In the Face of Suffering: Anesthesiologists’ Moral Distress when Caring for Patients with Serious Illness

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.