Moral Distress Amongst American Physician Trainees Regarding Futile Treatments at the End of Life: A Qualitative Inquiry
Appendix 1: Sample interview guide questions
Have you ever had to do a procedure (including resuscitation) that you thought to be against your moral beliefs? What did you do in that situation?Have you experienced moral distress or conflict over the therapies you were asked to provide? Can you describe that situation?
Have you had a situation where you felt that your clinical and/or personal beliefs were in conflict with what a patient wanted? With what the team wanted?
Have you ever felt like you have had to give therapies that you thought were futile?
What do you think is the appropriate balance between patient autonomy and acting in the best interest of the patient and doing no harm?
How do you feel about the current approach that you take regarding DNR decision-making?
Appendix 2: Additional quotations
Theme / Quotation
Treatments perceived to be futile / “This ICU patient was in severe sepsis and septic shock. There were multiple rounds in this. The family said absolutely we are going to do everything and he was on four pressers. Was on every antibiotic and had all of these MDR bugs. He had peritoneal signs but was not a surgical candidate. The family was just very upset and it had been going on for quite a while so it’s like a lot of ICU resources even though we think that there is nothing further to be gained by it. This guy was on CVVH. He was intubated.” (B, PGY-2)
“The patient had been in the hospital for ages several months or something and essentially did not have higher brain function. Was bed-bound and horrible ulcerations and I was working on night float and just continued working with her and she was just crashing overnight.” (B, PGY-3)
“…a gentleman who had cancer that had spread, completely wiped out his liver and he came here because they told him nothing else was to be done at [another hospital]. We felt there was nothing to be done. He and his family didn’t want to hear it. They insisted. They brought us the patients’ bill of rights and said we can see liver, we can see oncology. Oncology said there's nothing to do and the liver fellow said there's
nothing to do and then the liver attending said, well lets stent him” (A, PGY-3)
Torture and Suffering / “I think that as a resident it’s almost cruel to us to resuscitate people when there’s no chance of bringing them back or it’s going to lead to a long ICU admission that they probably won’t survive.”(Hospital A, PGY-2)
“There are scenarios in people with metastatic disease that familymembers have a tough time being able to give up and that you knowthey're in DIC or something and they have this really gruesomebloody codes that feel wrong and feels like this is just not the way weshould be doing it.” (C, PGY-3)
Moral Distress / “The person who was on call that night that he died, who gave him the bag of blood is still really upset about having done that, cause she feels she's prolonged his suffering…” (B, PGY-1)
“A lot of the residents who coded her, from talking to them, it sounds like some of them felt somewhat violated by being in the situation where that sort of had to do, against any judgement that they have.” (B, PGY-2)
“I felt plenty of emotional distress from just a very human way about what we do to others and how I would never want that for myself or a loved one. And then also from a kind of societal and medical system vein, distress of just how much resources there were and energy we’re putting in to things that are practices that I don’t necessarily agree with.” (C, PGY-2)
“It was horrible taking care of him because he seemed to be in so much pain. There was a point I wished that we could have made a decision to withdraw care and let him die. There was actually discordance between the parents. Dad wanted care withdrawn and Mom didn't. I thought ethically: Why did we have to go with the parent that's going to be more aggressive? Dad was having his wishes not honored. That was hard, because I agreed with him. Everyday we'd round on him and I felt horrible.” (B, PGY-2)
Patient Autonomy / “I think it’s really tough.It’s this American value that patients get to dictate. I do think you should have some say in how you end your life, that’s the right of the patient. But it’s difficult when the decision is to have everything done. And you’re wondering, what are we doing? We’re spending all of these resources, all of this money on somebody that is clearly not going to benefit from it. So it’s tough…you see so often how poorly it turns out.” (A, PGY-2)
”…and if they still say, yes, I want everything to be done, I do probably subscribe to autonomy over beneficence in the sense that…I don’t know, maybe I’m jaded too much in the sense that, in this hospital I’ve seen people do so much to themselves. I can’t force you to do the right thing.” (B, PGY-3)
One senior attending and director of the Ethics committee at one hospital site remarked that this was not an uncommon concern:
“As I say, I often say, there are things in medicine that are ethical but not legal and there are things that are unethical but legal. I think the house staff…agree with me and are loath to carry out resuscitations on people who are hopelessly ill. They’re human beings. They feel that there is something wrong with this picture. It is not a mannequin. I think they are very sympathetic to it and they really find themselves in very uncomfortable positions. Some people are more sensitive than others, some will really recoil but do it, and others will say, ‘look, it’s part of the job.’ It is a lousy law but you have got to do what you have got to do.” (A, Attending)
Coping Mechanisms / “I got feedback from the ethics team that therewere some people that were severely still morally distressed about what happened. Some of the providersactually reflected afterwards in mass emails and I think that also helped dispel some ofthe residual distress that remained. So yes, I definitely rely a lot on my colleagues andparticularly ethics consult if there is something that I feel isn’t right.” (C, PGY-6)
Death Rounds / “We have death rounds because the interns see a lot of things that I think they find rather disturbing. Often times whenyou start death rounds, every single death rounds that I have facilitated everybody’sdead silent. It takes one of the attendings or one of the senior residents to be like ‘wasn’tthere that Mr So-and-So?’ Then once you bring up a case everybody starts talking oryou’ll have somebody who starts talking and sometimes starts crying. I mean it’s reallyfascinating to see how they are very much at the beginning and then as soonas you bring one of the cases up that has been really challenging, then people all starttalking.” (C, PGY-6)
“I think just giving permission to talk about death and to talkabout end of life issues normalises it for us and then makes it easier to talk about it withpatients, because nobody wants to talk about death.” (C, PGY-6)