Understanding and addressing moral distress caused by COVID-19

During the COVID-19 pandemic, Victoria’s health care workers are likely to encounter moral distress, anxiety and regret arising from ethical challenges in cancer care.

Professor Clare Delany, Clinical Ethicist and Chair of the Victorian COVID-19 Cancer Network (VCCN) Clinical Ethics Expert Advisory Group, explains that moral distress typically occurs when a clinician has to implement a decision made by somebody else, and which they believe is wrong. It is different to “ordinary” distress about a tragic situation, such as the death of a patient despite everyone’s best efforts.  Moral anxiety refers to a state of being worried or afraid of a decision that may have to be made in the future, and moral regret refers to a feeling that an important value was not fulfilled.

Interruptions to cancer care caused by delays to cancer screening and diagnostic tests, reallocation of staff, and the introduction of new safety-based procedures and hospital visitation policies are examples of ethically complex situations that contribute to moral distress.

“COVID-19 has created additional layers of complexity involved with providing care for our cancer patients,” observed Associate Professor Zee Wan Wong, Head of Oncology at Peninsula Health, Joint Clinical Director of the Southern Melbourne Integrated Cancer Service and co-Chair of the Victorian COVID-19 Cancer Network.

“Our role as clinicians is to inform patients about the potential benefits and risks associated with their decision, whether it is to come to the hospital to undergo cancer treatment or hug their grandchildren. The key challenge is that now we have more risks to consider than ever before,” A/Prof Wong added.

“In situations where a person’s survival depends on availability of cancer treatments, they require their clinician to “hold” them and guide them through their care. The idea of “holding” in cancer care encompasses the clinical authority derived from a clinician’s experience, and use of evidence to guide the best available treatment. It also includes emotional care comprising warmth, reassurance and empathy,” Prof Delany explained.

“We are now seeing heightened levels of distress and anxiety among our patients, meaning we now need to hold them more closely than in ordinary times. Similarly, we need to hold ourselves and each other,” said Dr Alexandra Clinch, Deputy Director of Palliative Care, Peter MacCallum Cancer Centre.

“The anxieties, stresses and isolations that out patients have, our healthcare workers have too, and this means collegial support is a really important part of getting through these times,” Dr Clinch added

Balancing competing values in unprecedented, ethically complex situations is stressful because there is not a clear roadmap to guide these decisions and there may not be one clear ethical response. Each case must be considered according to its unique set of circumstances, including the patients’ individual values and preferences.

“There is great value in talking about your experiences with your colleagues. What feels wrong to you might be something they’re grappling with too, and together you can work through ways to resolve moral distress,” Prof Delany observed.

A clinical ethics approach to supporting clinicians’ experiences of moral distress assists them to unpack and process their ethical concerns and underlying emotional responses. This ultimately supports clinicians to find new ways to hold their patients.

“At Peninsula Health, we have organised social zoom sessions at the end of the week to share experiences, chill out and re-charge with our colleagues online. Working within the VCCN helps us to connect with our peers, debrief  on complex and challenging situations, and contribute to an important cause – and ultimately improve our own well-being,” said A/Prof Wong.

Health professionals in need of further information on strategies for dealing with moral distress are invited to email Prof Clare Delany: c.delany@unimelb.edu.au

Phoenix Australia – Centre for Posttraumatic Mental Health in collaboration with the Canadian Centre for Excellence-PTSD have developed a resource for healthcare workers and organisations to better understand the range of moral emotions arising from the COVID-19 pandemic and to develop organisational and individual strategies to mitigate risk of lasting harm. The document provides a good overview of terms and possible approaches to supporting staff, including providing opportunities to discuss and debrief.  See: Moral stress amongst healthcare workers during COVID-19: a guide to moral injury.