Clinicians’ Perceptions About Institutional Factors in Moral Distress Related to Potentially Nonbeneficial Treatments

Importance: Clinicians commonly experience moral distress related to potentially nonbeneficial life-sustaining treatments (LST). Hospitals' institutional culture (eg, shared beliefs, values, and practices), structures (eg, policies, practices, resource allocation), and societal-level factors (eg, national culture, local and national policies, medical hierarchies) may contribute to moral distress related to potentially nonbeneficial LST. Objective: To investigate clinicians' perspectives on how hospitals' institutional culture and structures might exacerbate, prevent, or mitigate the influence of societal factors contributing to moral distress related to potentially nonbeneficial LST. Design, Setting, and Participants: This qualitative study used comparative ethnographic methods. Semistructured, in-depth interviews were conducted between February 2018 and June 2022 at 4 West Coast academic hospitals selected for their varying intensities of end-of-life care. Interview participants were hospital-based clinicians (eg, nurses, physicians), hospital leaders (eg, unit nursing and medical directors), and administrators with differing clinical backgrounds and professional responsibilities. Data were analyzed in 2 phases, from January 2019 to December 2022 and from June to September 2024. Main Outcomes and Measures: Clinicians were asked about their hospitals' institutional culture and structures and their relationship to clinicians' experiences of moral distress related to potentially nonbeneficial LST in end-of-life care. Results: A total of 122 interviews were conducted (75 physicians 61%; 22 nurses 18%; 6 advanced practice clinicians 6%; 68 56% women; mean range age, 42 27-74 years). Respondents felt hospitals' institutional culture and structures could exacerbate moral distress. Respondents reported that a hospital culture of health care consumerism influenced clinicians', patients', and families' expectations for treatment intensity, contributing to morally distressing situations. Nurses and primary team physicians felt constrained by medical hierarchies, leading to perceptions of disempowerment and moral distress. Clinicians also reported that institutions lacked sufficient structures to support efforts to de-escalate potentially nonbeneficial treatments. However, respondents also reported that hospitals' institutional culture and structures could prevent or mitigate moral distress. Respondents felt policies empowering clinicians across the medical hierarchy to participate in decision-making reduced moral distress. They reported that institutional resources could manage conflicts and provide emotional support when moral distress occurs. Furthermore, respondents felt that clinician-driven quality improvement initiatives and supportive hospital leaders could address hospitals' institutional cultural and structural contributors to moral distress. Conclusions and Relevance: In this qualitative study, clinicians perceived that institutional factors affected their experiences of moral distress related to potentially nonbeneficial LST by exacerbating, preventing, or mitigating the influence of 3 societal factors: defaults of high-intensity treatments, health care consumerism, and medical hierarchies. These results have implications for developing tailored institutional-level interventions to address societal and institutional contributors to moral distress from potentially nonbeneficial LST.