What Do You Know About Moral Distress?

“If it helps you and the team with your moral distress, I’m happy to touch base with you again in the future.  Is there anything else you’d like to discuss?”

Massaging my temples, I felt the underlying muscles tense as I clenched my jaw to prevent some choice words from coming out.

No, I think you’ve wasted more than enough of my time today.  Thank you for showing me how incredibly unhelpful an ethics consultation can be.  It’s been an education.

“No, thanks for your time.”

Quickly hanging up, I resisted the urge to collapse forward and rest my head on the nursing station desk, instead closing my eyes in an effort to re-center.

Already defeated by 11 am, M?  On your first day of this rounding stretch in the hospital, no less.  You were supposed to be replenished by your Kauai vacation, ready to come back and save the world.

“You’re hurting me!  Get your hands off me!  I have rights – you can’t keep me here against my will!  LET ME OOOOOUUUUUT!”

Shutting out the screams of my patient drifting down the hall, I looked over at the charge nurse and head security officer hovering next to me.  Awaiting my next instructions.  As if I knew how to clean up this mess.

In the background, a flap of a white coat caught my eye as I watched my colleague scurry down the hall past 4 security guards and countless nurses with concerned looks on their faces.  For a brief second, the urge to beg an attending-ier attending to take over this situation consumed me.

Who are you kidding?  It’s not just this situation you want to escape from, it’s this whole doctor thing.  You don’t want to be here any more than she does.  You want to run out of the hospital too, but unlike her, there’s no one holding you back.  You’re the one forcing yourself to be here. 

So who’s the one who’s lost their damn mind?

As my internal thoughts started to fuse with my patient’s screams, the anxiety radiating off the charge nurse interrupted my surreal moment.

Sighing, I returned to reality.

“Is the psych hold really necessary, Dr. M?  I think this is going to be more harmful for her in the long run.”

“Maybe.  She certainly won’t forget this traumatic experience.  But is it more harmful than allowing her to leave the hospital against medical advice and having her start the cycle of self harm again, just to come back within a couple of days?  We can’t keep doing this – there needs to be a better plan, and this gives us time to come up with one.”

“… are you sure?  You can stop this.  This is on you.  This is your signature.”

Moral distress

How quaint.

How concise a term, effectively securing enough emotional distance for the person saying it from the people who are left dealing with the ramifications of their decisions.

It’s scrubbed up enough so 3rd party surveyors can discuss these situations in academic and philosophic terms without ever feeling what it’s like on the ground.

What it’s like to assess the bruises on someone’s wrists after having to physically restrain them, knowing that was your order even if it wasn’t your personal hands on them.

What it’s like to ignore the grimace of someone with rigid whole body contractures from a massive stroke while you try to move their arm to examine the feeding tube that never should have been placed.  The one that you ordered.

What it’s like to hand over a newborn to dad, giving him discharge instructions while mom is yelling in the background,

“That’s not my baby!  I don’t want it!  Why are you making us take a monster home with us?!” 

Because DHS doesn’t think it’s a problem to send this baby home to a mom with post-partum psychosis, as long as dad promises to not leave mom and baby together alone.

Moral distress doesn’t even come close to describing the warping of our reality as we become so used to being in someone else’s nightmare.  The only way to survive this is to numb ourselves to the horror or get out.

So we numb.  We justify our actions.  We tell ourselves if it was easy, everyone else would do it. 

Then we go on with our day as if nothing happened.

This is what separates us from the rest – our resilience, our ability to resist the emotional enmeshing that exists with other people who still allow themselves to be human.  

We’re the elite few who’ve risen above such frivolous things – after all, we’re doctors.  

Until those moments of quiet when you wonder why you feel so unwell, why you can’t seem to shake this unsettled restlessness.  Why you can’t seem to find peace even after 2 weeks of vacation in paradise.  Why just one difficult situation seems to have the magnitude of 1000 explosions – not realizing that the moral injury from every other distressing encounter is converging into one.

Why a single line about moral distress from an ethicist’s script likely recited multiple times a day is enough to throw you into a fantasy where you strangle him with his M.Div degree, but not before you drag him to the patient’s room and demand he watch her frail body bounce off security guards as they attempt to thwart her escape.

Force him to look into the tearful eyes of her nurses as they try to calm her before her PTSD takes over and she dissociates.

Sign his name next to yours as you pretend to confidently place your stamp of approval to this cluster.

See the rest of your patients on your list and not allow the morning’s frustration to bleed into your other encounters.

Make him take the weight of all this home with him, too.

Now do it over and over again for 9 years and talk to me about moral distress.

Is there anything else you’d like to discuss?

Give your expert advice on how to minimize the dread you feel when you wake up in the dark to face yet another day, unsure of your ability to hold yourself back when your patient says to you,

“You don’t care about me!  You don’t care about anyone!  You’re a liar and this is abuse.

You’re ruining my life!“

Let me know you, too, will mourn the person you thought you’d be the moment you realize you didn’t even flinch when you internally respond to her,

“Why are you even here?  Stop coming back to the hospital.  How about you find a ditch to crawl into and go f*ck up your life there.   

Anywhere else but here.”

Tell me you understand what it’s like to pull yourself back from your rage and return to digging for your drying well of compassion, because once upon a time, your bleeding heart wanted to help these people – the most marginalized, sick souls who only needed your gentle hand to show them the way.  That you’re intimately familiar with the wrenching wistfulness of holding on to these delusions because it’s the only way to make it through the day.

Then maybe I’ll hear what you have to say about my moral distress.

Let me out

At some point, this isn’t going to be worth it anymore.

I’m going to tire of trying to figure out how I ended up here. 

I’ll be done with wondering if the system is truly rigged to suck me dry or if I’ve just been slowly losing my damn mind due to inadequate setting of emotional boundaries or lack of enough self-reflection.

I’ll eventually lose my grip on my rage, the last thing standing between me and a black hole of apathy.  At least the constant simmer beneath my deceptively calm facade distracts me from the futility of what we do. 

As I count down the days to when my student loans will have finally been paid off, I can’t help but wonder – is there anything else keeping me here?

Or will I just decide one day to walk out and not come back?

.

.

.

***

Photo of waterfalls taken at the entrance to the Fiordland National Park, New Zealand.

***

A note from M:

Every Wednesday and Thursday I watch a little blue spike on the site’s traffic metrics as people head to the blog to see if there’s a new story to read.

And for the last 2 months, they’ve been greeted with nothing but silence.

I’d love to say the void has been filled with adventuring and happy times in the real world, but the truth is I was doing the thing that 45% of physicians admit doing when they’re burned out: Isolating themselves.

It’s funny what denial sounds like when you believe yourself to be all too self-aware.

“I can’t write right now – I’m unbusying my life.”
“I’m engaging in self care – letting the non-essentials/aka the blog/hangouts/conversations go.”
“I don’t have enough time to respond at the moment… I’ll just answer that email/text/voicemail later.”

While there may be some truth to the excuses we give, in the end it boils down to avoidance.

So here’s the truth:

• I stopped writing because I didn’t want to dissect the new emotional lows I’ve fallen into the last 3 months.
• I stopped hanging out with people because I was tired of feeding them the same old lines.
• I stopped answering emails and texts because I was afraid once the rage and frustration started spewing, I wouldn’t be able to stop.

The scary thing is, it’s so very easy to hide.  

Everyone’s busy schedules allow us to intentionally slip through the cracks.  It’s not difficult to figure out how to do the bare minimum to prevent sounding off any alarms.  Ironically, our training has instilled in us the know-how to avoid any tell tale signs of red flag behavior.

Fortunately, I’ve clawed my way out of this hellscape I’ve been living in for the last 3 months with the support of my husband, family and friends.

With that being said, the next few posts will probably be the darkest I’ve ever written.  I was tempted to scrub the anger and frustration from them, but this is what burnout looks like for me.  Creating a revisionist rendering of the last 3 months would make me no better than those annoying people on social media who post positive affirmations as if that’s all you need to make it through this ugly middle.

We can’t heal until we stop pretending we’re not hurt.

It’s easy to cover the things you don’t want to deal with in layers of bullshit and excuses.  

But when you withhold grace and acceptance for what you feel right now, you effectively rob yourself of the opportunity to heal.

Maybe you’re not quite there yet.  Maybe you need someone else to say the words you didn’t know were in you.  So I’ll keep writing and trying to be honest.  

Thanks for your continued attention.

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