Palliative Care Nursing: Inner Strength and Moral Distress

Alexander Wolf, author of the study Palliative Care and Moral Distress. — Alexander Wolf, DNP, RN, APRN, author of Palliative Care and Moral Distress, a study of moral distress among critical care nurses.

Palliative care nursing mainly revolves around enhancing the quality of life of seriously ill patients and their families during life-sustaining treatment and at the end of life. Whether or not they have been trained in palliative care, critical care nurses frequently have patients who are in need of such care. How prepared do they feel?

Or, what happens when critical care nurses encounter a lack of palliative care for their patients, or find themselves in circumstances that run counter to their precepts of care-taking? Alexander Wolf, DNP, RN, APRN has published a paper on nursing, palliative care, and the impact of “moral distress” on critical care nurses. DailyNurse conducted an interview with Dr. Wolf to discuss his paper and its findings.

DailyNurse: What are some examples of palliative care nursing practices a critical care nurse might perform?

Alexander Wolf: Critical care nurses are regularly tasked with assessing and managing the distressing physical, psychological, and spiritual symptoms of critical illness. Those of us who are palliative care specialists can benefit from critical care nurses’ insight into patient/family dynamics, psychosocial situation, and cultural background.

In addition, these nurses frequently have a difficult job of bearing witness to suffering, providing a therapeutic presence in difficult circumstances, and employing two-way communication skills to help determine the treatment goals of the patient and family. These nurses must also be adept in ethical and legal aspects of care, for instance. They also need to be able to help interpret patients’ advance directives and to advocate for the wishes that patients have outlined, when appropriate.

Critical care nurses are also instrumental in providing expert, compassionate end-of-life care in the intensive care unit, which may involve the careful withdrawal of life-sustaining treatments such as dialysis and mechanical ventilation. This often requires thoughtful preparation and culturally sensitive communication with patients and family members, and skilled symptom management throughout the dying process.

DN: What is the phenomenon of “moral distress” that affects many palliative care providers?

AW: Nurses and other providers frequently report episodes of moral distress, in which an individual identifies the morally correct action to take, but feels unable to take it due to some type of constraint. Helplessness or frustration are just a few of the many emotions that an individual might feel as a result — others might include outrage or guilt, among others.

“Critical care nurses tend to experience frequent and intense moral distress in situations pertaining to the end of life, such as providing treatment perceived as inappropriate or futile, prolongation of life or death and lying to or withholding information from patients or family members.”
Alexander Wolf, Palliative Care and Moral Distress, Critical Care Nurse, Vol. 39.5, October 2019

Previous studies have also indicated that these feelings don’t seem to entirely go away either. “Moral residue” often remains, and repeated episodes of moral distress often remind an individual of the previous episodes, causing their distress to intensify. As a result, an individual may try to protect themselves by avoiding or withdrawing emotionally from ethically challenging situations, or by quitting their job.

DN: Is palliative care training appropriate only for certain providers?

AW: Palliative care has evolved so much in recent years — it is no longer solely a subspecialty — now it is an important skill set for all healthcare providers, including nurses and physicians.

In addition, there is a continued shortage of specialists relative to the number of patients with palliative care needs. This really underscores the importance of nurses and other healthcare providers to be proficient to provide basic palliative care. In 2014, the National Academies of Medicine recommended taking measures to improve the palliative care knowledge base of all clinicians.

DN: Ideally, what changes would you like to see result from your study?

AW: There are many changes we would love to see, but here are a select few.

Bedside nurses — particularly those who have had palliative care education — need to be empowered as leaders for integrating palliative care in their practice environment. They would be in an ideal position to educate their peers and interprofessional team members. We need to better recognize nursing excellence. Physician and nurse leaders need to collaborate to ensure that bedside nurses have a voice when they feel their patients’ needs are not being met.

The critical care nurses in our study seemed to highly value palliative care, but few felt highly competent, and even fewer reported having any recent education in palliative care. Many nursing programs have done a great job in recent years to include palliative care in school curricula and in student clinical experiences, but it cannot just be “squeezed in”. There is clearly still a lot we need to do to integrate palliative care as a key competency area for nurses across specialties, particularly in critical care.

“Nearly half of respondents [in this study] rated themselves as not competent or somewhat competent in knowledge of advance directives, living wills, and do-not-resuscitate order policies. Previous studies have illuminated knowledge gaps among acute and critical care nurses in this domain…. Given the legal and ethical implications, this knowledge gap should be a key focus of palliative care education initiatives…”
Wolf, Palliative Care and Moral Distress, Critical Care Nurse, Vol. 39.5, October 2019

Additionally, the nurses in our study placed a high value on interprofessional collaboration. In continuing education for nurses it would be wise to be inclusive of other healthcare professionals. This could help foster increased recognition of patients’ palliative care needs by all team members.