Recognizing and supporting morally injured ICU professionals during the COVID-19 pandemic

Dear Editor,

The COVID-19 pandemic is producing a maelstrom of morally distressing and potentially morally injurious events (pMIEs). PMIEs are defined as “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations” [1]. Moral distress, which occurs when intensive care unit (ICU) professionals cannot fulfill their moral requirements due to internal or contextual constraints, can fade over time. However, moral injury, a concept originating in military psychology, signifies a durable mental wound characterized by symptoms such as guilt, shame, existential or moral conflict, a loss of trust in goodness, moral detachment and/or moral disorientation [1,2,3]. A person becomes morally injured if exposed to repeated incidents of moral distress or due to a single egregious violation of morality.

Particularly in public health disasters, it is important to recognize moral injury with ICU professionals apart from post-traumatic stress disorder (PTSD) and the aforementioned moral distress. Moral injury, moral distress and PTSD differ with regard to etiology and consequences (see Table 1). PTSD does not necessarily involve guilt, shame, moral conflict or disorientation. The term “moral injury” signifies a deep mental wound, as opposed to a physiological or characterological disorder. Moral injury and PTSD can, however, be comorbid, and both may lead to avoidance symptoms, substance abuse and increased risk of suicide [3].

Table 1 Differences between moral injury, moral distress and PTSD [2, 3, 5]

During the COVID-19 pandemic, ICU professionals who participated in informal interviews and peer support consultations expressed events akin to pMIEs. Professionals described cases in which quality of care and basic care duties were compromised due to being responsible for a large volume of COVID-19 patients. Professionals reported feelings of disorientation, worry, a loss of control and powerlessness. Many professionals explained that because all COVID-19 patients suffer from the same disease and receive similar treatment, and due to restrictions on family visits, patients seemingly become “bodies” without context. Professionals, moreover, sometimes had to act while being confronted with the almost impossible choice between safe working conditions and quality of patient care.

The COVID-19 surge demands from ICUs to commit to long-term mental and moral support, as moral injury and a severe loss of moral integrity does not easily or quickly dissolve. Efforts are needed to prevent harm to individual professionals and substantial turnover in a highly qualified workforce.

First, we recommend ICUs to set up peer support mechanisms that take into account the needs and wishes of professionals. Generally, intensive care attracts perfectionists who may experience moral demands as especially stringent [4]. Peers should encourage professionals to facilitate self-forgiveness and start re-integrating moral transgressions into their moral code and accept that good persons sometimes, out of necessity, act badly. Since guilt and shame are not easily addressed, peers should aim for building long-lasting working relationships.

Second, we advise to stimulate grassroots dialogues on moral requirements in pandemic times. Small-group ethical deliberations help professionals explicate the values and principles at stake and clarify personally felt moral requirements and frameworks. Recognizing the wound is the first step out of moral disorientation and detachment.


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The research was supported by ZonMw, Project Number 516012513.

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All authors contributed to the study conception and design. Acquisition, analysis and interpretation of the data were performed by Niek Kok, Astrid Hoedemaekers, Marieke Zegers and Jelle van Gup. The first draft of the manuscript was written by Niek Kok, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Niek Kok.

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Kok, N., Hoedemaekers, A., van der Hoeven, H. et al. Recognizing and supporting morally injured ICU professionals during the COVID-19 pandemic. Intensive Care Med 46, 1653–1654 (2020).

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