Moral distress and attitudes toward intramural goal-of-care discussions

BackgroundAdvance directives (ADs) document the patient's preferences regarding future medical care and are used to ensure goal-concordant care and patient autonomy when the patient becomes incapacitated. In a clinical setting, goals of care (GOC) discussions are a tool that helps health care providers (HCPs) provide goal-concordant care. A lack of documentation of the patient's wishes, either as AD or following GOC discussions, can, especially in emergency or critical situations, lead to moral distress among HCPs, a psychological disequilibrium that stems from the perceived inability to act in the best interests of the patient.ObjectivesThis study aimed to (1) assess attitudes toward GOC discussions among patients and HCPs in general wards at Vienna General Hospital, (2) identify barriers and facilitators for their implementation, and (3) measure and compare moral distress between HCPs.MethodsA cross-sectional survey was conducted between October 2022 and June 2023 across six wards (cardiology, pulmonology, infectious diseases, maxillofacial surgery, palliative care, and chronic haemodialysis). Paper-based questionnaires were administered to patients (n = 47) and HCPs (n = 75). Moral distress among HCPs was assessed using a culturally adapted German translation of the Measure of Moral Distress - Health Care Professionals (MMD-HP).Ethical considerationsThe study was approved by the ethics committee and the data protection commission of the Medical University of Vienna. Informed consent was obtained from all participants. The questionnaires contained no identifying information. Participation was voluntary and not participating carried no disadvantages.ResultsMost patients (70.5%) considered GOC discussions appropriate during hospitalisation, 71.4% considered them relieving, and 79.1% considered them helpful. Only 10.9% had ever been asked about ADs during a hospital stay. Among HCPs, the majority considered GOC discussions suitable for patients with multimorbidity (80.0%) and life-shortening conditions (86.7%) as well as those with a simple medical condition (54.7%). However, the majority (51.4%) of HCPs practice GOC discussions for less than 10% of their patients. The lack of standard operating procedures (SOPs), personnel, time, translators, and material were reported as the most relevant barriers. The mean MMD-HP total score was 105.0. Nurses scored significantly higher than physicians (125.7 vs 86.9, p = 0.020).ConclusionsBoth patients and HCPs expressed strong support for GOC discussions, yet the implementation is hindered by resource limitations and the lack of standardised protocols. At the same time, nurses experience high levels of moral distress. There seems to be a need for organisational and policy measures to facilitate structured GOC discussions and goal-concordant care.