title: A framework for understanding moral distress among palliative care clinicians.
abstract: BACKGROUND
  Palliative care clinicians confront suffering as they care for people living with life-limiting conditions. When the degree of suffering becomes unjustified, moral distress can ensue. Promising work from neuroscience and social psychology has yet to be applied to clinical practice.
  
  
  OBJECTIVE
  Our objective was to expand a social psychology model focusing on empathy and compassion in response to suffering to include an ethical dimension and to examine how the interrelationships of its proposed components can assist clinicians in understanding their responses to morally distressing situations.
  
  
  METHODS
  In the clinical context, responses to distressing events are thought to include four dimensions: empathy (emotional attunement), perspective taking (cognitive attunement), memory (personal experience), and moral sensitivity (ethical attunement). These dynamically intertwined dimensions create the preconditions for how clinicians respond to a triggering event instigated by an ethical conflict or dilemma. We postulate that if the four dimensions are highly aligned, the intensity and valence of emotional arousal will influence ethical appraisal and discernment by engaging a robust view of the ethical issues, conflicts, and possible solutions and cultivating compassionate action and resilience. In contrast, if they are not, ethical appraisal and discernment will be deficient, creating emotional disregulation and potentially leading to personal and moral distress, self-focused behaviors, unregulated moral outrage, burnout, and secondary stress.
  
  
  CONCLUSIONS
  The adaptation and expansion of a conceptual framework offers a promising approach to designing interventions that help clinicians mitigate the detrimental consequences of unregulated moral distress and to build the resilience necessary to sustain themselves in clinical service.
authors.affiliation: 1 School of Nursing and Medicine, Berman Institute of Bioethics, Johns Hopkins University , Baltimore, Maryland.
authors.forename: Cynda H
authors.initials: CH
authors.lastname: Rushton
authors.forename: Alfred W
authors.initials: AW
authors.lastname: Kaszniak
authors.forename: Joan S
authors.initials: JS
authors.lastname: Halifax
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D003220:Conflict, Psychological; D004645:Empathy; D005260:Female; D006801:Humans; D007588:Job Satisfaction; D008297:Male; D009014:Morals; D010166:Palliative Care / Q000941:ethics*; D010820:Physicians / Q000941:ethics* / Q000523:psychology*; D013315:Stress, Psychological