Moral Injury – an NPs Tale


by Laura Kinkade, MS, RN, AG-ACNP

“Moral injury is the damage done to one’s conscience or moral compass when that person perpetrates, witnesses, or fails to prevent acts that transgress one’s own moral beliefs, values, or ethical codes of conduct.” – The Moral Injury Project

In the last year, there has been a lot of discussion about moral injury in physicians.

The concept of Moral injury was first identified in front line military personnel as the psychological foundation for PTSD. Syracuse University has an excellent summary of what moral injury is on their Moral Injury Project webpage.

In 2018, Statnews wrote a compelling piece identifying the source of physician “burnout” as moral injury. Then our boy, ZDoggMD, did a video on Moral Injury in physicians that went viral.

All providers can relate to his video. Admin pushes through-put, insists on higher “productivity” (more patients in a day = more billables, but less patient care), the clunky EMR cash register that causes us to ignore our patients when they are right in front of us, etc. But as midlevel providers, we can experience a type of moral injury that is unique to our status in the medical profession. This scenario is infrequent, but it has happened often enough that it has etched a furrow in my heart.

I’d gotten to know my patient and their family very well over the last several days in the ICU. My patient had a complex set of problems, both exacerbations of chronic problems, and acute ones that had tipped the delicate scales of health towards worsening organ failure and impending death.  My patient was alert and able to make decisions, though.  I’d spent hours with them and their family explaining how each medical condition was impacting the others, treatments we were attempting to make things better, and what options were available if those treatments didn’t work. After several medical therapies failed to improve their conditions, my patient told me that they’d had enough. They didn’t want the heroic stuff anymore. They wanted to go home to die.  Though there were other medical options that could have been attempted, I felt confident my patient had a good understanding of their health and had made an informed decision to proceed with hospice care. There is a certain satisfaction in helping your patient create a good death. There are so many bad ones in the ICU. Other members of the healthcare team were notified of the patient’s choice and plans for discharge.

Other members of the healthcare team did not agree with the patient’s choice.

A physician team member talked to my patient and convinced them that some long-shot therapy would possibly – maybe, we-should-at-least-give-it-a-try-before-we-give-up – help.

Typically, the reasons for attempting the long-shot therapy have more to do with fulfilling some bundled service or the physician’s belief that no avenue should be unexplored, than about the patient’s goals for care. Medicine in the service of medicine, rather than medicine in the service of people.

As a nurse practitioner, this places me in an awful position. I’ve already had long conversations with the patient and included the long shot therapy as an option. When I describe what it may do for them and at what personal cost (benefit vs risk), if they decline, then it’s removed as an option for their therapy. Now a physician – the higher authority – has convinced them that the long shot should be attempted.

For a short while, I’m no longer trusted, and no longer welcome in my patient’s care.

As an NP, I am subordinate in the hierarchy of medicine.  But as an NP, I have fewer patients to cover, so I’m there at the bedside more often. I’m there when the long shot treatment instead causes rapid deterioration. I’m there when the patient sinks into delirium, and then hemodynamic instability. I’m there when the family again turns to me, to make sense of what is happening. I’m the one that tells the family, that it’s too late, their loved one will never go home again. And I help them make a plan to ease the patient’s suffering as they die.

I feel such rage at the injustice that has been done to my patient, and I feel impotent. Sometimes I’ve participated in these injustices by inserting a special line or tube, and I feel shame. More than once, the dissenting physician will have these conversations with the patient, and then go off-service, never witnessing what came next. Not only do I get to witness the suffering the actions of others have caused, but I get to clean it up too. I get to manage another ICU “bad death” that someone else engineered.

And then, I need to find a way to navigate my relationship with the physician. After the patients die and the families go home, it’s still necessary to collaborate on other patients with these same physicians. But I feel like trust has been lost. I don’t understand their decisions because they didn’t include me in them. Nor did they confer with me prior to the conversations with our patient. Nor do they talk to me about the outcome after the patient has died.

Fortunately, I have attending physicians and fellow NPs that understand these moral dilemmas and will listen to my concerns. My team has helped me make sense of these events as much as possible, or to commiserate. If I am especially conflicted about a procedure, I can refuse without jeopardizing my job.

I don’t believe these events can ever entirely be avoided. We don’t live in an ideal world, because everyone’s ideal world is not identical. Providers arrive at the bedside with differing sets of driving moral and ethical principles. Maybe one day, all physicians will see NPs as full team partners and include us in difficult decisions rather than reporting to us a fait-accompli change in plan. In the meantime, I will continue to do what I do best and develop a medical plan of care that meets my patient’s needs.

Laura Kinkade is an AG-ACNP specializing in adult critical care. She works at Doctor’s Medical Center in Modesto, CA and its sister hospital in a nearby town. She is an avid gardener and is working to turn her city lot into a permaculture food production machine. She’s married with two grown sons, a daughter in law, multiple “found’ sons, two dogs and a cat.

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