Confronting Moral Distress as an Oncology Clinician

Lara Traeger, PhD

Oncologists and oncology nurses face difficult treatment decisions on the daily basis. Sometimes, these experts are challenged with whether to administer a life-saving therapy or hold off, and this decision may be accompanied with moral distress.

In 2020, moral distress was identified as the key cause of burnout in physicians.¹ Moral injuries may be caused by physician/patient interactions or by how systems are set up within a medical practice. The common issue also expands beyond the United States.²

In an interview with Targeted Oncology, Lara Traeger, PhD, a licensed clinical psychologist at the Massachusetts General Hospital Cancer Center and an assistant professor in the Department of Psychiatry at Harvard Medical School, discuss how oncologists and other clinicians working in oncology can cope with moral distress, which she recently talked about during a session hosted by the Cancer Support Community as part of their First Aid Tool Kit.

TARGETED ONCOLOGY: What are the main factors contributing to oncologists needing to hold off on giving treatment that could prolong the patient lives?

Traeger: There are a lot of reasons why an oncologist may not be able to give the type of care or the amount of care that they ideally would like to give. Some reasons will be specific to patient clinical factors, but many factors are not entirely clinical in nature.We think every day oncologists are facing the realities of gaps in our healthcare system, limited resources, and inequities and how those limited resources are being used or distributed. Also, when care is delivered as a team with the involvement of many different specialists in patient, and outreach and providers, other stakeholders, different members of the team may leave feeling that a treatment decision was not necessarily [made] in the patient's best interest.

In Germany, a 2018 showed a high prevalence of moral distress among oncologists and oncology nurses. How do you think this picture looks and the United States (US) today?

Traeger: In the US, I'm sure, we also have seen a high prevalence of moral distress among oncologists and oncology nurses as well. So, the picture here is similar, although some of the contributing factors may be different because of our different health care systems. Also, given the diversity of healthcare systems that we have within the US, there are likely variations within the US as well as between the US and other countries.

Generally, we think that the unique context of oncology does set the stage for the rates that we see. Delivering cancer care involves a lot of contextual demands, no matter where you are, we have patients with psychiatric or medical crises at all points across the cancer care trajectory, continuous exposure of our clinicians to life threatening illness, limited treatment options, and death. Then on the other hand, we have a growing number of survivors who also have complex needs and often multiple comorbidities. On top of that, we have ethically challenging situations that can happen every day related to end-of-life care, and navigating that kind of care of right alongside our patients and their families. These factors can set the stage for moral distress no matter where we are.

As I’ve mentioned, we have the issues of healthcare system gaps and inequities. One thing I will mention, though, is that rates of moral distress still are somewhat hard to measure. There are a limited number of tools to do that, and they're not widely used. We do know from a recent survey from the American Society of Clinical Oncology [on a] number of medical oncologists and almost half reported some symptoms of burnout, which is a related syndrome, and rates maybe even higher in nurses and pharmacy clinicians.

What is underway in your practice, or what have you seen in other practices that can help with these situations?

Traeger: Although there's not a 1 size fits all solution for everything, in my practice, one of the things that we do is we've worked with both oncology clinicians and palliative care clinicians as well. Something that we provide is what we call group or peer supervision. This is a very common practice in the field of psychology, although less common in other fields. These supervision meetings are a place for clinicians to discuss the type of ethically challenging cases that really come home with us at the end of the day. It's a place to normalize and validate our experiences of these cases and how we feel about them. It also is a place to reality test our interpretations of these cases, and of the decisions that we made, and possibly learn some psychological strategies to cope with the aftermath of these situations or try something new for the next time thissimilar kind of situation comes up.

Beyond that, I think that generally, practices can help with these situations by first recognizing and acknowledging the demands of cancer care delivery, those factors that I described earlier as setting the stage for moral distress. Then, practices can consider what can they do at both a system level and a clinician level to start to shift costs and increase that recognition and acknowledgement of moral distress. We cannot ask clinicians to do this on their own.

What is some advice you can give to help oncologists cope with their decisions?

Traeger: In working with oncologists and palliative care clinicians, I've learned that to help clinicians cope with their decisions, and they cannot do this work in a bubble. Think about who needs to be next to you in the foxhole, take time to reflect on what type of support is most helpful to you as a clinician. This will be different for everybody. When you have gone through a difficult morally distressing situation at work, what is most helpful to you? To go back to the data or the literature and to find information that's going to guide choices and help you understand the choices that were made? Is it most helpful for you to take time to talk with the other clinicians who were involved in the case to either go over the data or to go how you were feeling about what just happened? Is it helpful to talk with other clinicians who weren't involved, but maybe they are in your discipline, and they understand where you're coming from?

For some of us, it's actually most helpful to talk with a family member or a friend who's outside of the situation completely but has our backs. You have to think about what is important to you, recognize why it's important, and understand how you can access that support. Sometimes when we're talking with somebody else about what we've been through, it can take a few days to get our ground and our bearings on what happened. So, even talking about it a few days later is helpful.

I think that's important for all of us to consider, because as we're all working a bit remotely right now, the support that we might need may not be right next to us when we need it. Again, when you do talk with somebody about what's happened, remember what you're trying to do, or you're trying to solve the problem. You're also trying to tend to how you feel about what happened. Even if the other person can't solve the problem, sometimes just hearing them say, I wouldn't have known what to do either is powerful.

I worry most about trainees and fellows, and clinicians who don't have a support network in place either because they are new to the practice or for any other reason. Again, a piece of advice is for oncologists to recognize that everyone has their way of coping. By recognizing our differences, not only can we support ourselves better, but we can actually also support each other and our teams better. Make sure we're seeking the support that we need from the people who are able to provide it.

_References:

_{1. Dzeng E, and Wachter RM.Ethics in Conflict: Moral Distress as a Root Cause of Burnout. J Gen Intern Med. 2020;35(2):409-411. doi: 10.1007/s11606-019-05505-6.}

_{2. Mehlis K, Beirwirth E, Laryionava K, et al. High prevalence of moral distress reported by oncologists and oncology nurses in end-of-life decision making. Psychooncology. 2018; 27(12):2733-2739. doi: 10.1002/pon.4868.}