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Moral Injury of a Different Kind

February 16, 2023
Moral Injury of a Different Kind

by Craig Nakatsuka, MD

Much is being made of the “moral injury” healthcare professionals suffer, which, rightly so, has been exposed and highlighted during the COVID-19 pandemic. Moral injury consists of an accumulation of a number of things, such as straining to care for the overwhelming number of incredibly sick patients, having to make wrenching decisions on prioritizing use of medical resources, etc. The focus on the subject is to address a practical need, like workforce supply in the face of increasing burnout among healthcare professionals, but it also addresses a personal human desire to ensure the personal well-being of another, which is the healthcare professional in this case.

This topic apparently applies to a type of healthcare professional we may not immediately think about—veterinarians. This February 5, 2023 article published with was written by a veterinarian, and the article’s secondary title caught my eye: “I never understood why veterinarians are at such a high risk of suicide. Until I became one.”

In it, this vet interestingly describes work pressures similar to physicians: demanding work schedules, unrealistic pet owner demands, the dispirited ache one feels when, despite all one has tried in saving an animal, there comes a time when not much more can be done. He goes on to describe, within this context, an illuminating event that he gives his title heading to: I never understood why veterinarians are at such a high risk of suicide, until I became one. You should read it for yourself, for he describes it in much more moving and articulate detail than I ever could. To briefly explain, he tells of a young couple that brings their beloved dog in for care after the dog sustained a severe comminuted fracture of its leg as a result of trauma. After sensitively conveying the news of the strong likelihood of a poor outcome with surgery and yet the probability of a reasonably good functional outcome even with amputation, the couple refuses and demands their pet be euthanized. The euthanasia goes smoothly, but the vet addresses the staff who were obviously experiencing conflicting emotions on top of a difficult workday. Empathizing with their griefs, frustrations and conflicting emotions, he started by affirming that they were the best techs he had ever worked with. He concluded by stating: “We don’t get to choose the challenges we’re faced with. What happened now with the pup and all the angry clients was beyond our control. Sometimes animals just die. You can push as hard as you want, and sometimes they still die.” The techs nod and are in obvious appreciation for his comforting words, but the essay closes with one tech speaking up: “We get it, Andrew, but do you? It’s really important that you do.”

As I finished reading this essay, I thought of an event that has been etched in my mind for the last five years. Although the context was not that of “moral injury” in the strictest sense as there was no personal agency involved, the resultant emotions of despair, helplessness and depression provoked that flashback. I was driving my mom back to her care home where she was residing because of her advancing dementia. When she was younger, she was the kindest person I knew, but she was also somewhat of a worrywart. I remember she had read a newspaper article about someone with dementia and stated: “If I ever get to the point where I’m that bad, just don’t feed me and let me die, even give me a pill if need be.” In her ensuing years, to my great relief and joy, although her cognitive abilities predictably deteriorated, instead of her becoming, as has been generally said, “with Alzheimer’s, you tend to become more like who you are,” the pleasantness and kindness remained but the anxiety and worries that she used to exhibit largely disappeared. That memory flashed back at me as we were driving as she now stated, sparked by something said on the radio, that same thing, this time chuckling softly as she said it: “Oh boy, if I ever get to that stage, just don’t feed me and let me die.”

I in turn stifled a smile, as I noted that she was now clinically at the stage that she had initially stated five years ago of having her life ended, if even with a pill. This calm, pleasant mother of mine, whom I could still enjoy a conversation in warmth and laughter with despite her sometimes not remembering me, was repeating her request. The incongruity of the context seemed strangely humorous.

As Canada continues to expand its euthanasia act, one of the sure-to-be passed bills will be to allow Canadians to authorize in their advanced directives the provision to euthanize oneself when that person loses their decision-making capacity. As I glanced over to my mom sitting in the passenger seat, comfortable, pleasant, laughing, I realized just then that if we were Canadian citizens, the scenario of my mother being euthanized because she had signed such an authorization years prior would be very possible, and even likely. What would it be like for myself and my fellow healthcare professionals, to witness, beyond my control, my mother and other patients whom we have developed such great relationships with, which indeed have been the reason why we do not “burn out,” being euthanized because of the authority of an advanced directive?

A moral injury of a different kind.

Author’s Note: My mother passed away peacefully of a natural death in November 2022, about two years after the event described above.

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