Moral Injury Among Transplant Providers: Evaluating the Effects of Training in End-of-Life Counseling.

Introduction: Ethical issues are pervasive in healthcare, but few specialties rival the moral complexity of transplant medicine. Transplant providers must regularly inform patients that they are no longer eligible to receive a potentially life-saving operation and the stress of these conversations poses a high risk of moral injury. Training in end-of-life counseling (EOLC) has proven to significantly reduce provider stress and burnout. The purpose of this study was to determine whether training in EOLC reduces levels of moral injury among transplant providers. Methods: This was a mixed methods study. We interviewed 10 patient participants and administered a survey to staff in the solid organ transplant department at the University of Kansas Health System. Respondents indicated whether they had received training in EOLC and completed the standardized Moral Injury Symptom Scale-Healthcare Professionals version (MISS-HP). A two-sample, one-sided t-test compared levels of moral injury between trained and untrained staff. Subsequently, we conducted semi-structured interviews with transplant providers, then performed inductive coding followed by thematic network analysis. Results: Thirty-seven percent (14/38) of respondents reported a moral injury score at or above the threshold for psychosocial dysfunction associated with moral injury. Analysis revealed no difference in moral injury scores between the trained and untrained groups (p = 0.362, power (1-β) = 0.842). Thematic network analysis demonstrated high-level themes of "challenges", "training", and "stress relief". Conclusions: Our study demonstrated a concerning prevalence of moral injury among transplant staff and suggested that EOLC training did not significantly mitigate the threat of moral injury.