End-of-life care of the geriatric patient and nurses' moral distress

Abstract

Objectives: Moral distress (MD) occurs when the health care provider feels certain of the ethical course of action but is constrained from taking that action. The purpose was to examine MD in geriatric nursing care and to identify factors related to MD.

Design: Cross-sectional survey.

Setting: Twenty nursing homes and 3 acute geriatric wards in Flanders (Belgium).

Participants: Participants were 222 nurses providing geriatric care.

Measurements: Moral distress was assessed with an 18-item questionnaire, adapted from the Moral Distress Scale. Multivariate linear regression analysis was used to identify key factors (situational, work, and personal factors) related to MD.

Results: The response rate was 57%. The frequency score of MD was 1.1 (mean, range 0-4) and the intensity score of MD was 2.3 (mean, range 0-4). Nurses identified situations involving unjustifiable life support (mean product score MPS 4.8), unnecessary tests and treatments (MPS 4.4), and working with incompetent colleagues (MPS 4.3) as causing the most MD. Responding to requests for euthanasia (MPS 0.8) and increasing morphine in an unconscious patient believed to hasten death (MPS 1.2) were least likely to cause MD. The total MD score (sum of the 18 product scores) was significantly higher in nurses with intentional or actual job-leave (mean difference = 15.1, t = -3.5, P = .001). After adjusting for demographic factors, the following factors were independently associated with elevated MD: working in an acute geriatric care setting (as compared with the chronic geriatric care setting), a lack of involvement in end-of-life decisions, a lack of ethical debate, and specific measures of burnout (emotional exhaustion and personal accomplishment).

Conclusion: Providing futile and inadequate care contributes to moral distress more than euthanasia and believing to hasten an unconscious patient's death by increasing morphine in geriatric end-of-life care. Nurses' moral distress is related to situational and work characteristics as well as to burnout and job-leave.