Angustia moral y educación médica: revisión temática para la visibilización de un problema en expansión.
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ene 8, 2022
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Resumen
La angustia moral (AM) es un fenómeno descrito en el personal de salud, que poco a poco va ganando interés por estar involucrado en la cotidianidad de la toma de decisiones clínicas. El objetivo del presente trabajo fue estructurar una visión general del concepto. Se realizó una revisión temática con análisis cualitativo del contenido de 40 artículos relacionados con el tema y obtenidos de la base datos PubMed. Obteniendo que la AM es un fenómeno multicausal del cual no se tiene aún un modelo concreto que permita entenderla e interpretarla por lo que no se conoce su frecuencia, su intensidad o el alcance de su impacto a ciencia cierta. La AM es un fenómeno que no tiene un cuerpo teórico que permita entenderla por completo, por lo que se hace necesario diseñar herramientas interdisciplinares que permitan su comprensión y abordaje.
Keywords
“Moral distress”, , moral distress, palliative care, end of life, educationcuidados paliativos, educación médica, angustia moral, final de vida
References
BIBLIOGRAFÍA
1. Sierra JC, Ortega V, Zubeidat I. Ansiedad, angustia y estrés: tres conceptos a diferenciar. Revista Mal-estar E Subjetividade. 2003;3(1):10-59. https://www.redalyc.org/articulo.oa?id=27130102
2. Beng TS, Chin LE, Guan NC, Yee A, Wu C, Pathmawathi S, et al. The experiences of stress of palliative care providers in Malaysia: a thematic analysis. Am J Hosp Palliat Care. 2015;32(1):15-28. https://doi.org/10.1177/1049909113503395
3. Prentice TM, Gillam L. Can the Ethical Best Practice of Shared Decision-Making lead to Moral Distress? J Bioeth Inq. 2018;15(2):259-68. https://doi.org/10.1007/s11673-018-9847-8
4. Jameton A. Práctica de enfermería: las cuestiones éticas. Englewood Cliffs, NJ: Prentice Hall; 1984
5. Fumis RRL, Junqueira Amarante GA, de Fátima Nascimento A, Vieira Junior JM. Moral distress and its contribution to the development of burnout syndrome among critical care providers. Ann Intensive Care. 2017;7(1):71. https://doi.org/10.1186/s13613-017-0293-2
6. Mehlis K, Bierwirth E, Laryionava K, Mumm FHA, Hiddemann W, Heußner P, et al. High prevalence of moral distress reported by oncologists and oncology nurses in end-of-life decision making. Psychooncology. 2018;27(12):2733-9 https://doi.org/10.1002/pon.4868 . 7. Larson CP, Dryden-Palmer KD, Gibbons C, Parshuram CS. Moral Distress in PICU and Neonatal ICU Practitioners: A Cross-Sectional Evaluation. Pediatr Crit Care Med. 2017;18(8):e318-e26. https://doi.org/10.1097/PCC.0000000000001219
8. Cullati S, Cheval B, Schmidt RE, Agoritsas T, Chopard P, Courvoisier DS. Self-Rated Health and Sick Leave among Nurses and Physicians: The Role of Regret and Coping Strategies in Difficult Care-Related Situations. Front Psychol. 2017;8:623. https://doi.org/10.3389/fpsyg.2017.00623
9. Rushton CH, Kaszniak AW, Halifax JS. A framework for understanding moral distress among palliative care clinicians. J Palliat Med. 2013;16(9):1074-9. https://doi.org/10.1089/jpm.2012.0490
10. Curtis JR, Levy MM. Our responsibility for training physicians to understand the effect patient death has on them: the role of the intensivist. Chest. 2014;145(5):932-4. https://doi.org/10.1378/chest.13-2600
11. Dodek PM, Wong H, Norena M, Ayas N, Reynolds SC, Keenan SP, et al. Moral distress in intensive care unit professionals is associated with profession, age, and years of experience. J Crit Care. 2016;31(1):178-82. https://doi.org/10.1016/j.jcrc.2015.10.011
12. Lamiani G, Setti I, Barlascini L, Vegni E, Argentero P. Measuring Moral Distress Among Critical Care Clinicians: Validation and Psychometric Properties of the Italian Moral Distress Scale-Revised. Crit Care Med. 2017;45(3):430-7. https://doi.org/10.1097/CCM.0000000000002187
13. St Ledger U BA, Reid J, Prior L, McAuley D, Blackwood B. Moral distress in end-of-life care in the intensive care unit.: J Adv Nurs; 2013. p. 69(8):1869-80. https://doi.org/10.1111/jan.12053
14. Clay AS, Ross E, Chudgar SM, Grochowski CO, Tulsky JA, Shapiro D. The emotions of graduating medical students about prior patient care experiences. Patient Educ Couns. 2015;98(3):344-9. https://doi.org/10.1016/j.pec.2014.11.023
15. Mache S, Vitzthum K, Hauschild I, Groneberg D. A pilot study evaluation of psychosocial competency training for junior physicians working in oncology and hematology. Psychooncology. 2017;26(11):1894-900. https://doi.org/10.1002/pon.4403
16. Dodek PM, Norena M, Ayas N, Wong H. Moral distress is associated with general workplace distress in intensive care unit personnel. J Crit Care. 2019;50:122-5. https://doi.org/10.1016/j.jcrc.2018.11.030
17. Al-Dubai SA, Ganasegeran K, Perianayagam W, Rampal KG. Emotional burnout, perceived sources of job stress, professional fulfillment, and engagement among medical residents in Malaysia. ScientificWorldJournal. 2013;2013:137620. https://doi.org/10.1155/2013/137620
18. Ben-Ezra M, Bibi H. The Association Between Psychological Distress and Decision Regret During Armed Conflict Among Hospital Personnel. Psychiatr Q. 2016;87(3):515-9. https://doi.org/10.1007/s11126-015-9406-y
19. Tremolada M, Schiavo S, Tison T, Sormano E, De Silvestro G, Marson P, et al. Stress, burnout, and job satisfaction in 470 health professionals in 98 apheresis units in Italy: A SIdEM collaborative study. J Clin Apher. 2015;30(5):297-304. https://doi.org/10.1002/jca.21379
20. Henrich NJ, Dodek PM, Gladstone E, Alden L, Keenan SP, Reynolds S, et al. Consequences of Moral Distress in the Intensive Care Unit: A Qualitative Study. Am J Crit Care. 2017;26(4):e48-e57. https://doi.org/10.4037/ajcc2017786
21. Austin CL, Saylor R, Finley PJ. Moral distress in physicians and nurses: Impact on professional quality of life and turnover. Psychol Trauma. 2017;9(4):399-406. https://doi.org/10.1037/tra0000201
22. Houston S, Casanova MA, Leveille M, Schmidt KL, Barnes SA, Trungale KR, et al. The intensity and frequency of moral distress among different healthcare disciplines. J Clin Ethics. 2013;24(2):98-112. https://pubmed.ncbi.nlm.nih.gov/23923809/
23. Rosenthal MS, Clay M. Initiatives for Responding to Medical Trainees' Moral Distress about End-of-Life Cases. AMA J Ethics. 2017;19(6):585-94. https://doi.org/10.1001/journalofethics.2017.19.6.stas1-1706.
24. Whitehead BR. Health behaviors in older adults: Considering age, affect, and attitudes. J Health Psychol. 2017;22(13):1652-7. https://doi.org/10.1177/1359105316631814
25. Henrich NJ, Dodek PM, Alden L, Keenan SP, Reynolds S, Rodney P. Causes of moral distress in the intensive care unit: A qualitative study. J Crit Care. 2016;35:57-62. https://doi.org/10.1016/j.jcrc.2016.04.033
26. Whitehead PB, Herbertson RK, Hamric AB, Epstein EG, Fisher JM. Moral distress among healthcare professionals: report of an institution-wide survey. J Nurs Scholarsh. 2015;47(2):117-25. https://doi.org/10.1111/jnu.12115
27. Epstein EG. End-of-life experiences of nurses and physicians in the newborn intensive care unit. J Perinatol. 2008;28(11):771-8. https://doi.org/10.1038/jp.2008.96
28. Smith-Han K, Martyn H, Barrett A, Nicholson H. That's not what you expect to do as a doctor, you know, you don't expect your patients to die." Death as a learning experience for undergraduate medical students. BMC Med Educ. 2016;16:108. https://doi.org/10.1186/s12909-016-0631-3
29. Jones R, Finlay F. Medical students' experiences and perception of support following the death of a patient in the UK, and while overseas during their elective period. Postgrad Med J. 2014;90(1060):69-74. https://doi.org/10.1136/postgradmedj-2012-131474
30. Leombruni P, Loera B, Miniotti M, Zizzi F, Castelli L, Torta R. Confirmatory factor analysis of the Frommelt Attitude Toward Care of the Dying Scale (FATCOD-B) among Italian medical students. Palliat Support Care. 2015;13(5):1391-8. https://doi.org/10.1017/S1478951515000139
31. Ratanawongsa N, Teherani A, Hauer KE. Third-year medical students' experiences with dying patients during the internal medicine clerkship: a qualitative study of the informal curriculum. Acad Med. 2005;80(7):641-7. https://doi.org/10.1097/00001888-200507000-00006
32. Førde R, Aasland OG. Moral distress among Norwegian doctors. J Med Ethics. 2008;34(7):521-5. https://doi.org/10.1136/jme.2007.021246
33. Rhodes-Kropf J, Carmody SS, Seltzer D, Redinbaugh E, Gadmer N, Block SD, et al. "This is just too awful; I just can't believe I experienced that...": medical students' reactions to their "most memorable" patient death. Acad Med. 2005;80(7):634-40. https://doi.org/10.1097/00001888-200507000-00005
34. Bekkema N, de Veer AJ, Hertogh CM, Francke AL. 'From activating towards caring': shifts in care approaches at the end of life of people with intellectual disabilities; a qualitative study of the perspectives of relatives, care-staff and physicians. BMC Palliat Care. 2015;14:33. https://doi.org/10.1186/s12904-015-0030-2
35. Lamiani G, Dordoni P, Argentero P. Value congruence and depressive symptoms among critical care clinicians: The mediating role of moral distress. Stress Health. 2018;34(1):135-42. https://doi.org/10.1002/smi.2769
36. Boland JW, Dikomitis L, Gadoud A. Medical students writing on death, dying and palliative care: a qualitative analysis of reflective essays. BMJ Support Palliat Care. 2016;6(4):486-92. https://doi.org/10.1136/bmjspcare-2016-001110
37. Bovero A, Tosi C, Miniotti M, Torta R, Leombruni P. Medical Students Reflections Toward End-of-Life: a Hospice Experience. J Cancer Educ. 2018;33(3):634-9. https://doi.org/10.1007/s13187-017-1171-1
38. Tse CS, Morrison LJ, Ellman MS. Preclinical Medical Students' Diverse Educational and Emotional Responses to a Required Hospice Experience. Am J Hosp Palliat Care. 2017;34(8):704-12. https://doi.org/10.1177/1049909116652574
39. Lewis C, Reid J, McLernon Z, Ingham R, Traynor M. The impact of a simulated intervention on attitudes of undergraduate nursing and medical students towards end of life care provision. BMC Palliat Care. 2016;15:67. https://doi.org/10.1186/s12904-016-0143-2
40. McBain L, Donnelly S, Hilder J, O'Leary C, McKinlay E. "I wanted to communicate my feelings freely": a descriptive study of creative responses to enhance reflection in palliative medicine education. BMC Med Educ. 2015;15:180. https://doi.org/10.1186/s12909-015-0465-4
41. Kearsley JH, Lobb EA. 'Workshops in healing' for senior medical students: a 5-year overview and appraisal. Med Humanit. 2014;40(2):73-9. https://doi.org/10.1136/medhum-2013-010438
42. Devlin MJ, Cutler JL, Harper OL. Taking it personally: exploring medical students' emotional responses and professional roles during the psychiatry clerkship. Acad Psychiatry. 2012;36(3):243-5. https://doi.org/10.1176/appi.ap.11060109
1. Sierra JC, Ortega V, Zubeidat I. Ansiedad, angustia y estrés: tres conceptos a diferenciar. Revista Mal-estar E Subjetividade. 2003;3(1):10-59. https://www.redalyc.org/articulo.oa?id=27130102
2. Beng TS, Chin LE, Guan NC, Yee A, Wu C, Pathmawathi S, et al. The experiences of stress of palliative care providers in Malaysia: a thematic analysis. Am J Hosp Palliat Care. 2015;32(1):15-28. https://doi.org/10.1177/1049909113503395
3. Prentice TM, Gillam L. Can the Ethical Best Practice of Shared Decision-Making lead to Moral Distress? J Bioeth Inq. 2018;15(2):259-68. https://doi.org/10.1007/s11673-018-9847-8
4. Jameton A. Práctica de enfermería: las cuestiones éticas. Englewood Cliffs, NJ: Prentice Hall; 1984
5. Fumis RRL, Junqueira Amarante GA, de Fátima Nascimento A, Vieira Junior JM. Moral distress and its contribution to the development of burnout syndrome among critical care providers. Ann Intensive Care. 2017;7(1):71. https://doi.org/10.1186/s13613-017-0293-2
6. Mehlis K, Bierwirth E, Laryionava K, Mumm FHA, Hiddemann W, Heußner P, et al. High prevalence of moral distress reported by oncologists and oncology nurses in end-of-life decision making. Psychooncology. 2018;27(12):2733-9 https://doi.org/10.1002/pon.4868 . 7. Larson CP, Dryden-Palmer KD, Gibbons C, Parshuram CS. Moral Distress in PICU and Neonatal ICU Practitioners: A Cross-Sectional Evaluation. Pediatr Crit Care Med. 2017;18(8):e318-e26. https://doi.org/10.1097/PCC.0000000000001219
8. Cullati S, Cheval B, Schmidt RE, Agoritsas T, Chopard P, Courvoisier DS. Self-Rated Health and Sick Leave among Nurses and Physicians: The Role of Regret and Coping Strategies in Difficult Care-Related Situations. Front Psychol. 2017;8:623. https://doi.org/10.3389/fpsyg.2017.00623
9. Rushton CH, Kaszniak AW, Halifax JS. A framework for understanding moral distress among palliative care clinicians. J Palliat Med. 2013;16(9):1074-9. https://doi.org/10.1089/jpm.2012.0490
10. Curtis JR, Levy MM. Our responsibility for training physicians to understand the effect patient death has on them: the role of the intensivist. Chest. 2014;145(5):932-4. https://doi.org/10.1378/chest.13-2600
11. Dodek PM, Wong H, Norena M, Ayas N, Reynolds SC, Keenan SP, et al. Moral distress in intensive care unit professionals is associated with profession, age, and years of experience. J Crit Care. 2016;31(1):178-82. https://doi.org/10.1016/j.jcrc.2015.10.011
12. Lamiani G, Setti I, Barlascini L, Vegni E, Argentero P. Measuring Moral Distress Among Critical Care Clinicians: Validation and Psychometric Properties of the Italian Moral Distress Scale-Revised. Crit Care Med. 2017;45(3):430-7. https://doi.org/10.1097/CCM.0000000000002187
13. St Ledger U BA, Reid J, Prior L, McAuley D, Blackwood B. Moral distress in end-of-life care in the intensive care unit.: J Adv Nurs; 2013. p. 69(8):1869-80. https://doi.org/10.1111/jan.12053
14. Clay AS, Ross E, Chudgar SM, Grochowski CO, Tulsky JA, Shapiro D. The emotions of graduating medical students about prior patient care experiences. Patient Educ Couns. 2015;98(3):344-9. https://doi.org/10.1016/j.pec.2014.11.023
15. Mache S, Vitzthum K, Hauschild I, Groneberg D. A pilot study evaluation of psychosocial competency training for junior physicians working in oncology and hematology. Psychooncology. 2017;26(11):1894-900. https://doi.org/10.1002/pon.4403
16. Dodek PM, Norena M, Ayas N, Wong H. Moral distress is associated with general workplace distress in intensive care unit personnel. J Crit Care. 2019;50:122-5. https://doi.org/10.1016/j.jcrc.2018.11.030
17. Al-Dubai SA, Ganasegeran K, Perianayagam W, Rampal KG. Emotional burnout, perceived sources of job stress, professional fulfillment, and engagement among medical residents in Malaysia. ScientificWorldJournal. 2013;2013:137620. https://doi.org/10.1155/2013/137620
18. Ben-Ezra M, Bibi H. The Association Between Psychological Distress and Decision Regret During Armed Conflict Among Hospital Personnel. Psychiatr Q. 2016;87(3):515-9. https://doi.org/10.1007/s11126-015-9406-y
19. Tremolada M, Schiavo S, Tison T, Sormano E, De Silvestro G, Marson P, et al. Stress, burnout, and job satisfaction in 470 health professionals in 98 apheresis units in Italy: A SIdEM collaborative study. J Clin Apher. 2015;30(5):297-304. https://doi.org/10.1002/jca.21379
20. Henrich NJ, Dodek PM, Gladstone E, Alden L, Keenan SP, Reynolds S, et al. Consequences of Moral Distress in the Intensive Care Unit: A Qualitative Study. Am J Crit Care. 2017;26(4):e48-e57. https://doi.org/10.4037/ajcc2017786
21. Austin CL, Saylor R, Finley PJ. Moral distress in physicians and nurses: Impact on professional quality of life and turnover. Psychol Trauma. 2017;9(4):399-406. https://doi.org/10.1037/tra0000201
22. Houston S, Casanova MA, Leveille M, Schmidt KL, Barnes SA, Trungale KR, et al. The intensity and frequency of moral distress among different healthcare disciplines. J Clin Ethics. 2013;24(2):98-112. https://pubmed.ncbi.nlm.nih.gov/23923809/
23. Rosenthal MS, Clay M. Initiatives for Responding to Medical Trainees' Moral Distress about End-of-Life Cases. AMA J Ethics. 2017;19(6):585-94. https://doi.org/10.1001/journalofethics.2017.19.6.stas1-1706.
24. Whitehead BR. Health behaviors in older adults: Considering age, affect, and attitudes. J Health Psychol. 2017;22(13):1652-7. https://doi.org/10.1177/1359105316631814
25. Henrich NJ, Dodek PM, Alden L, Keenan SP, Reynolds S, Rodney P. Causes of moral distress in the intensive care unit: A qualitative study. J Crit Care. 2016;35:57-62. https://doi.org/10.1016/j.jcrc.2016.04.033
26. Whitehead PB, Herbertson RK, Hamric AB, Epstein EG, Fisher JM. Moral distress among healthcare professionals: report of an institution-wide survey. J Nurs Scholarsh. 2015;47(2):117-25. https://doi.org/10.1111/jnu.12115
27. Epstein EG. End-of-life experiences of nurses and physicians in the newborn intensive care unit. J Perinatol. 2008;28(11):771-8. https://doi.org/10.1038/jp.2008.96
28. Smith-Han K, Martyn H, Barrett A, Nicholson H. That's not what you expect to do as a doctor, you know, you don't expect your patients to die." Death as a learning experience for undergraduate medical students. BMC Med Educ. 2016;16:108. https://doi.org/10.1186/s12909-016-0631-3
29. Jones R, Finlay F. Medical students' experiences and perception of support following the death of a patient in the UK, and while overseas during their elective period. Postgrad Med J. 2014;90(1060):69-74. https://doi.org/10.1136/postgradmedj-2012-131474
30. Leombruni P, Loera B, Miniotti M, Zizzi F, Castelli L, Torta R. Confirmatory factor analysis of the Frommelt Attitude Toward Care of the Dying Scale (FATCOD-B) among Italian medical students. Palliat Support Care. 2015;13(5):1391-8. https://doi.org/10.1017/S1478951515000139
31. Ratanawongsa N, Teherani A, Hauer KE. Third-year medical students' experiences with dying patients during the internal medicine clerkship: a qualitative study of the informal curriculum. Acad Med. 2005;80(7):641-7. https://doi.org/10.1097/00001888-200507000-00006
32. Førde R, Aasland OG. Moral distress among Norwegian doctors. J Med Ethics. 2008;34(7):521-5. https://doi.org/10.1136/jme.2007.021246
33. Rhodes-Kropf J, Carmody SS, Seltzer D, Redinbaugh E, Gadmer N, Block SD, et al. "This is just too awful; I just can't believe I experienced that...": medical students' reactions to their "most memorable" patient death. Acad Med. 2005;80(7):634-40. https://doi.org/10.1097/00001888-200507000-00005
34. Bekkema N, de Veer AJ, Hertogh CM, Francke AL. 'From activating towards caring': shifts in care approaches at the end of life of people with intellectual disabilities; a qualitative study of the perspectives of relatives, care-staff and physicians. BMC Palliat Care. 2015;14:33. https://doi.org/10.1186/s12904-015-0030-2
35. Lamiani G, Dordoni P, Argentero P. Value congruence and depressive symptoms among critical care clinicians: The mediating role of moral distress. Stress Health. 2018;34(1):135-42. https://doi.org/10.1002/smi.2769
36. Boland JW, Dikomitis L, Gadoud A. Medical students writing on death, dying and palliative care: a qualitative analysis of reflective essays. BMJ Support Palliat Care. 2016;6(4):486-92. https://doi.org/10.1136/bmjspcare-2016-001110
37. Bovero A, Tosi C, Miniotti M, Torta R, Leombruni P. Medical Students Reflections Toward End-of-Life: a Hospice Experience. J Cancer Educ. 2018;33(3):634-9. https://doi.org/10.1007/s13187-017-1171-1
38. Tse CS, Morrison LJ, Ellman MS. Preclinical Medical Students' Diverse Educational and Emotional Responses to a Required Hospice Experience. Am J Hosp Palliat Care. 2017;34(8):704-12. https://doi.org/10.1177/1049909116652574
39. Lewis C, Reid J, McLernon Z, Ingham R, Traynor M. The impact of a simulated intervention on attitudes of undergraduate nursing and medical students towards end of life care provision. BMC Palliat Care. 2016;15:67. https://doi.org/10.1186/s12904-016-0143-2
40. McBain L, Donnelly S, Hilder J, O'Leary C, McKinlay E. "I wanted to communicate my feelings freely": a descriptive study of creative responses to enhance reflection in palliative medicine education. BMC Med Educ. 2015;15:180. https://doi.org/10.1186/s12909-015-0465-4
41. Kearsley JH, Lobb EA. 'Workshops in healing' for senior medical students: a 5-year overview and appraisal. Med Humanit. 2014;40(2):73-9. https://doi.org/10.1136/medhum-2013-010438
42. Devlin MJ, Cutler JL, Harper OL. Taking it personally: exploring medical students' emotional responses and professional roles during the psychiatry clerkship. Acad Psychiatry. 2012;36(3):243-5. https://doi.org/10.1176/appi.ap.11060109
Cómo citar
Medina, A. M., Arias Delgado, D., Ramírez Pazos, J., Velasquez Robles, D., Cuervo Landinez, M. P., López Sanmiguel, A., & Salgado Cendales, A. (2022). Angustia moral y educación médica: revisión temática para la visibilización de un problema en expansión. Universitas Medica, 63(1). https://doi.org/10.11144/Javeriana.umed63-1.amem
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