing Maria's suffering and the distress that accompanied it. A particularly poignant moment in the consultation occurred when the surgeon spoke about his distress and sense of accountability for doing the transplant in the first place and the overwhelming sense of responsibility for her current status. Additionally, moral sensitivity was cultivated by the questions posed by the ethics consultation team, illuminating the morally salient aspects of her case and leading to greater awareness of the ethically permissible boundaries of treatment. At the end of the meeting several of the clinicians expressed a renewed commitment to provide care for Maria because of greater understanding of Tom's perspective and the acknowledgement of each other's predicament.

Subsequent meetings with consultants familiar with the proposed framework included an overview of the elements of the framework and highlighted the contribution of memory, empathic overarousal, and the physiologic consequences of unregulated moral distress. Various strategies outlined in Table 2 were offered as alternatives. Although there has not yet been systematic adoption of all the strategies, the case has fueled ongoing exploration of individual and system contributions to the issues that arose, continued dialogue, and commitment to design support systems and educational programs to enlarge the professional repertoire.

Table 2.

Strategies to Address Moral Distress

1. Cultivate strategies to stabilize attention and affect

Intentionally employ ways to maintain a “zone of resilience” during the workday.¹⁰ Pause before entering a patient's room, take an in-breath, and recall intentions. Take a few breaths and let things settle before responding to the patient. Notice if signals of negative emotional responses arise and create intentional spaces to down-regulate. This might include excusing yourself briefly from the situation, as well as engaging in peer-to-peer processing and support.

2. Practice mindfulness

Mindfulness involves tracking and training the mind to remain nonjudgmentally aware in the present moment and stable in the midst of distraction, emotional arousal, and proliferation of thoughts. Practitioners of mindfulness appear to be more emotionally regulated than nonpractitioners,⁵² and highly experienced meditation practitioners have been shown to have enhanced compassion-related brain responses to the distress of others.⁵³ Specific practices that focus on mindfulness of breath, attention on a neutral part of the body, noticing flow of thoughts and physical sensations, attention on a phrase or word can help to down-regulate the nervous system and reduce reactivity.⁵⁴ Methods such as Mindfulness Based Stress Reduction (MBSR) can be particularly helpful in cultivating greater awareness and stability.⁵⁵

3. Apply the GRACE process to support principled compassion

The mnemonic GRACE can help to ground clinicians in their values and aspirations to serve others.⁵⁶ This is an internal process assisting clinicians in cultivating compassion in interactions with patients. The process is: Gather attention; Recall your intention; Attune to somatic, affective, and cognitive subjective content and then attune to the patient using perspective taking, empathy, observation; Consider what will really serve through recalling intentions and allowing insight to arise; and Enact and considerately end the interaction. Learning to pause and to consciously shift awareness using this process can support clinicians to remain connected to their deeper commitments and values in the midst of challenging circumstances.

4. Monitor somatic responses

Bringing awareness to one's body can help clinicians recognize sensations that accompany being activated in positive or aversive ways. Attunement to bodily signals and emotions can offer useful insights. Practices such as a mindful body scan can help clinicians to become more aware of their body sensations and patterns of responses. Awareness of the body's responses creates opportunities for clinicians to ground themselves and bring needed resources to bear to stabilize in the face of difficult or emotionally charged situations.^10,11,57

5. Cultivate compassionate intention

Compassionate intention can be cultivated by regularly engaging in practices that prime kindness, gratefulness, generosity, and other prosocial emotions and can support the development of conditions for compassion to arise.^47,58 Even a small number of weeks of practice can significantly positively impact prosocial attitudes and interactions with others and reduce the practitioner's own physical symptoms.⁵⁹ This, coupled with an expanding repertoire of skills of emotional intelligence,^60,61 can support clinicians in connecting with their deeper values and commitments and assist them in embodying their moment-to-moment interactions.

6. Recognize empathic overarousal and personal distress

As one's awareness of body, emotions, and thoughts deepens, it can become easier to recognize the situations triggering personal distress. Familiarity with cases that are similar in circumstances or characteristics can be unconsciously projected onto other patients or situations. Patterns of aversion, somatic responses to aversive/repulsive situations, and negative somatic or affective responses to the patient's physical or cognitive distress of patient experience can offer cues about the potential for future distress to arise. Signals of empathic overarousal especially when persistent include autonomic fight, fright, or freeze responses; rumination; symptoms of anxiety such as insomnia; inability to focus attention; somatic responses such as nausea, headache, localized or generalized pain (e.g., neck, back, joints); depression, sadness, anger, or agitation; and addiction behaviors. These can be a source of insight for the clinician; for example, the felt sense of tightening in the throat, signaling fear, can be interpreted as the need to express something.⁶² Batson⁶³ and Eisenberg's research^64,65 suggests that when the focus is on the impact of the situation on oneself, it is more likely that empathic overarousal and distress will occur and more energy will be used to relieve one's own distress. In contrast, taking the perspective of the other tends to modulate empathic arousal and shift the focus to those steps that will serve both self and other.⁶⁴

7. Develop methods to foster reflection and inquiry

Intentionally creating pauses in the process in order to enhance clarity, insight, and accurate perception of the situation can support ethically grounded action. Cultivating a quality of silence as a way of being⁴³ can help to create more spaciousness in the discernment process.⁶⁷ Validating one's assumptions and monitoring one's mindset and biases can foster the Art of Pause⁴⁴ and enhance reflection and inquiry. Developing peer support systems can help clinicians to recognize in each other when responses are disproportionate to the situation and to maintain a zone of stability supports clinicians in maintaining clear boundaries of responsibility for both process and outcome of their actions.

8. Develop insight to distinguish self from other

Develop clarity in distinguishing self from other through the insight that you are not your patient, though you can sense into your patient's experience. Overidentification can cause a loss of boundaries that can adversely affect clinicians. Cultivating a stance of equanimity through embodying a healing presence with present moment awareness and stability can support efforts to realize the distinction between self and other. When signs of negative arousal arise, pause to recalibrate attention and intentionally distinguish what is happening to the other from one's personal experience. Mindfulness practices that cultivate awareness of bodily experience help decrease a tendency to get caught up in self-relevant narratives or imagery that can blur the distinction between self and other experience.¹⁷

10. Cultivate moral sensitivity

Expand the repertoire of ways to discern when an ethical conflict or dilemma is present, including trusting intuition and monitoring emotions, cognitive appraisal, and somatic responses. Monitor the activation of conscience and the resulting emotional responses, either positive or negative. Support discernment of the morally salient aspects of the situation, the range of permissible responses, and their impact on self and others, as well as the intention and manner that decisions are implemented.⁶⁸

11. Develop and refine skills in moral reasoning

Stabilization is a necessary but insufficient element of integrity preserving ethical action. Alongside efforts to stabilize the mental continuum, refinement of cognitive skills in moral reasoning can assist in discerning the range of ethically permissible options, the nuances of conceptual definitions, and the contours of ethical perspectives.^68,69 Ongoing application of ethical decision making models creating forums for dialogue with clinical ethicists, continuing education, and use of ethics consultation services can be supportive.

12. Take care of basic needs

When clinicians become depleted or their systems imbalanced, their ability to respond to difficulties narrows and they are more likely to react rather than respond, or become unregulated and overaroused. Getting enough sleep, eating a balanced diet, exercising, socializing, and cultivating interests and relationships can all contribute to a sense of wholeness and stability.⁷⁰ Commitment to an ongoing plan for addressing these issues is foundational to clinician well-being.

13. Foster systems to address ethical concerns and dilemmas

Develop a comprehensive interprofessional program to create mechanisms for ethics rounds, ethics consultation, and proactive organizational ethics policies and systems. Use experiential learning sessions to explore the contours of the framework with actual clinical cases; collaborate with mental health providers, spiritual care providers, and ethicists. Address organizational barriers and patterns that create repeated circumstances that breed the conditions for moral distress to arise.

The authors propose that moral distress might be transformed through the adoption of various interventions that assist clinicians in the regulation of emotion and attention and assist with cultivating insight and a metacognitive perspective. Table 2 includes strategies that might prevent or transform aversive responses to moral dilemmas and provide the stability to foster principled compassion instead of ungrounded moral outrage. These include cognitive, attentional, affective, and somatic approaches that are derived from contemplative traditions used for capacity building, resilience training, and reduction of distress.⁴⁴ According to Halifax,⁴⁵ five interrelated domains need strengthening when developing principled compassion. These include attentional balance; affective balance; cognitive dimensions, including intention and insight; and embodiment.⁴⁵ Mental training techniques aid in the development of these domains and aid individuals with mental pliancy, equanimity, and principled, ethically based compassion.

Approaches to transform moral distress include mindfulness practices aimed at stabilizing attention and emotions; insight practices to distinguish self from other (patient/family); the development of the capacity to inquire and explore;⁴⁶ awareness practices that assist clinicians in recognizing emotional triggers and states of negative arousal, including symptoms of empathic overarousal; and an ethic of care derived from insight into the nature of suffering (see Table 2).

Peer support and use of experiential learning to enhance socialization, while exploring actual cases to foster ethical responsibility, are also recommended. Reported in more detail elsewhere,^17,45,47 these modalities are most effective when coupled with systems-focused approaches⁴⁸ beyond the scope of this paper, such as patient care conferences on goals of care,⁴⁹ proactive identification of ethically problematic cases,⁵⁰ and debriefings after patients die.⁵¹

Footnotes

Conclusion

Applying the Framework for Understanding Moral Distress to the case involving Maria provides opportunities for understanding response mechanisms amenable to intervention. Using the proposed framework as a guide, it is possible to notice where the process can go awry, causing emotional destabilization, personal distress, avoidance behaviors, and unregulated moral outrage. Alternative strategies and practices are illustrated above and in . Using the framework to understand the process may help mitigate or avoid the progression of distress and a concurrent negative appraisal that leads to moral distress or moral outrage. Intervention evaluation research is needed to determine the efficacy of the framework.

Acknowledgments

The authors acknowledge their colleagues of the Upaya Institute's Professional Training Program in Compassionate End-of-Life Care (Being with Dying) for their invaluable contribution to the development of this model and the various researchers, cited in this article, whose work has inspired us. Gratitude to Cheryl Zogg and Kelly Wilson-Fowler for assistance with manuscript preparation.

Author Disclosure Statement

No competing financial interests exist.

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