Moral distress occurs when a clinician is unable to act in accordance with their ethical beliefs due to external constraints. It differs from emotional distress and post-traumatic stress disorder because it directly links to a violation of ethical principles (J Health Psychol 2017;22:51-67; JAMA 2020;323:923-4; asamonitor.pub/3XsYXfX). In the example described, all clinicians caring for the patient must find a balance between the principles of autonomy and nonmaleficence (the ethical principle to do no harm). Proceeding with general anesthesia in a high-risk patient with a life-limiting condition could certainly be construed as causing harm. She could suffer a variety of major complications, all of which diminish her already-short prognosis. Even if the operation proceeds smoothly, her decision to decline hospice raises questions about her perception of her overall prognosis. Without insight into her understanding, many anesthesiologists would struggle to accept her decision to proceed with a large abdominal operation, especially one made while in active discomfort. While some patients might justifiably choose surgery, it is not obvious that this patient recognizes the difficulties associated with recovering from an exploratory laparotomy in the setting of incurable metastatic cancer. In this way, proceeding with surgery also raises concerns about violation of the patient’s autonomy, as it is unclear whether she possesses the information necessary to make complex care decisions. Thus, the pressure that the anesthesiologist feels to continue with the emergent surgery generates moral distress in the face of potential, yet very real, ethical violations and harms to the patient.

Most studies exploring contributing factors to the development of moral distress come from nursing. However, one study which included nurses and physicians in critical care noted that moral distress occurred in both groups when clinicians felt compelled to provide aggressive treatment despite feeling such care was not justified (Crit Care Med 2007;35:422-9). Other clinical situations in which anesthesiologists risk experiencing moral distress were described earlier this year in the ASA Monitor article by Drs. Kussman and Brown (ASA Monitor 2024;88:e10-11).

An anesthesiologist’s experience of moral distress is often mediated by the broader clinical environment – thus, systems-level factors must also be considered. Some of the systems-level factors identified through prior research that are relevant to anesthesiologists include lack of support from peers when caring for difficult patients, lack of respect from patients, and limited ability to collaborate with colleagues (J Health Psychol 2017;22:51-67). Notably, organizational environments differ in their propensity to generate moral distress. For example, individual hospitals vary in how supportive they are of clinician efforts to de-escalate potentially nonbeneficial life-sustaining therapies (JAMA Intern Med 2023;183:839-48). Similarly, societal and cultural factors shape a clinician’s experience of moral distress (J Gen Intern Med 2021;36:1890-7). When viewed from this vantage point, the OR environment in the United States may be particularly prone to generating moral distress among anesthesiologists due to an ever-increasing volume of surgeries, a progressively older and sicker patient population, and time pressures (J Clin Monit Comput 2012;26:329-35).

Importantly for anesthesiologists, lack of power also causes moral distress (J Adv Nurs 2013;69:415-24). Power, defined as “the information, support, professional resources, and opportunities needed to accomplish work,” may be particularly scarce for anesthesiologists, who often enter a patient’s care only when a procedure has already been offered to and accepted by the patient (J Adv Nurs 2013;69:415-24). When the surgical informed consent process occurs in a high-risk patient without their involvement, the anesthesiologist may feel obligated to proceed (J Gen Intern Med 2021;36:1890-7; JAMA Surg 2016;151:309-10).

Let’s recall our hypothetical patient. For clinical situations like this one, a perioperative goals-of-care discussion may help limit moral distress for anesthesiologists. A patient’s goals of care represent intentions of treatment during a particular episode of care. While our hypothetical patient most likely engaged in goals-of-care discussions throughout her cancer treatment, an additional discussion is needed in the preoperative setting because the patient’s health status has changed, and a new treatment option – major surgery – has been introduced.

By eliciting the patient’s goals within the context of the perioperative period, the anesthesiologist learns whether the patient’s expectations align with realistic surgical outcomes. This information also clarifies whether the patient possesses the necessary information to make an autonomous decision about his/her medical care. Lastly, this conversation provides an opportunity for the anesthesiologist to discuss any ethical concerns with the patient.

Let’s say our patient decides to pursue surgery with the goal of relieving pain. The anesthesiologist may have concerns about added pain in the immediate postoperative period from surgery, prolonged intubation, and reduced physical function due to immobility. Discussing the patient’s goals and the anesthesiologist’s concerns prior to surgery may decrease moral distress: At the end of the conversation, the anesthesiologist may come to feel as though they acted in concordance with, rather than in violation of, broadly accepted ethical principles.

Various frameworks for conducting goals-of-care discussions exist (asamonitor.pub/3zg3qJx; J Oncol Pract 2017;13:e844-e50). A key component of each involves the discussion leader expressing a desire to understand the patient’s hopes for the future in the context of their illness. To gain this knowledge, anesthesiologists may use open-ended questions, such as asking how the patient envisions life following surgery. While answers will vary significantly, the anesthesiologist should evaluate whether the patient’s expectations align with anticipated postoperative outcomes. If the anesthesiologist is uncertain of what expectations are reasonable, or if the patient’s hopes for the future differ greatly from the likely outcomes, then the surgeon and possibly a palliative care specialist should be engaged for further conversation. Overall, increasing interdisciplinary discussions in complex clinical scenarios may alleviate moral distress for all involved parties (JAMA Surg 2016;151:309-10).

While perioperative goals-of-care discussions can be carried out by individual anesthesiologists, systems-level interventions are required to prevent morally distressing situations from arising. While a full discussion of systems-level interventions is beyond the scope of this article, anesthesiologists should consider quality improvement efforts at their own institutions that identify and address the root causes of moral distress. Anesthesiologists can consider improving systems surrounding perioperative code status, completion of advance directive documents prior to planned major surgeries, and/or creation of preoperative optimization protocols for patients with serious illness (asamonitor.pub/4ggZHft). Forming a peer support program, providing access to individuals trained in psychological first aid, and/or implementing structured debriefs following unexpected outcomes provide outlets for anesthesiologists who may be suffering from moral distress (Int J Environ Res Public Health 2021;18:4594; Cochrane Database Syst Rev 2002;2:CD000560; J Bioeth Inq 2021;18:573-87).

Moral distress commonly occurs in anesthesiologists who care for seriously ill patients. Contributing factors include the feeling of providing care that may seem unwarranted, lack of support and respect from peers, patients, and hospital systems, and lack of power to decide if and when high-risk surgeries are offered. To mitigate this distress, anesthesiologists can improve their skills in conducting focused perioperative goals-of-care discussions. Such conversations provide anesthesiologists with insights into the patient’s goals and expectations following surgery. If significant discrepancies between the patient’s hopes and the likely realities are revealed, then more in-depth goals-of-care discussions with other stakeholders should be conducted. On top of these skills, anesthesiologists may also engage in systems-level quality improvement projects aimed at prevention of moral distress. Through partnership with our patients, surgeons, and other OR staff, we can create a healthier environment for all by limiting the frequency at which morally distressing situations occur and promoting strategies at both individual and systems levels for coping with them.

WFSA Council Member and Regional Representative for Central and South America, Mexico, and the Caribbean Islands

The health care landscape in Latin America faces numerous challenges, but perhaps the most pressing issue that needs to be addressed is the expansion of access to quality health care. This issue is paramount because it underpins a wide array of other health care concerns, including perioperative care, the response to public health emergencies, and the reduction of health disparities.

Latin America is a region of profound economic and social disparities. While countries like Brazil, Argentina, and Chile have relatively structured health care systems, albeit with challenges, many others struggle with inadequate resources, shortages of health care workers, and poor infrastructure. According to the Pan American Health Organization, nearly 30% of the population in Latin America still lacks access to essential health services (asamonitor.pub/3zPiONr).

One of the primary barriers to improving the quality of care is the shortage of health care workers. According to the WHO, many countries fall below the recommended density of professionals required to achieve development goals (asamonitor.pub/4h7WIXo). This dearth is not merely a quantitative issue, but also a professional quality problem. Facilities often operate with inadequate staffing, leading to overworked professionals and high risk of burnout. In perioperative care within some countries, there is also a problem with under-trained nonphysician anesthesiologists (Curr Anesthesiol Rep 2018;8:448-55).

In addition to workforce shortages, the region’s health care infrastructure is often insufficient to support care. Many facilities, especially in rural and remote areas, lack essential equipment, are outdated, or are poorly maintained.

The quality of care is significantly impacted by this dual challenge. In areas where the situation is most acute, there is often a higher prevalence of preventable diseases, increased mortality rates, and poorer health outcomes. In the field of anesthesiology, these issues can have particularly severe consequences. A report on the safety of anesthesia practices in Latin America highlights how inadequate infrastructure and a lack of properly trained personnel contribute to increased risks during surgical procedures. The report underscores the need for improvements in both training and facility conditions to ensure safer outcomes for patients (Curr Anesthesiol Rep 2018;8:448-55).

Improving quality requires an approach that addresses both problems. Firstly, investing in workforce development is essential. This includes increasing training and retention, particularly in underserved areas, avoiding “brain drain,” and creating supportive work environments that reduce burnout and improve satisfaction (asamonitor.pub/4h7WIXo). When trying to overcome this issue, however, many countries tend to fall into the trap of increasing the number of professionals with little or no care about their qualifications. This, in turn, reduces the quality and safety of care.

Secondly, there must be a concerted effort to improve infrastructure. Governments should prioritize the construction, renovation, and maintenance of health care facilities, ensuring that they are equipped with the necessary resources. This includes access to clean water, reliable electricity, and essential medical equipment. In the field of anesthesiology, for example, greater availability of monitors, equipment, drugs, and tests can significantly enhance surgical care.

Finally, embracing technology and innovation, such as telemedicine, can help bridge some of the gaps in care quality. Telemedicine offers a viable solution for extending the reach of health care services to remote populations (Healthc Inform Res 2012;18:153-5).

By investing in workforce development, enhancing infrastructure, and leveraging technological innovations, countries can make significant strides toward providing high-quality, equitable health care for all.

WFSA Council Member and Regional Representative for Australia, New Zealand, and the Pacific Islands

Australia and New Zealand are high-income countries (HICs) without the workforce challenges of our Pacific neighbours. The Australian Society of Anaesthetists and New Zealand Society of Anaesthetists (NZSA) have worked closely with the Pacific (PSA) and Papua New Guinea (PNGSA) Societies over the last 30 years to support workforce development, with an emphasis on education, training, and anesthesia capacity-building. These ongoing challenges are highlighted by the recent update on the WFSA’s Workforce map, with key physician anesthesia provider densities per 100,000 populations as follows.

• Australia: 20.57
• New Zealand: 18.26
• Fiji: 2.53
• Papua New Guinea: 1.11 (but projected <1 with accurate population data)
• Solomon Islands: 0.97
• Vanuatu: 0.93

There are two universities in the Pacific offering postgraduate specialty medical education – the University of Papua New Guinea and the Fiji National University. The Australian Society of Anaesthetists and NZSA support postgraduate training with both academic and financial resources, and Pacific Island workforce capacity is improving but still has a way to go to meet the aspirational workforce targets of four physician anesthesia providers per 100,000 population.

Other workforce challenges in the Pacific relate to medical migration, with loss of valuable clinicians to nearby high-income countries like Australia, and workforce fatigue and burnout. However, as physician anesthesia provider workforce numbers have improved over the last 20 years, movement of anesthetists is now predominantly within the Pacific region, as they look to support each other’s workforce needs.

The Pacific Society of Anaesthetists annual National Scientific Congress is a vitally important opportunity for physician anesthesia providers from the member countries (Timor-Leste, Fiji, Tuvalu, Kiribati, Nauru, Tonga, Samoa, Solomon Islands, Vanuatu, and the Cook Islands) to meet. The primary aim of the congress is to provide CME opportunities, networking, and respite from arduous clinical practice for the anesthesia professionals who work in these challenging environments. Networking opportunities have been enhanced in recent years, with representatives from the Society of Anaesthetists of Papua New Guinea joining the congress with financial support from ANZCA.

The Australian Society of Anaesthetists and NZSA support the congress with funding, provision of speakers, and, most importantly, sourcing locum support to enable physician anesthesia providers from often remote locations to travel to Fiji and benefit from the collaboration and collegiality of their NSC. The meeting also allows each member country to present and update others on current and projected workforce challenges, with fatigue, burnout, and work stress highly prevalent. Workforce and further strategic planning are crucial elements of these presentations.

WFSA Council Member and Regional Representative for Asia

The anesthesiology leaders across the Association of Southeast Asian Nations (ASEAN) and other parts of Asia have provided valuable insights into the key challenges facing the field in the region over the next four years. Among the recurring themes are sustainability, access to quality care, technological advancements, and regional collaboration.

One of the most significant issues facing the region is how to align anesthesiology practices with environmental sustainability. Several countries have acknowledged the need to reduce the environmental impact of anesthesia practices. A growing focus has emerged on adopting environmentally conscious strategies without compromising clinical care. This includes the awareness of waste products management and increasing the use of total intravenous anesthesia (TIVA) to complement traditional inhalation anesthesia, providing a balanced approach to minimize environmental harm (Curr Opin Anaesthesiol 2023;36:188-95). However, a more critical area of focus for the region is the work of the Asian Malignant Hyperthermia Alliance in collaboration with Taiwan, Japan, Singapore, Philippines, Thailand, Malaysia, Indonesia, and Hong Kong. Malignant hyperthermia (MH) in Asia is associated with unique genetic variations that distinguish it from other regions. The Asian population exhibits specific MH susceptibility due to distinct genetic markers, leading to varying prevalence rates. The Asian Malignant Hyperthermia Alliance highlights the need for region-specific research, particularly in documenting genetic predispositions and family histories across different Asian countries. This focus allows for more tailored prevention, detection, and improvement of crisis management approaches to MH in the region. Further details can be found at amha.asia.

Across Southeast Asia, disparities in access to qualified anesthesia personnel remain a critical challenge, especially in rural and underserved areas. Many countries, including some parts of Thailand, face shortages in anesthesia professionals, leading to reliance on nurse anesthetists under the supervision of surgeons (WHO South East Asia J Public Health 2021;10:5-11). Strengthening the anesthesia workforce through continued education, certification programs, and telemedicine could ensure higher standards of care in remote locations. Tele-anesthesia has emerged as a potential solution for providing consultations and expert supervision in regions lacking trained anesthesiologists. Collaboration through domestic and international exchange programs for residents and fellows is also seen as a beneficial strategy for improving training standards and anesthesia workforce well-being.

Rapid advancements in anesthesia technology, particularly in artificial intelligence (AI) and ultrasound-guided regional anesthesia, are transforming anesthesiology practices across Asia. AI-driven tools are expected to improve decision-making processes and enhance patient safety by improving teamwork protocolization, follow up, and predicting potential complications (Int J Surg 2023;109:655-7). Furthermore, increasing access to ultrasound machines for regional blocks and point-of-care applications has been highlighted as a critical need, especially in public hospitals and underfunded health care systems. As the region continues to adopt these technologies, and with the increase of knowledge and cooperation of Asian patients, it is also expected to see growth in ambulatory surgery centers and the use of enhanced recovery after surgery (ERAS) protocols. In addition, ambulatory surgery is gaining momentum in several Asian countries. China, India, South Korea, and Thailand have recently become new members of the International Association for Ambulatory Surgery, reflecting the growing trend toward one-day surgeries. Ambulatory surgery centers offer a cost-effective and patient-friendly alternative to traditional hospital stays, and the integration of ERAS protocols, multimodal pain management, and goal-directed therapies is helping to improve outcomes and reduce recovery times. These advancements are expected to significantly reshape anesthesia practices in the region over the coming years (Knee Surg Sports Traumatol Arthrosc 2024;32:1405-13).

Regional collaboration remains essential for addressing common challenges in anesthesiology. Events like the ASEAN Congress of Anesthesiologists, South Asian Association for Regional Cooperation-Association of Anesthesiologists, and the Asian Australasian Congress of Anesthesiologists provide critical platforms for knowledge exchange and technical collaboration. More specific subspecialties like the Asian Society of Cardiothoracic Anesthesiologists, Asian Society of Paediatric Anaesthesiologists, Asian Society for Neuroanesthesia and Critical Care, and the Asian & Oceanic Society of Regional Anaesthesia and Pain Medicine (AOSRA-PM) foster knowledge sharing and collaboration between experts in the field. These platforms allow for joint research projects, the dissemination of technological advancements, and policy development to improve anesthesiology practices across the region. In the coming years, strengthening these collaborative ties will be key to addressing regional challenges and advancing the field in Asia.

Over the next four years, anesthesiology in Asia will face both opportunities and challenges. Addressing sustainability, improving access to quality anesthesia care, integrating advanced technology, and fostering regional collaboration will be essential. By working together and sharing knowledge, the region’s anesthesiology community is well-positioned to make meaningful advancements that can elevate global anesthesia care.