She was in her mid-40s, training for a marathon—vibrant and seemingly unstoppable.
During a practice run, she became short of breath and came to the emergency department. Imaging found metastatic lung cancer with superior vena cava syndrome. We proceeded with intubation, bronchoscopy, and endobronchial stent placement, each step thoughtfully clinical.
Over the next three weeks, her husband remained at her bedside, desperate for any sign of improvement. When recovery was no longer possible, she was transitioned to comfort-focused care. As she died, he hugged me and we both cried. In that embrace, the boundaries between professional and personal completely dissolved. In the profound grief for her and her family, I felt the weight of my own despair.
Experiences like this are woven into our daily work, yet we rarely pause to name how they shape us. Conversations about clinician burnout tend to focus on workload and productivity, but for many ICU clinicians, the deeper injury lies not simply in how much we do, but rather in what we are asked to do and how often it conflicts with what we believe is right.
This tension is moral distress: the painful psychological response that arises when clinicians know the ethically appropriate action but feel constrained from taking it by internal or external barriers. It has been closely linked to burnout.
In the ICU, end-of-life care sits at the center of this distress. Prognostic uncertainty, complex family dynamics, expectations to “do everything possible,” and fear of litigation converge with pressure to continue nonbeneficial treatments and perform invasive procedures in the face of inevitable death. Over time, the ICU can shift from a place of rescue to a site of protracted dying, and each ethically uncomfortable step along that path compounds the tension, creating a quiet but durable emotional injury.1–6
The consequences extend beyond individual suffering. Surveys show that ICU clinicians report burnout, anxiety, depression, and post-traumatic stress at rates exceeding many other high-risk professions. Challenging end-of-life care is a predictor of intent to leave the ICU or medicine altogether. When experienced clinicians walk away, units lose not only personnel but also mentorship and institutional memory. Recruitment is challenging; trainees observe the emotional climate and reconsider their careers.
If clinicians repeatedly find themselves in situations where they feel compelled to provide care they believe is inappropriate, distress is a predictable system output. To frame burnout as a problem of personal resilience, then, is a missed opportunity to address a systemic issue. If we accept that ICU burnout may be related to morally distressing end-of-life care, then improving end-of-life processes becomes not only a patient-centered imperative but also a clinician wellness intervention.
Early, candid goals-of-care conversations—ideally triggered by poor prognostic indicators before crisis—help align treatment with what matters most to patients. Routine family meetings can create opportunities to normalize uncertainty and create space to explore values beyond survival alone. Integrating palliative and ethics consultation into the ICU also reduces the burden of conflict and signals that clinicians do not need to carry these shared, complex decisions in isolation.
Training in serious-illness communication equips clinicians with language that helps navigate difficult discussions by framing recommendations around preventing suffering and honoring values rather than “doing everything possible.” Structured opportunities for reflection and Schwartz Rounds® can honor the emotional burden of ICU work. These should not be framed as wellness initiatives but instead as essential safety mechanisms for the workforce.1,3,5–8
For me, that patient’s death and her husband’s tears crystallized a painful truth: The emotional burden of this work does not end when a monitor goes silent. It lingers in the silence afterward, in the questions we ask ourselves in the dark. Did we do the right thing? Did we wait too long to talk about what mattered most?
If we are to sustain a workforce capable of meeting the immense demands of critical care, we must treat burnout as a signal that our systems are struggling to support humane end-of-life practices rather than as a personal shortcoming. By improving how we care for our dying patients—through earlier conversations, clearer processes, shared decision-making, and collective reflection—we honor our patients and their families, in addition to the clinicians who stand with them.
Caring for dying patients is not a symbol of defeat; it is among the most profound expressions of our vocation. To continue doing it well, we must allow ourselves and each other the grace, support, and structural protection needed to remain fully human in the face of inevitable loss.
Read more about burnout, mental health, and clinician wellness in CHEST Advocates.
References
1. Kok N, van Gurp J, van der Hoeven JG, Fuchs M, Hoedemaekers C, Zegers M. Complex interplay between moral distress and other risk factors of burnout in ICU professionals: findings from a cross-sectional survey study. BMJ Qual Saf. 2023;32(4):225-234. doi:10.1136/bmjqs-2020-012239
2. Department of Human Services. Moral distress. Commonwealth of Pennsylvania.
3. Rosenwohl-Mack S, Dohan D, Matthews T, Batten JN, Dzeng E. Understanding experiences of moral distress in end-of-life care among US and UK physician trainees: a comparative qualitative study. J Gen Intern Med. 2021;36(7):1890-1897. doi:10.1007/s11606-020-06314-y
4. Maeckelberghe E. Moral distress: Ethically appropriate actions. Eur J Public Health. 2021;31(suppl 3):ckab164.455. doi:10.1093/eurpub/ckab164.455
5. Morley G, Ives J, Bradbury-Jones C, Irvine F. What is “moral distress”? A narrative synthesis of the literature. Nurs Ethics. 2019;26(3):646-662. doi:10.1177/0969733017724354
6. Advancing Health Communications. How should we address moral distress and burnout in ICU workers? Centre for Advancing Health Outcomes. January 4, 2018.
7. Guttormson JL, Calkins K, McAndrew N, Fitzgerald J, Losurdo H, Loonsfoot D. Critical care nurse burnout, moral distress, and mental health during the COVID-19 pandemic: a United States survey. Heart Lung. 2022;55:127-133. doi:10.1016/j.hrtlng.2022.04.015
8. Nelson, C. The effect of providing end of life care on the mental health of critical care nurses. San Jose State University Master’s Projects. 2023:1295. doi:10.31979/etd.tsyc-xj9z
9. Davydow DS, Zatzick D, Hough CL, Katon WJ. A longitudinal investigation of posttraumatic stress and depressive symptoms over the course of the year following medical-surgical intensive care unit admission. Gen Hosp Psychiatry. 2013;35(3):226-232. doi:10.1016/j.genhosppsych.2012.12.005
10. Critical care experts to outline strategies for coping with loss, burnout. CHEST Physician. September 12, 2023.
