1 Berman Institute of Bioethics, Johns Hopkins University , Baltimore, Maryland.
J Palliat Med. 2013 Sep;16(9):1080-8. doi: 10.1089/jpm.2013.0105. Epub 2013 Aug 9.
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.
道德困境是姑息治疗实践中普遍存在的现实。已经提出了一个现有的理解框架，作为开始解决道德困境对临床医生的不利影响的一种方式。
目的是说明将这个改编的概念框架应用于临床案例，并为扩大应对涉及道德困境的挑战性案例的专业应对方案提供建议。
在临床案例中，临床医生应该根据四个因素来回应患者的痛苦：同理心（情感协调）、换位思考（认知协调）、记忆（个人经验）和道德敏感性（道德协调）。这些相互关联和迭代的因素中的每一个都可能在临床医生为患有生命有限疾病的患者提供护理时被激活。这为临床医生的反应奠定了基础。当面对道德困境时，反应有变得令人不快的风险时，就需要策略来培养有原则的同情心，而不是不受监管的道德愤怒。一些源自沉思传统的认知、注意力、情感和躯体方法与该框架一致。与包含组织因素的系统为重点的方法相结合，为应对困难情况提供了改善专业应对方案的手段。
将提出的框架应用于临床案例为理解可能易于干预的反应机制提供了机会，并为提出适当的替代策略和做法提供了机会。对整个过程的充分理解有助于减轻或避免困境的发展，并同时评估导致道德困境或道德愤怒的情况。
