Moral distress in end-of-life care in the intensive care unit

J Adv Nurs. 2013 Aug;69(8):1869-80. doi: 10.1111/jan.12053. Epub 2012 Dec 4.


Aim: To explore moral distress in relatives doctors and nurses, in end-of-life care decision-making, in the adult intensive care unit.

Background: Many deaths in intensive care involve decisions about withholding and withdrawing therapy, potentially triggering moral distress. Moral distress occurs when individuals feel constrained from acting in accordance with moral choice, or act against moral judgement, generating painful, unresolved emotions, and problems that continue long after an event. Prior research has focused mainly on nurses; less is known about doctors' experiences and occurrence and impact on relatives is unknown.

Design: A narrative inquiry case study approach, funded by a Northern Ireland Health and Social Care Doctorate Fellowship Award (April 2011).

Methods: In-depth digitally recorded interviews will be conducted with relatives, doctors, and nurses involved in end-of-life cases comprising: (1) withdrawal of therapy, including circulatory death organ donation; (2) non-escalation of therapy; and (3) brain stem death with a request for organ donation. Relatives will be offered the opportunity to share their experiences on 'Healthtalkonline' by copyrighting audio-visual interviews to the Health Experiences Research Group, Oxford University. Research Ethics Committee approval was obtained (April 2012).

Discussion: This is the first time that moral distress is explored, in a case approach, among relatives, doctors, and nurses intimately involved in end-of-life decisions in intensive care. Dissemination of findings will make a large contribution to international knowledge and understanding in this area and alert healthcare professionals and relatives to an otherwise under-recognized, but potentially detrimental, experience. Findings will inform education, practice, and policy.

Keywords: doctors and nurses; end-of-life care; intensive care; moral certainty; moral distress; narratives; relatives.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Caregivers / ethics
  • Caregivers / psychology
  • Conflict, Psychological*
  • Decision Making / ethics*
  • Humans
  • Intensive Care Units / ethics
  • Morals*
  • Multicenter Studies as Topic
  • Narration
  • Northern Ireland
  • Nursing Research*
  • Nursing Staff, Hospital / ethics
  • Nursing Staff, Hospital / psychology
  • Physicians / ethics
  • Physicians / psychology
  • Qualitative Research
  • Research Design
  • Stress, Psychological*
  • Terminal Care / ethics*