Have you experienced moral injury?

RE: Have you experienced moral injury?

Gillian Mostyn — Thu, 27 Aug 2020 16:18:03 GMT

I can't say I'm aware I've suffered any 'moral injury' over the years but I have the same approach as Clive - discuss all options with the owner and come to a mutual decision.

I think that this idea of there existing a 'gold standard' is part of the problem. I've never really thought of there being a 'right' and a 'wrong' way to treat - every pet and every owner has it's own individual set of circumstances. If you approach this job thinking that there is a gold standard approach to every problem, you are going to end up feeling like you've failed in your job more often than not.

However, there is a de-skilling happening which is meaning that primary care vets aren't now able to ofer what I would have thought were basic surgical procedures - anal gland removal, pinning etc - so maybe the gap between primary care and referral level care is now too wide to allow an intermediate level of care to be offered? It's all or nothing....

[quote userid="5012" url="~/001/nonclinical/f/life-in-practice-discussions/29308/have-you-experienced-moral-injury/225107#225107"]I hate to use the phrase, and will undoubtedly be lambasted for it, but some folk need to man up a bit and grow a pair.[/quote]

If you hate to use it, don't. I'm not aware that being female and not possessing a large pair of testicles has held me back!

RE: Have you experienced moral injury?

Clive Ansell — Thu, 27 Aug 2020 15:10:00 GMT

[quote userid="11202" url="~/001/nonclinical/f/life-in-practice-discussions/29308/have-you-experienced-moral-injury/225100#225100"]

Gillian Mostyn said:
Couldn't it be as simple as constantly seeing cases where finances limit treatment options? Amputation, as fracture fixation too expensive etc?

If that is case then I have suffered moral injury as a local charity clinic now seem devoid of any bone fixing skills and go for leg removal.

They suggest referral and of course their clients cannot afford the fees.

It is very frustrating and disappointing but moral injury ?

Just having a go or cage rest are deemed inappropriate.

[/quote]

Really, the world has gone mad.

What's described here is all in a days work for a veterinary surgeon. How can it constitute moral injury in any way whatsoever? I hate to use the phrase, and will undoubtedly be lambasted for it, but some folk need to man up a bit and grow a pair.

A history and clinical examination is carried out, followed by any necessary investigative work. The findings are discussed with the client, and course of action decided upon, which in the case of a limb fracture would be;

1. Referral to specialist centre (so called Gold standard we are told) (Last one I referred, straight forward cat femur fracture = £5000)

2. Referral to non specialist

3. hand over to someone else in practice if available

4. have a go oneself, with pre discussed limitations etc (Although many feel we shouldn't do this, god only knows why)

5. Apply dressing if appropriate (I hate dressings on fractures limbs, seem to cause as many if not more problems than they cure)

6. Amputation

7. Leave to heal unaided, with analgesia, welfare permitting

8. PTS.

We advise and offer to treat, or refer on to someone better able to do so. Client makes the decision. Job done. End of. I really cannot see the issue at all; sometimes suboptimal treatment is given, but as long as we discuss and offer all reasonable options, the ultimate responsibility begins and ends with the animal owner/client.

RE: Have you experienced moral injury?

Malcolm Ness — Wed, 26 Aug 2020 19:50:10 GMT

doi: 10.1136/vr.144.5.115.Adaptation of dogs to the amputation of a limb and their owners' satisfaction with the procedure

J Kirpensteijn¹, R van den Bos, N Endenburg

Jolle Kirpensteijn has published several related papers around the same subject - if you search PubMed with Kirpensteijn AND amputation you should get them.

PS Sadly, the paper contains no lame jokes.

RE: Have you experienced moral injury?

vetbl.locum — Wed, 26 Aug 2020 16:28:17 GMT

Thanks

Been going round in circles over it

RE: Have you experienced moral injury?

Iain Richards — Wed, 26 Aug 2020 11:37:03 GMT

[quote userid="11202" url="~/001/nonclinical/f/life-in-practice-discussions/29308/have-you-experienced-moral-injury/225100#225100"]PS Is there any studies on long term outcomes following leg removal ?[/quote]

Yes, but they are bit one-sided

RE: Have you experienced moral injury?

vetbl.locum — Wed, 26 Aug 2020 10:45:20 GMT

[quote userid="2457" url="~/001/nonclinical/f/life-in-practice-discussions/29308/have-you-experienced-moral-injury/225083#225083"]Couldn't it be as simple as constantly seeing cases where finances limit treatment options? Amputation, as fracture fixation too expensive etc? [/quote]

If that is case then I have suffered moral injury as a local charity clinic now seem devoid of any bone fixing skills and go for leg removal.

They suggest referral and of course their clients cannot afford the fees.

It is very frustrating and disappointing but moral injury ?

Just having a go or cage rest are deemed inappropriate.

Rgds

PS Is there any studies on long term outcomes following leg removal ?

RE: Have you experienced moral injury?

Miriam Lodewyks — Tue, 25 Aug 2020 19:44:11 GMT

Well this is an interesting thread.
On the one hand I do feel chronically “injured” by clients who do not share my desire to provide their pets with the best care I can (they’ll never admit it of course! They just don’t want kitty “messed with”...) but then I agree with Dinu... who am I to dictate what level of care a pet should receive?
I think I’ve grown a little immune to the dilemma over the years but I do regularly catch myself thinking: “can’t save em all!” Guess that’s a coping mechanism?

RE: Have you experienced moral injury?

Evelyn Barbour-Hill — Tue, 25 Aug 2020 18:22:46 GMT

[quote userid="4367" url="~/001/nonclinical/f/life-in-practice-discussions/29308/have-you-experienced-moral-injury/225073#225073"]Moral injury describes the challenge of simultaneously knowing what care patients need but being unable to provide it due to constraints that are beyond our control[/quote]

Jeepers, if that's "moral injury" we really are a load of wimps. I really find it quite insulting to people who really are suffering psychological injury from something they were required to do while fighting a war.

A professional knows that their obligation is to provide the best care they can within the constraints imposed by reality. And takes pride in doing so. Claiming "moral injury" is just ridiculous.

Dinu has it spot on.

RE: Have you experienced moral injury?

Iain Richards — Tue, 25 Aug 2020 14:13:40 GMT

I suspect that some vets are vets because they enjoy the challenges that are animal diseases along with the accompanying human aspects, others are wanting to save animals' lives regardless of reality (be it welfare or money), others still want to be doctors and follow cases with infinite tests. Each will therefore have conflicts between their ideal and reality, which I would hardly describe as an injury.

RE: Have you experienced moral injury?

Arlo Guthrie — Tue, 25 Aug 2020 12:36:58 GMT

[quote userid="2457" url="~/001/nonclinical/f/life-in-practice-discussions/29308/have-you-experienced-moral-injury/225083#225083"]I don't see this as individual instances of going against a strong moral code, but more as a constant issue of not being able to work or behave as you would if barriers to doing so weren't in place?[/quote]

That was what I was thinking. And it is not something other professions have to face on quite the same scale. The mechanic isn't going to lose sleep because the owner said they'd prefer the cheapest Bridgestones, and not the top-of-the-range Pirellis.

Accountants perhaps find themselves being asked to cook the books a little, but that's easy enough to decline.

Lawyers? I guess they must find themselves defending things which run counter to their moral code, but they have a higher imperative of delivering justice.

My old boss (in public relations) always used to say (when I cocked up): "Don't worry, we're just doing PR here. Nobody's gonna die."

You, on the other hand (and doctors), are making decisions about life, and that must lead to greater ethical conflict. Arguably more so for vets, because Drs have the luxury of explaining things to their patients, whereas you are the patient's only champion is some cases.

RE: Have you experienced moral injury?

Gillian Mostyn — Tue, 25 Aug 2020 12:24:43 GMT

[quote userid="4367" url="~/001/nonclinical/f/life-in-practice-discussions/29308/have-you-experienced-moral-injury/225081#225081"]I can't think of many instances where a moral conflict could occur that a vet can't walk away from, [/quote]

Couldn't it be as simple as constantly seeing cases where finances limit treatment options? Amputation, as fracture fixation too expensive etc? Or time constraints limiting how thorough you can be with each case? I don't see this as individual instances of going against a strong moral code, but more as a constant issue of not being able to work or behave as you would if barriers to doing so weren't in place?

RE: Have you experienced moral injury?

Iain Richards — Tue, 25 Aug 2020 11:54:26 GMT

My thoughts too, which will make this challenging, then there are the general ethical aspects of being a vet, which may also be a conflict. I can't think of many instances where a moral conflict could occur that a vet can't walk away from, or report the practice as being unethical.

RE: Have you experienced moral injury?

Dinu Catilina — Tue, 25 Aug 2020 11:07:05 GMT

[quote userid="4367" url="~/001/nonclinical/f/life-in-practice-discussions/29308/have-you-experienced-moral-injury/225073#225073"]our deeply held moral beliefs[/quote]

Well Ian, some people's deeply held moral beliefs may be in absolute conflict with other people's deeply held moral beliefs. Moral beliefs are contextual and subjective, how do we decide who's moral beliefs are more important and who has the right to claim moral injury?

RE: Have you experienced moral injury?

Iain Richards — Tue, 25 Aug 2020 09:07:55 GMT

I had to look this up and found a paper with this as a definition, "Moral injury occurs when we perpetrate, bear witness to, or fail to prevent an act that transgresses our deeply held moral beliefs. In the health care context, that deeply held moral belief is the oath each of us took when embarking on our paths as health care providers: Put the needs of patients first."

The term arose after Vietnam, applied to people with PTSD like problems (whcih arose from a real threat to life) due to conflicts (eg napalming civilians).

The paper goes on to this: Moral injury describes the challenge of simultaneously knowing what care patients need but being unable to provide it due to constraints that are beyond our control

RE: Have you experienced moral injury?

Dinu Catilina — Mon, 24 Aug 2020 22:10:26 GMT

Moral injury? Or hurt feelings?

I take it not many follow american wrestling or MMA but this video will show the difference better than I can:

www.youtube.com/watch

RE: Have you experienced moral injury?

Evelyn Barbour-Hill — Mon, 24 Aug 2020 21:43:22 GMT

[quote userid="2675" url="~/001/nonclinical/f/life-in-practice-discussions/29308/have-you-experienced-moral-injury/225063#225063"]can we include our governing body deciding that we are too stupid to be able to perform our work to a standard worthy of a MRCVS by suggesting that, as suspected all along, that practice standards imposed by said governing body are in fact desirable and in the 'public interest' - a useful catch-all phrase that effectively leaves anyone trying to argue against to be classed as a morally inferior specimen?[/quote]

Probably not, I'm afraid.

RE: Have you experienced moral injury?

Richard Carter — Mon, 24 Aug 2020 17:34:20 GMT

can we include our governing body deciding that we are too stupid to be able to perform our work to a standard worthy of a MRCVS by suggesting that, as suspected all along, that practice standards imposed by said governing body are in fact desirable and in the 'public interest' - a useful catch-all phrase that effectively leaves anyone trying to argue against to be classed as a morally inferior specimen?