FROM THE FIELD | When the Soul Knows Too Much: Understanding Moral Injury (Part 1)

Deborah M. Jackson, MDiv, MA, BCC, PLPC

I was called to a code blue. When I got to the room to assess the situation, I was greeted by surrounding staff, entered the room and contacted the attending physician and nurses surrounding an elderly woman. After concluding no staff was in distress, I looked outside the room and, in the distance, saw what was confirmed to be the patient’s husband noticeable upset. After greeting him he shared with me he and his wife had been married for almost 50 years.

I stood with him with affirming silent presence. He expressed gratefulness. I asked him if he would be okay if I left him briefly to go check on his wife in the room; he said yes. When I entered the room (doctors and nurses in full blown code mode trying to save her life.) Suddenly, I heard the tone shift from one of the attending physicians on the case to what I discerned as an inappropriate dismissive tone with a vocalized interest in convincing the husband to sign a do not resuscitate. Highly inappropriate my heart became disturbed. I immediately left the room and quietly went to stand with the husband (almost as a spiritual guard) While it is appropriate and to help a family member understand the damage created at the most crucial point of attempts to revive someone – it is not appropriate to get a family member in a moment of distress to sign a DNR. A DNR is only appropriate prior to someone coding. I don’t know if my presence was enough that day. But the physician did not proceed with his expressed intent that day. Even more. The patient did not die that day. I met with the husband and wife and her son the very next morning – her son was on a plane in route the moment she was coding. He made it. I sat with that family for hours. While she was very ill (with no more clinical options available to save her life) and preparing to die - she shared with me her husband simply needed more time to accept it.I left the interaction clear headed that what I experienced personally was a morally distressing alarm bell for in me. While my response was to stand near the husband as a shield/advocate, and it likely prevented an inappropriately timed action/request by the physician to the husband – I understood I was in the middle of a moral related incident happening quietly behind the scenes.

So, What Is Moral Injury?Moral injury (MI) is the internal emotional unrest one can experience because of a lapse in moral values, feeling trapped or positioned by an outside source from speaking out because of a violation of someone else’s. It can happen when observing others transgress moral values or being the victim of others' wrongdoing. Moral Injury starts as distress then can escalate to an injury and then a trauma. Initially, Moral Injury received attention in active-duty military and Veterans following combat trauma, but now it has expanded to include first responders, healthcare professionals, and others exposed to severe negative life events and moral challenges. Beyond that, moral distress and injury can be experienced by any person at any time. While these wounds don’t show up on scans or charts — they are the kind that stand at the doorway of conscience.