Abstract

Distress occurred within the hospital Specialist Palliative Care Team (SPCT) following the withdrawal of high flow oxygen at the request of a patient with capacity to make the relevant decisions.

These SPCT members work at a large specialist cardio-respiratory hospital and are often involved in discussions and decisions about, and the act of, withholding and withdrawal of treatment including oxygen and non-invasive ventilation.

This was the first occasion where team members specifically articulated distress, including moral distress, following their involvement in treatment withdrawal. Moral distress can be described as the ‘psychological disequilibrium associated with knowing the ethical/appropriate action but being unable to take that action.’

Initial explorations of the distress identified only that this case ‘felt different’ to other withdrawal scenarios and team members used different vocabulary to describe their experiences and their impact. Within ethical literature, ‘felt moral difference’ is not considered to be a reliable guide to ethical conduct but nonetheless is important to address.

One team member used the American ‘4A’s Approach to Moral Distress’ (Ask, Affirm, Assess, Act) to help better understand their experience.

Relevant individual case factors included the very high flow rate of oxygen involved and the time-bound nature of the request. Analysis revealed different weights that individuals (patient and staff members) placed on autonomy and non-maleficence as a source of tension. Furthermore, there were different views and values about individual and wider harms, including how these were explored and managed.

A combination of open communication, self-directed learning and reflection, enabled SPCT members to understand the source of their distress more clearly. Moral distress and a felt moral difference can impact on wellbeing, team functioning and ability to undertake specific work tasks. It is hoped this experience will enable the team to better articulate ethical dilemmas and understand their own perspectives.