By Carolyn Crist

(Reuters Health) – When patients cannot make their own decisions about life-prolonging care, many doctors feel “moral distress” acting on the choices of surrogates like family members, a small survey suggests.

Doctors most often felt ethical strain when the patient was older or the surrogate wanted more life-sustaining treatment than the doctor felt appropriate, researchers report in the Journal of General Internal Medicine.

“Moral distress, especially when it goes unaddressed, is associated with physician burnout,” said coauthor Lucia Wocial, a nurse ethicist at Indiana University Health in Indianapolis.

“The more we learn about what contributes to physician moral distress, the more we can intervene to help them to overcome barriers to doing what they feel is the right thing to do,” she told Reuters Health by email.

Wocial and colleagues analyzed survey responses from 154 doctors with patients in intensive care units who lacked the capacity to make decisions. Surrogate decision-makers for 362 patients also took part in the survey.

Doctors reported experiencing moral distress when caring for 152 of the patients, or about 42%.

In general, disagreements between the doctor and surrogate about the plan of care didn’t cause much distress. Instead, doctors were more likely to feel moral conflict when facing a decision about life-sustaining treatment, especially when the doctor preferred a comfort-focused or hospice-focused plan.

“One of the hardest experiences I have had as a physician was the feeling that I was doing something to a patient that wasn’t in their best interest or what they would have wanted,” said coauthor Dr. Alexia Torke of the Indiana University Center for Aging Research at the Regenstrief Institute.

“When a physician has this feeling, it can be a sign that something has gone wrong. We ought to pay attention to this,” she told Reuters Health by email. “It might be a sign that we are not communicating effectively with our patients or their families about the outcomes of some of the treatments we provide, especially treatments that can be burdensome or ineffective.”

Moral distress occurred more often when the doctor was male and the patient was older, but it was less common when patients lived in a nursing home.

When doctors felt confident about what mattered to the patient, either through a living will or by talking to family members who knew the patient’s wishes, they were less likely to feel distress and felt they could make clearer recommendations and suggest choices that were consistent with the patient’s values.

“Our own work has found that most of the causes of moral distress in the critical care setting are ‘system’ issues, such as inadequate communication and inadequate advance care planning,” said Dr. Peter Dodek of the University of British Columbia in Vancouver, who wasn’t involved in the study.

“Addressing this issue is not just a personal task for healthcare workers – it also requires system improvements,” Dodek told Reuters Health by email.

For patients and families, this could mean clearer communication about advance directives and living wills before a family member loses decision-making capacity.

“Advance directives can be helpful in reducing family members’ stress, anxiety and depression,” said Beth Epstein of the University of Virginia’s Center for Biomedical Ethics and Humanities in Charlottesville, who also wasn’t part of the current study.

“Now, it looks like advance directives and patient conversations about future medical wishes can be helpful to healthcare providers, too, in terms of reduced moral distress,” she said by email.

SOURCE: Journal of General Internal Medicine, online February 24, 2020.