Moral Distress Among Critical Care Nurses During End-of-Life Care Decision-Making

Introduction

Moral distress, originally defined as the psychological disequilibrium that occurs when a clinician knows the ethically appropriate action to take but feels constrained from taking it, remains one of the most consistently documented occupational hazards of critical care nursing, and end-of-life care decision-making has been repeatedly identified as one of its most potent triggers (Jameton, 1984; Hamric & Blackhall, 2007). Prior survey-based research has established that critical care nurses report moral distress related to the provision of care they perceive as excessively aggressive or futile at rates substantially higher than nurses in most other specialty areas, with this distress associated in longitudinal work with burnout, intention to leave the profession, and, when repeatedly unresolved, an accumulating phenomenon described as moral residue (Meltzer & Huckabay, 2004; Epstein & Hamric, 2009).

Much of the existing moral distress literature has relied on standardized quantitative instruments, such as the Moral Distress Scale and its revisions, to measure the frequency and intensity of morally distressing situations across a broad sample of nurses (Wiegand & Funk, 2012; Whitehead et al., 2015). While this survey-based literature has been essential in establishing the scope and correlates of moral distress as a measurable phenomenon, comparatively less research has used in-depth, idiographic qualitative methodology to explore the specific, felt texture of moral distress as critical care nurses themselves experience and describe it during an actual, remembered end-of-life decision-making situation, rather than as an abstracted, generalized construct (Gutierrez, 2005; McAndrew et al., 2011).

This distinction matters because a standardized instrument score cannot fully capture how multiple sources of distress, positional, relational, and emotional, may compound and interact within a single nurse’s experience of a specific case, nor can it capture the particular language nurses themselves use to make sense of that experience. Interpretative phenomenological analysis, an approach specifically oriented toward the detailed exploration of how individuals make sense of significant personal experience, is well suited to this gap (Smith, Flowers, & Larkin, 2009). The purpose of this study was to use interpretative phenomenological analysis to explore critical care nurses’ lived experience of moral distress during end-of-life care decision-making.

Methods

Design. This study used interpretative phenomenological analysis (IPA), following the methodological approach described by Smith, Flowers, and Larkin (2009), selected specifically because the research question concerned the detailed, meaning-making experience of a specific, personally significant professional situation, rather than the generation of a broad thematic map or a theoretical process model.

Sample. Consistent with IPA convention, a small, purposively selected, and relatively homogeneous sample was recruited to allow the detailed, idiographic analysis characteristic of this approach. Eleven critical care nurses were recruited from three intensive care units across two hospitals, each with direct personal experience of a specific, memorable end-of-life decision-making situation within the preceding two years. Recruitment continued until the research team judged that sufficient depth and richness had been achieved across the sample to support meaningful cross-case analysis, consistent with IPA’s emphasis on depth over breadth.

Data collection. Individual, in-depth, semi-structured interviews, lasting 60 to 90 minutes, were conducted by a researcher trained in phenomenological interviewing technique. Interviews began with an open invitation for participants to describe a specific, memorable end-of-life decision-making case in detail, followed by exploratory questions addressing the participant’s internal experience, reasoning, and emotional response at each stage of that case, consistent with IPA’s emphasis on rich, first-person description of lived experience rather than researcher-directed categorical questioning. Interviews were audio-recorded and transcribed verbatim.

Data analysis. Each transcript was first analyzed individually and in depth, following IPA’s idiographic commitment: close, line-by-line reading, identification of exploratory comments addressing descriptive, linguistic, and conceptual content, and development of emergent themes specific to that participant’s account. Only after this individual, case-by-case analysis was complete for all eleven transcripts did cross-case analysis proceed, identifying patterns of convergence and divergence across participants and developing a smaller number of superordinate themes that captured shared experiential structure while preserving documented individual variation. This analysis involved a double hermeneutic, the researcher’s interpretation of the participant’s own sense-making of their experience, consistent with the interpretative dimension central to IPA.

Trustworthiness. Trustworthiness was supported through an audit trail documenting the progression from individual exploratory comments to emergent and then superordinate themes for each transcript, peer review of a subset of individual case analyses by a second researcher trained in IPA, and reflexive memoing addressing the researchers’ own assumptions and reactions throughout analysis.

Ethical considerations. The study was approved by the relevant institutional review boards. Written informed consent was obtained from all participants. Given the sensitive and emotionally demanding nature of the topic, participants were offered the option to pause or end the interview at any time, and information regarding professional emotional support resources was provided to all participants following the interview. Pseudonyms are used throughout, and identifying case details have been altered or generalized to protect participant and patient confidentiality.

Findings

Idiographic analysis of each of the eleven transcripts, followed by cross-case analysis, resulted in four superordinate themes, illustrated in Figure 1. While each superordinate theme was present in some form across the majority of individual accounts, participants varied meaningfully in which theme dominated their account, a pattern of convergence alongside preserved individual variation illustrated in the idiographic emphasis matrix in Figure 2.

Superordinate Theme 1: Caught Between Competing Voices

Across many accounts, participants described occupying a position between a family’s wishes, the medical team’s recommended plan, and, at times, a patient’s own previously expressed but now unspoken preferences, communicated to the nurse in an earlier, more lucid moment of the admission and not always known to the rest of the team. Participants who emphasized this theme most strongly, including Nora, Priya, and Colin, described a specific and recurring discomfort in feeling that they alone held a piece of information, a patient’s earlier stated wish, that might have changed the shape of a family meeting they were not present for.

Superordinate Theme 2: The Weight of Continued Treatment

Many participants described the specific distress of physically administering treatments, medications, ventilator adjustments, or resuscitative measures, that they privately believed were prolonging a dying process rather than providing meaningful benefit. Participants who emphasized this theme most strongly, including Elijah, Marcus, and Renata, described this as a distinct form of complicity, distinguishing it from simple disagreement with a medical decision by emphasizing that they were the ones physically carrying out the action, hour after hour, in a way that made the moral weight feel personally embodied rather than abstract.

Superordinate Theme 3: Powerlessness Within the Hierarchy

Several participants described a felt gap between the depth of their bedside knowledge of a patient and family, accumulated across days or weeks of continuous presence, and the comparatively limited formal weight that knowledge carried within team decision-making structures dominated by physician authority. Participants who emphasized this theme most strongly, including Elijah, Fatima, Devon, and Yusuf, frequently described hesitancy to directly voice a concern or observation during rounds, describing a learned sense that doing so might be received as overstepping rather than as valuable clinical input.

Superordinate Theme 4: Grief Without Closure

A subset of participants described the cumulative emotional toll of repeated exposure to death and dying, compounded by an expectation, often unstated but keenly felt, of moving directly from one patient’s death to the next admission without any structured pause or opportunity for processing. Participants who emphasized this theme most strongly, including Marcus, Renata, Adaeze, and Yusuf, often connected this theme directly to the other three, describing the accumulated weight of competing loyalties, complicity, and powerlessness as the specific content of a grief they described carrying without ever fully setting down.

Discussion

This interpretative phenomenological analysis found that critical care nurses’ moral distress during end-of-life decision-making was experienced not as a single, discrete ethical conflict but as a sustained positional and emotional strain arising from standing at the intersection of family, medical team, and patient, a finding consistent with, and extending in experiential depth, prior survey-based research documenting elevated moral distress specifically around end-of-life and perceived futile care in critical care nursing (Hamric & Blackhall, 2007; Meltzer & Huckabay, 2004). What this analysis adds is the specific, felt structure underlying that documented distress, in particular participants’ description of physically embodied complicity in Theme 2 and the informational isolation described in Theme 1, both of which are difficult to capture through standardized instrument items alone.

The powerlessness within the hierarchy theme, and participants’ specific description of hesitancy to reassert a concern already raised once, is consistent with broader nursing literature documenting the influence of professional hierarchy on nurses’ willingness to voice a differing clinical or ethical concern (McAndrew et al., 2011; Zuzelo, 2007). This finding has a specific and actionable implication distinct from moral distress education alone: institutional structures that explicitly and routinely solicit nursing perspective during end-of-life family meetings and team decision-making, rather than leaving that inclusion to individual physician discretion or individual nurse assertiveness, may address a structural source of distress that ethics education alone would not resolve.

The grief without closure theme, and its frequent connection within individual accounts to the other three themes, extends the concept of moral residue, the lingering, cumulative effect of repeated, unresolved moral distress, by suggesting that this residue may be experienced by nurses less as a distinct psychological aftereffect and more as an undifferentiated accumulation directly continuous with the original distress itself (Epstein & Hamric, 2009; Corley, 2002). Several participants’ description of the absence of any structured pause between a patient’s death and the next clinical demand points toward a concrete, low-resource intervention, protected time or structured debriefing immediately following a patient death, that available literature suggests remains inconsistently implemented in current critical care practice (Rushton, 2006).

Consistent with IPA’s idiographic commitment, the emphasis matrix in Figure 2 makes visible that not all participants experienced these four themes with equal weight, and this variation is itself an important finding. Participants whose accounts emphasized the weight of continued treatment most strongly tended to describe cases involving a family requesting continued aggressive intervention against the team’s recommendation, while participants whose accounts emphasized powerlessness most strongly more often described cases in which they held clinically relevant information or observation that they felt was not adequately solicited, suggesting that the specific dimension of moral distress a given nurse experiences most acutely may depend substantially on the particular contours of the case encountered rather than reflecting a uniform, generic experience.

Several limitations should be considered. This study’s eleven-participant sample, appropriate for the depth of analysis IPA requires, was not intended to be representative and should not be interpreted as establishing the prevalence of any given theme across the broader population of critical care nurses. Participants were drawn from three intensive care units within two hospitals in a single general region, and transferability to nurses practicing in settings with substantially different institutional ethics support, palliative care integration, or team hierarchy structures should be considered carefully rather than assumed. As with all retrospective interview-based research on a specific remembered case, participants’ accounts reflect their current sense-making of a past experience rather than a direct, contemporaneous record of their thinking at the time.

Future research should examine whether structural inclusion of nursing perspective in end-of-life decision-making processes and routine, protected post-death debriefing, the two most concretely actionable findings from this study, measurably reduce moral distress and moral residue over time, and should extend this phenomenological approach to related but distinct roles, including physicians and chaplains, to examine whether the specific theme structure identified here is unique to nursing or reflects a more broadly shared experience across the interprofessional end-of-life care team. Taken together, these findings suggest that addressing moral distress among critical care nurses during end-of-life decision-making may depend as much on structural and relational change, formal inclusion of nursing voice in decision-making and protected space for grief, as on ethics education addressing moral reasoning alone.

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