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PP24.001 A narrative literature review of moral distress experienced by ACP facilitators and frontline clinicians
  1. Siew Fong Goh1,
  2. Chou Chuen Yu1,
  3. Jia Ying Tang1,
  4. James Alvin Yiew Hock Low1,2,
  5. Chong Jin Ng2,
  6. Maria Teresa Cruz4,
  7. Roland Chong5,
  8. Ka Yan Kathleen Cheung6,
  9. Andy Hau Yan Ho3,
  10. Sumytra Menon7 and
  11. Raymond Ng1,8
  1. 1Geriatric Education and Research Institute, Singapore
  2. 2Department of Geriatric Medicine, Khoo Teck Puat Hospital, Singapore, Singapore
  3. 3School of Social Sciences, Nanyang Technological University, Singapore, Singapore
  4. 4Department of Advanced Internal Medicine, National University Hospital, Singapore, Singapore
  5. 5Department of Ops (DICC), Tan Tock Seng Hospital, Singapore, Singapore
  6. 6Department of Medical Social Services, Singapore General Hospital, Singapore, Singapore
  7. 7Centre for Biomedical Ethics, National University of Singapore, Singapore, Singapore
  8. 8Palliative and Supportive Care, Woodlands Health, Singapore, Singapore


Background Since 2011, the Respecting Choices framework of Advance Care Planning (ACP) has been rapidly implemented as a nationwide programme named Living Matters in Singapore. Despite numerous trained ACP facilitators and documentations completed, anecdotally, there were reports of strain in inter-professional teamwork in the ACP process, moral distress of ACP facilitators as well as healthcare providers at point of care and ethical conundrums faced. As part of an empirical study on moral distress and coping of healthcare professionals in ACP, a narrative review was first undertaken to investigate on this topic.

Methods xLiterature relating to moral distress among ACP facilitators and frontline clinicians was systematically retrieved from PubMed, using keywords search as such Advance Care Planning, ethical dilemmas, ethical considerations, ethical conflicts, surrogate decision making, Moral Distress, Decision making. We included original studies, case studies, reviews and expert opinion pieces on the topic from 2011 to 2021 and excluded articles written in other languages than English.

Results Research in moral distress is limited mainly to case reports and opinion pieces. Sources of moral distress were purported to arise from discordance in views amongst healthcare professionals, patients and/or family caregivers in the following contexts: goals of care; operationalization of preferences; changes in preferences; professional responsibilities; definition of best interest; purpose of ACP facilitation; type of subjects to broach; choice of narratives; sources to incorporate in ACP discussion; interpretation of personhood of the patient; types of recommendations to adopt; understanding of risks; range of outcomes; temporal priority of preferences; ethical and moral values; content for documentation. There are no studies examining adaptive coping of clinicians in ACP work.

Conclusion Review established the lack of empirical research on the extent and depth of moral distress and future studies are needed to elucidate this construct and also adaptive coping of clinicians in ACP.

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