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J Palliat Med. 2013 Sep;16(9):1080-8. doi: 10.1089/jpm.2013.0105. Epub 2013 Aug 9.

Addressing moral distress: application of a framework to palliative care practice.

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1 Berman Institute of Bioethics, Johns Hopkins University , Baltimore, Maryland.



Moral distress is a pervasive reality of palliative care practice. An existing framework for understanding it has been proposed as a way to begin to address moral distress's detrimental effects on clinicians.


The objective was to illustrate the application of this adapted conceptual framework to a clinical case and to offer recommendations for enlarging the professional repertoire for responding to challenging cases involving moral distress.


In the clinical case, clinicians are expected to respond to the patient's suffering based on four factors: empathy (emotional attunement), perspective taking (cognitive attunement), memory (personal experience), and moral sensitivity (ethical attunement). Each of these interrelated and iterative factors may become activated as clinicians care for patients with life-limiting conditions. This creates the foundations for clinicians' responses. When responses risk becoming aversive in the face of moral dilemmas, strategies are needed to foster principled compassion instead of unregulated moral outrage. A number of cognitive, attentional, affective, and somatic approaches derived from contemplative traditions are consistent with the framework. Combined with a systems-focused approach that incorporates organizational factors, they offer a means of improving professional repertoires for responding to difficult situations.


Application of the proposed framework to a clinical case provides opportunities for understanding mechanisms of response that may be amenable to intervention and for suggesting appropriate alternative strategies and practices. A full understanding of the process can help to mitigate or to avoid the progression of distress and concurrently to appraise the situation that leads to moral distress or moral outrage.

[Indexed for MEDLINE]

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