A registered nurse (RN) is caring for a patient who is terminally ill with cancer. The patient is in a lot of pain and is begging the RN to give them more medication. The RN knows that giving the patient more medication will likely hasten their death, but they also know that the patient is in a lot of suffering. The RN is feeling conflicted about what to do.

AACN’s Four A’s:

Ask:

• What is the source of my distress?
• Is my distress related to my personal values or beliefs?
• Is my distress related to my professional obligations?
• Is my distress related to the patient’s situation?
• Is my distress related to the healthcare system?

Affirm:

• It is okay to feel distressed.
• I am not alone in feeling this way.
• I have a responsibility to take care of myself.
• I have a responsibility to advocate for my patient.

Assess:

• What are my options?
• What are the potential consequences of each option?
• What are my professional obligations?
• What are my personal values and beliefs?

Act:

• What is the best course of action for me to take?
• How can I advocate for my patient?
• How can I take care of myself?

Possible mitigation strategies:

• The RN can talk to their supervisor or another trusted colleague about their distress.
• The RN can seek counseling or support from a professional.
• The RN can advocate for the patient to receive palliative care.
• The RN can advocate for the patient to have access to all of their treatment options, including those that may hasten their death.
• The RN can take care of themselves by getting enough sleep, eating healthy foods, and exercising regularly.

Additional thoughts:

Moral distress can be a difficult experience for RNs. It is important to remember that it is okay to feel distressed and that you are not alone. There are a number of things that you can do to mitigate moral distress, such as talking to a trusted colleague or seeking professional help. You can also advocate for your patient and for yourself.