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Healthcare professionals’ moral distress in adult palliative care: a systematic review
  1. Marina Maffoni1,
  2. Piergiorgio Argentero1,
  3. Ines Giorgi2,
  4. Julia Hynes3 and
  5. Anna Giardini4
  1. 1 Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy
  2. 2 Psychology Unit of Pavia, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
  3. 3 Department of Primary Care and Population Health, Medical School at the University of Nicosia, Nicosia, Cyprus
  4. 4 Psychology Unit of Montescano, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
  1. Correspondence to Dr Marina Maffoni, Department of Brain and Behavioural Sciences, University of Pavia, Pavia 27100, Italy; marina.maffoni01{at}


Objectives Palliative care providers may be exposed to numerous detrimental psychological and existential challenges. Ethical issues in the healthcare arena are subject to continual debate, being fuelled with ongoing medical, technological and legal advancements. This work aims to systematically review studies addressing the moral distress experienced by healthcare professionals who provide adult palliative care.

Methods A literature search was performed on PubMed, Scopus, Web of Science and PsycINFO databases, searching for the terms ‘moral distress’ AND ‘palliative care’. The review process has followed the international PRISMA statement guidelines.

Results The initial search identified 248 papers and 10 of them were considered eligible. Four main areas were identified: (1) personal factors, (2) patients and caregivers, (3) colleagues and superiors and (4) environment and organisation. Managing emotions of self and others, witnessing sufferance and disability, caring for highly demanding patients and caregivers, as well as poor communication were identified as distressing. Moreover, the relationship with colleagues and superiors, and organisational constraints often led to actions which contravened personal values invoking moral distress. The authors also summarised some supportive and preventive recommendations including self-empowerment, communication improvement, management of emotions and specific educational programmes for palliative care providers. A holistic model of moral distress in adult palliative care (integrating emotional, cognitive, behavioural and organisational factors) was also proposed.

Conclusions Cognisance of risk and protective factors associated with the moral distress phenomenon may help reframe palliative healthcare systems, enabling effective and tailored actions that safeguard the well-being of providers, and consequently enhance patient care.

  • adult palliative care
  • moral distress
  • healthcare professionals
  • systematic review

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  • Contributors MM completed the electronic search. MM, AG and PA performed the screening. All authors read the articles and took part in data analysis, model conceptualisation and draft writing.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Disclaimer The​ Authors are partners of the WeDistress HELL Project (WEllness and​ ​DISTRESS in HEalth care professionals​ ​dealing with end of Life and bioethicaL​ ​issues)​ approved by the Italian Maugeri Ethical Committee (Protocol N° 2211CE).​

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.