Monthly Archives: April 2024

Moral Injury: Taking care of Sam

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Moral Injury

When I Googled “moral injury” the first definition that populated was, “Moral injury refers to the psychological, social and spiritual impact of events involving betrayal or transgression of one’s own deeply held moral beliefs and values occurring in high stakes situations.” The definition came from the site Open Arms which provides mental health services to Australian veterans.

You may have heard the term “moral injury” in the context of the military. However, moral injury is also common in other professions, not the least of which is medicine. The 3 reasons that are most prominent in my mind for moral injury in medicine are:

  • Our (the US) healthcare system is limited. Without universal healthcare our healthcare system is a commercial business where those with more money have access to care that those who are poor don’t. It means that the rich get better care overall than the poor regardless of the attempts of individuals working in medicine to deliver just care. The injustice comes because insurance and personal finances have the last word on any person’s access to medications, equipment, home health services, procedures, and surgeries. Without money in the US, you do not get full access to any of these health services.
  • Health is essential to wellbeing. Those who seek medical attention often have serious injury, life changing illnesses, and may be imminently dying. In medicine, we often take care of people at the worst time of their lives. We often deliver terrible news. We don’t always have good outcomes.
  • Healthcare is about people and every individual has their own beliefs and values. The doctors, nurses, and others taking care of a patient have different beliefs/values than the patient and each other. I’ve never had an experience in healthcare where every member of the healthcare team and the patient all had the same beliefs and values. And, in truth, I don’t think it’s possible.

I’ve experienced moral injury multiple times in my medical career. Sam’s case illustrates how my questions related to wellbeing and differing beliefs/values while caring for a patient opened the door to my moral injury. The injustice of commercial healthcare I’ll leave for another day. I’ve modified the details of Sam’s case (including the patient’s name) for patient privacy.

Taking Care of Sam

Sam came to the hospital because they believed their nursing home was abusing them. They were bedbound. They could feed themselves (if someone brought them food); yet they didn’t eat much. Were they refusing to eat because they didn’t want to or because it was uncomfortable to eat for some medical reason? They ate just enough to stay alive but not enough to thrive. In the time I cared for Sam, they became weaker and more confused partly from malnutrition. They also refused their medications. Did they have the right to refuse to eat and to refuse their medications even if it would hasten death and worsen their condition?

It was possible that Sam could live for 40 years more. Given their condition, would they want to live for 40 more years? Sam had days in which they understood what was going on. Yet, they often forgot things. Sam sometimes answered questions correctly and sometimes their thoughts trailed off to a land that was only barely understandable. How confused was Sam? Eventually it was decided that Sam couldn’t make their own decisions because they were too confused. The only person in the world who knew Sam outside of their healthcare team was an ex-partner. The ex-partner was designated as their legal decision maker because there was no one else.  Was an ex-partner the right person to decide what Sam’s medical treatment should be? Did this ex-partner have any idea what Sam would want in complex situations they had never talked about?

Sam was full code and full interventions per their ex-partner’s decision. This meant that every intervention Sam needed for their multiple medical conditions was to be pursued even if it caused discomfort. To do this Sam needed an IV. Sam pulled out every IV we placed (so they pulled one out about daily).They also pulled out multiple more permanent lines (basically deeper IVs that access bigger veins and are often held in place by stitches). We kept replacing the IVs. Was Sam pulling out the IVs because they were confused or because they didn’t want them?

As Sam’s nutritional status worsened and they missed more medications, my team suggested placing a tube in Sam’s stomach so that they could get proper nutrition and medications even if they refused to eat and didn’t have an IV.  Most days when I talked about this feeding tube with Sam, Sam said they didn’t want it. Did Sam know what they wanted? The ex-partner decided that Sam should get the feeding tube in case it helped improve their condition. They got the feeding tube. Did we know what was best for Sam?

Not long after Sam got the feeding tube, they went to the intensive care unit because their blood pressure was too low. They were placed in medical restraints (basically tied to the bed) so they wouldn’t pull out the IV through which they received a medication to help increase their blood pressure. Without that blood pressure medication, they might have died. That medication had to be given through an IV. Were the medical interventions we did for Sam helping or hurting?

Sam hated the restraints. They screamed, pleaded, and cried for us to take off the restraints. Were the restraints doing more harm than good? They screamed and yelled that they didn’t want any of the interventions that we were doing. Was Sam aware enough to know what they did and didn’t want? Sam could tell you their name and where they were; they’d lost track of why they were in the hospital, the month, and the year.

Sam survived and eventually returned to the regular hospital floor before being discharged to a nursing home. Sam’s hospitalization lasted months before a nursing facility accepted them. Did Sam want to prolong their life even though that meant going to a new nursing home? Would they have preferred to be made as comfortable as possible without medications and without being forced to eat? Would anyone ever truly know what Sam wanted? Would Sam’s right to make their own decisions ever be regranted?

Despite doing everything medicine could do for Sam, I’m still not sure if any of it is what Sam wanted. I’m still not sure if we did the right thing. And because of these uncertainties, I’m not sure if Sam’s case broke several of the most important principles of medical ethics: patient autonomy, do no harm, and beneficence.

The Sorting Hat of Medicine

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Recently, I was back in the emergency department (ED). Not as an EMT this time but as a doctor. It’s different as a doctor. In the years leading up to medical school, I worked as an EMT in the ED and volunteered on an ambulance. Being an EMT was my first patient care experience. It was eye-opening in many ways. Among the things I learned as an EMT is that I did not wish to become an emergency medicine doctor. My residency program (internal medicine) has us do a month in the ED as part of our first year of training to get a different experience and a different perspective.

The ED is like no other place in healthcare or in the world. There are few places where the staff have as much camaraderie. There are few places in the hospital where the staff laugh so much and the adrenaline runs so high. The ED also, perhaps, provides as many reasons to cry as to laugh – which is why those who work in the ED find ways to pick laughter over sorrow.

The ED is the sorting hat of medicine. My rotation as a doctor in the ED showed me that ED doctors are the gatekeeps to the hospital and the safety net for everyone who can’t access healthcare anywhere else. The doctor’s role in the ED is different than that of the EMT. As an EMT my day was filled with tasks – placing IVs, performing EKGs, getting snacks for patients, and so on. As an ED doctor there are fewer tasks than as an EMT but the tasks that remain are heavy. ED doctors make big decisions about which tests a patient needs and where they should go next – home, surgery, a regular medical floor, or an intensive care unit. ED doctors stabilize patients before they are shuttled off to other parts of the hospital. ED doctors reassure patients that they are okay before sending them home. ED doctors are the last contact for many people as they leave this world for what comes after death.

Some days in the ED are hectic and some are slow. ED doctors connect with every other specialty in the hospital. They consult specialists and convince other doctors to accept ED patients so that the patients can be admitted into the hospital. As much as ED doctors are the gatekeepers, they are also the connectors.

The ED runs at a blistering pace but when things are running well no patient stays there for long. Hours, yes, but not for days. Yet, some patients become known to the ED. They’re called “frequent fliers.” Frequent fliers are known by their ED doctors much like primary care doctors know their patients. Often frequent fliers don’t have a primary care doctor. And, so, when ED doctors take care of a frequent flier they may be the only doctor that patient has. The only doctor standing between that patient and no medical care at all.

The ED is the sorting hat of the hospital. As the leaders of the sorting hat, ED doctors have many roles. They are gatekeepers. They are also connectors and, for some, the only option. The ED is the bridge between the outside world and the hospital. I’m grateful for the folks (doctors and all the others) who choose to work in the ED because being the sorting hat is no small feat.