Moral Distress in Nephrology Fellowship Programs

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Nephrology fellows experience high rates of moral distress during their fellowship training, according to a survey study in American Journal of Nephrology.

An online survey link was sent to the directors of 148 US nephrology fellowship programs, with a request to forward the survey to fellowship trainees. Adapted from a previous questionnaire, the survey focused on workplace scenarios relevant to nephrology training and practice in five domains: dialysis decision-making, futility of care, interdisciplinary communication, perceived powerlessness, and the institutional ethical environment.

Directors reported forwarding the survey to 386 nephrology fellows, of whom 142 responded: a rate of 37%. Ratings of 3 or higher, on a 0-to-4 scale, were considered to denote frequent or moderate to severe moral distress.

Respondents indicated moral distress in a wide range of scenarios involving all five selected domains. Scenarios most frequently rated as causing moderate to severe moral distress involved continuing dialysis in a hopelessly ill patient, 81% of respondents; initiating dialysis in situations perceived as futile, 77%; carrying a high patient census, 75%; and observing other practitioners give unduly optimistic descriptions of the benefits of dialysis, 64%.

Scenarios related to overly optimistic descriptions and futile kidney replacement therapy were cited as occurring often to frequently by more than one-half of respondents, as was following a family's wishes to continue dialysis in an incapacitated patient where the physician believes continued treatment is not in the patient's best interest.

Three-fourths of respondents perceived their fellowship program as stressful. Twenty-seven percent had considered quitting at some point during their fellowship training, including nine percent at the time they completed the survey.

Moral distress is a pervasive problem in healthcare settings. Nephrology fellows may experience uncertainty and constraint-related moral distress in many situations, including decisions about initiating, continuing, or withdrawing or withholding dialysis.

The new survey finds that nephrology fellows commonly experience situations involving moderate to high levels of moral distress. The authors discuss organizational and curricular changes and self-care opportunities to help address and reduce moral distress in fellowship programs [Saeed F, et al. Frequency of severity of moral distress in nephrology fellows: A national survey. Am J Nephrol, published online ahead of print June 21, 2021. doi: 10.1159/000516575;].