Moral Distress in the Critical Care Setting.

Abstract

We read with interest the article “Moral Distress in Clinicians Caring for Critically Ill Patients Who Require Mechanical Circulatory Support” in the September issue of the American Journal of Critical Care.1 We are nurses of varying degrees of background—including case management, critical care, and oncology. The focus on moral distress in the setting of mechanical circulatory support (MCS) is timely owing to the increased use of extracorporeal membrane oxygenation (ECMO), the high prevalence of moral distress, and nursing staff shortages in the critical care setting during the COVID pandemic.2,3 The study also illustrates the potential for palliative care and ethics consultations as strategies to reduce moral distress. We would like to congratulate the authors on their contribution to the literature on moral distress and are interested in learning more about the research and seek clarification.First, we note the low survey response rate (39%), which is concerning given that an ideal response rate is 70%.4 We understand the investigators aimed to measure moral distress amongst a niche population; however, a low response rate introduces bias and impacts the generalizability and translation of results. We are curious about what factors the authors associate with the low response rate among the sample.Second, the investigators queried participants about 9 potential strategies to reduce moral distress. We seek clarification on how these 9 strategies were selected and if there are plans to implement the strategies with the highest participant rankings (ie, palliative care consultations, ethics consultations, and debriefing sessions). Also, survey questions differ. The survey used in the cardiothoracic intensive care unit included questions regarding MCS, whereas the survey used in the medical intensive care unit did not. We wonder if this variation in questions influenced the study findings?Third, we request clarification regarding the moral distress instrument selection, scoring, and reporting. What was the rationale for selecting the Moral Distress Scale-Revised (MDS-R)5 rather than the current recommended version, Measure of Moral Distress for Healthcare Professionals (MMD-HP)?6 As for scoring, missing responses on the MDS-R were coded as zero. Because zero scores as “never” on the MDS-R, we wonder if the authors could share the impact of that coding on the study findings. Given that the study was conducted in 2 critical care units, we are interested to see if MDS-R scores differed between the 2 units as the unit-based MDS-R scores are not reported. In summary, we applaud the authors for this work on moral distress in the critical care setting, and we look forward to their response.