Background: Critical Care Providers (CCPs) experience situations that challenge their ethics and professional standards and may entail moral distress (MD). Aim: To analyze MD perceived by CCPs in intensive care units (ICUs) or emergency departments (EDs) and further clarify whether CCPs who rely on spiritual resources differ in their perception of MD from those who do not utilize these resources. Methods: A cross-sectional anonymous survey was administered using a modified version of the German language version of the Moral Distress Scale (MDS) with 2 × 12 items to assess the frequency and the respective perceived burden of specific situations by applying a 5-point Likert scale. Explorative factor analysis was performed and the sub-constructs of the respective items regarding MD frequency and burden were identified. Job burden and professional satisfaction were measured using visual analogue scales (VAS) and a four-point Likert scale, respectively. The 15-item SpREUK questionnaire was applied to measure spiritual attitudes and behaviours and to differentiate between religious and spiritual persons. Data from 385 German-speaking CCPs were included (55% physicians, 45% nurses). Results: Conflict situations are similar for physicians and nurses although they are perceived as more burdensome by nurses. Among physicians, the MDS factor Looking away/Resignation scores highest for assistant physician residents, whereas distress caused by looking away is more often perceived by specialist physicians without a managerial position. Work satisfaction is inversely associated with MD and emotional exhaustion is positively associated with it. Participants’ spirituality is marginally associated with MD. The best predictors of both MD frequency and burden are emotional exhaustion with further influences of work satisfaction, being a nurse, and being a non-believer on the frequency of MD perception. Being a nurse, participants’ experience in ICU/ED, and being of the male gender are further predictors of MD burden. Conclusions: MD is experienced differently by different groups of CCPs depending on their place in the hierarchy of responsibility. As MD perception is best predicted by emotional exhaustion, these situations should be avoided. Although some CCPs may rely on spiritual resources, all need individual and team support to cope with MD.

Anamnese und klinischer Befund: Eine 18-jährige Schülerin mit Kopf- und Gliederschmerzen, Fieber, Erbrechen, Diarrhö und orthostatischer Synkope wurde wegen eines akuten Nierenversagens aus einer auswärtigen Klinik zu uns verlegt. Die Patientin war somnolent, der Blutdruck betrug 90/60 mmHg, die Herzfrequenz 104/min, die Körpertemperatur 39,1˚C. Am Körperstamm fiel ein sonnenbandähnliches Exanthem auf. Untersuchungen: In den Laboruntersuchungen fanden sich niedrige Werte für Thrombozyten und Kalzium, sowie erhöhte Werte für Leukozyten, C-reaktives Protein, Kreatinin, Bilirubin, Transaminasen, Kreatinkinase und Laktat. Das Röntgenbild zeigte diffuse Verschattungen, die Patientin war hypoxisch. Im rechten Unterbauch ließ sich durch bildgebende Diagnostik eine walnussgroße Raumforderung abgrenzen. Die mikrobiologischen Befunde waren außer einer vaginalen Besiedlung mit »toxic-shock-syndrome-toxin-1«-(TSST-1-)bildendem Staphylococcus aureus unauffällig, der Serum-Antikörpertiter gegen TSST-1 war kleiner 1:25. Diagnose, Therapie und Verlauf: Auf Grund einer Assoziation mit Menstruation und Tamponbenutzung vermuteten wir ein toxisches Schocksyndrom (TSS) mit Multiorganbeteiligung. Ein noch liegender Tampon wurde entfernt. Die iliakale Raumforderung erwies sich laparoskopisch als Hämatom. Da eine bakterielle Sepsis nicht auszuschließen war, behandelten wir mit einer breiten Antibiose, die übrige Therapie war symptomatisch. Die Patientin erholte sich innerhalb von acht Tagen vollständig. Die charakteristische Hautschuppung bestätigte die Diagnose des Toxischen Schocksyndroms (TSS). Folgerungen: Die Diagnose des TSS ist in der Akutphase mit Unsicherheiten behaftet. Die Initialsymptome sind unspezifisch und erlauben zahlreiche Differentialdiagnosen. Eine Bestätigung der Diagnose ist - wenn überhaupt - erst in der Rekonvaleszenzphase anhand der Hautschuppung oder eines Anti-TSST-1-Antikörper-Titeranstiegs möglich. Zur Abgrenzung eines nicht-menstruellen TSS ist auch bei Assoziation mit der Menstruation eine Fokussuche erforderlich. History and admission findings: An 18-year-old schoolgirl was reffered for admission by another hospital because of headache, joint pains, fever, vomiting, diarrhoea and orthostatic syncope associated with renal failure. On admission he was somnolent with a blood pressure of 90/60 mmHg, heart rate of 104 beats/min and a slight fever of 39,1˚C. A sunburn-like skin rash was noted. Investigations: Laboratory tests indicated low levels of platelets and calcium, increased levels of white cells, C-reactive protein, creatinine, bilirubin, transaminases, creatinekinase and lactate. Chest X-ray demonstrated diffuse shadows, while other imaging revealed a space-occupying lesion, ca. 3 cm in diameter, in the right lowere quadrant of the abdomen. The patient was hypoxic. Microbiology revealed vaginal colonies of Staph. aureus (producing toxic shock syndrome toxin 1 [TSST-1]). Serum antibody titre against TSST-1 was less than 1:25. Diagnosis, treatment and course: A toxic shock syndrome (TSS) with multi-organ involvement was suspected because of the association of menstruation with the use of tampons. An inserted tampon was removed. At laparoscopy the space-occupying lesion proved to be a haematoma. As bacterial septicaemia could not ne excluded broad-spectrum antibiotics were administered together with symptomatic measures. The patient fully recovered within a week. The characteristic skin desquamation confirmed the diagnosis of TSS. Conclusion: In its acute phase the diagnosis of TSS is often uncertain. The initial symptoms are nonspecific and numerous conditions need to be considered in the differential diagnosis. The diagnosis can be confirmed, if at all, only in the convalescent phase by the skin desquamation or a rise in anti-TSST-1 antibody titre. A search for a focus of infection is essential for differentiation from a non-menstrual TSS, even if there is as association with menstruation.