On Moral Injury…

Moral injury is an element of physician burnout that needs more attention, so we can work on a solution.

These days I walk though the critical care units filled with patients who have lung injury that is not survivable. It seems cruel that their last days on Earth are spend unconscious and connected to machines as we place lines and tubes throughout their body. I know it’s only a matter of time before they succumb to their illness, just like the others. I feel helpless. Families hold onto hope even though the medical team explains the nature of the disease process and grave prognosis. They hope that “just a little more time” will change the end to the story. They ask for CPR and full code status, believing it’s not over until it’s over. We oblige. 

Seeing many humans in this condition day after day is difficult. Many healthcare workers discuss the concept of burnout, but less airtime is given to moral injury. Moral injury is when a person witnesses events or situations that go against their personal moral and ethical code. It is hard to wrap our heads around what we are experiencing and we feel like helpless bystanders. We feel guilty pushing on a patient’s chest at the end of life, even though we know it will not change the outcome. We view keeping patients alive artificially on life support even though their condition is irreversible as unnecessary suffering. These situations are not new, but the volume has drastically increased due to the pandemic.

Preventing moral injury will be challenging to overcome. It will require a shift in the culture around death and dying. At this time, many opt for quantity over quality of life. Death is inevitable, however, many patients do not discuss their end of life wishes with their families. There is also disbelief that death is coming, especially if a patient had overall good health prior to the events leading to their death. Additionally, medical professionals will need to regain the general public’s trust. This has been steadily declining in recent years, but is at an all time low at this moment. As healthcare professionals, we must continue to educate the public and welcome respectful conversation regarding health issues. Neither of these “requirements” are a small feat. 

What can healthcare workers do in the here and now? First,  recognizing that moral injury exists and knowing we are not alone in this experience is helpful. Second, we must protect our mental and emotional health. This  includes not taking on additional shifts if you recognize you are emotionally fatigued. It is important to have boundaries. It is reasonable to seek assistance from a mental health professional. Moral injury increases the incidence of depression and suicidal ideation. The old adage that you must care for yourself so you can care for others holds true. 

As healers, we hope our patients will get better and survive their illness, however, many times the body succumbs to the disease process. When it is clear the patient will not survive, we do not want to see our patients suffer. We want what is best for our patients. Some times that is to allow them to die with dignity. 


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