Moral Resilience: A Capacity for Navigating Moral Distress in Critical Care

E challenges are commonplace in critical care settings. Questions about the boundaries of ethically permissible treatment, assessment of decisionmaking capacity, determining who ought to decide on the ultimate treatment plan, or potentially medically inappropriate treatment are part of everyday practice. Contradictory views can result in lack of consensus or unsatisfactory decisions between patients and family members, within interprofessional teams, or among patients, patients’ families, and critical care teams. Often at stake are each person’s central ethical values, obligations, and commitments. When confronted with these challenges, many clinicians experience moral distress in response to threats or violations of their integrity.1-5 Moral distress ensues when clinicians recognize ethical conflicts and their responsibility to respond to them but are unable to translate their moral choices into ethically grounded action that preserves integrity.5 Although controversies persist regarding the definition and contours of moral distress, the literature is replete with data that documents the pervasive experience of moral distress by critical care clinicians and the profound human costs that accompany it.6-14 Spiraling rates of burnout, turnover, and shortages of critical care clinicians and diminished employee engagement threaten the quality and safety of patient care and the overall stability of the health care system.15-22 Moral distress is not likely to be extinguished, and given the complexities of the health care system, will continue to escalate in the future. Why is it that some people are able to navigate ethical dilemmas and moral distress without the deep sense of despair and hopelessness that others experience? What individual qualities and capacities do they possess? What is it that supports them to find meaning in situations that appear senseless? How do they transform their experiences into growth-producing transformations? These are some of the questions to which answers are needed in order to more fully understand how clinicians, particularly critical care clinicians, address moral distress. So far, strategies to address moral distress focused on building skills in ethical decision making, conflict resolution, interdisciplinary collaboration, system reforms, mediation, and ethics consultation have been only partial solutions.23-26 Much of what has been tried has been done on a small scale and has not sufficiently shifted the incidence or consequences of moral distress.27-30 Moreover, while clinicians resonate with data that verifies the existence of moral distress and its negative consequences, the accompanying narrative of disempowerment, despair, and hopelessness may have inadvertently