Tools · ACT

Reflect on a clinical decision that stays with you

Review the information and conditions around a clinical decision

Go to the questions →About 15–20 minutes · Every question is optional

Use this for a clinical decision you already made and are still thinking about. Separate the outcome, the decision as you understood it then and the conditions you were working in. Keep every answer general enough that it cannot identify a patient, colleague or institution. A fictional clinician writes, “I am still thinking about a discharge decision.” They describe the information and options available at the time, then separate those from what became known later. They leave out the diagnosis, date, location and other details that could identify a person.

Before you type anything

What happens to what you type

This worksheet does not send, save, or track anything you type. Entries stay in the page until you clear it or leave. Your own browser, keyboard, or extensions may still process what you type, so do not enter anyone's name or identifying details.

What this tool can't do

Any patient's care, diagnosis, treatment, or an active clinical decision
A morbidity and mortality review, incident report, quality review, root-cause analysis, complaint response, or any part of a formal process
Legal, regulatory, licensing, insurance, or professional-conduct advice, or any document intended to be disclosed
Assessment, screening, diagnosis, or measurement of burnout, moral injury, depression, PTSD, or any condition in yourself
Entering patient information, colleague names, institution-identifying details, or anything about a case that could identify a person

When to stop and use another route

Stop and use the real process if a patient-safety issue, disclosure obligation, reporting duty, or error requiring correction is involved. This worksheet is not that process and does not replace or delay it.
Stop if working through this increases distress rather than clarity. Distress that persists, worsens, or affects your functioning or safety is a reason to speak with your physician, your provincial physician health programme, or a colleague you trust — not a reason to complete a worksheet.
Stop if you find yourself writing anything that could identify a patient or colleague, and clear the page.

The questions

The whole exercise stays visible, and every question is optional. Start with the question that catches something useful, leave anything blank, and stop when the exercise stops helping.

Describe the decision and outcome in general terms

Start with the plainest possible account. Keep it general enough that nobody could be identified from it, including by you later.

What kind of decision was it?
One line, in general terms. No patient details, no names, no institution, nothing that could identify anyone. "A discharge I was not comfortable with" is enough.
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What outcome are you still thinking about?
Use a broad description without details that could identify anyone. You do not need to recreate a clinical record.
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Record what you knew and could change at the time

The outcome, the decision, and the conditions are different things. They are usually felt as one. Separating them does not decide anything; it makes the question you are actually asking visible.

What did you decide, with what you knew at the time?
The decision as it looked from inside it, before the outcome was known. Resist writing it with hindsight.
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What affected your options at the time?
For example: time, staffing, access, beds, transport, policy, competing demands or information you could not obtain. Keep the description general.
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Which of those conditions were actually yours to change in that moment?
Not what you could influence over months. What was within your control at the time you had to act.
Most of them — the decision was largely mine to shapeSome of themFew of themAlmost none — I was choosing between options someone else had narrowed

Identify what concerns you now and who could help

A decision keeps its weight when something you care about was at stake. Naming the value tends to be more useful than settling the verdict.

What professional responsibility or value were you trying to protect?
For example: taking a patient's concern seriously, avoiding preventable harm or treating people fairly. Describe what mattered to you.
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What feeling or question is still troubling you?
You might notice regret, anger, doubt or grief, or more than one. Write only what helps you think.
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Does your concern relate mostly to the outcome, your decision or the conditions?
Choose the closest description, or leave it unresolved. This is your interpretation of your account, not a finding about the decision.
Mostly in the outcome — a hard thing happenedMostly in the decision — I would decide differently now with the same informationMostly in the conditions — I could not act on what I believed was rightI cannot separate them yet
What is one thing you will do next?
Small enough to actually do this week, and consistent with the value you named. Talking to someone counts. So does deciding to raise a condition through the proper channel.
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Which kind of colleague or support service could you speak with?
Write a role or service, such as a trusted colleague, supervisor, your physician or a physician health programme. Keep names and case details out of this worksheet.
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What you have so far

Builds as you type

What you separated

Your own words, arranged so the three strands stay apart. There is no score and no conclusion here — the reading is yours.

THE DECISION: No entry yet
OUTCOME: No entry yet
DECISION AS IT LOOKED THEN: No entry yet
CONDITIONS: No entry yet
VALUE AT STAKE: No entry yet
STILL CARRYING: No entry yet
NEXT: No entry yet

This is a structured copy of your own entries. The tool does not score, interpret, diagnose, predict, or recommend.

Keep it or clear it

There is no submit button. Use Print if you choose to keep a copy, then Clear before leaving.

Before you use this to make a decision

If this identifies a patient-safety issue, reporting duty or correction that needs action, use the proper process. If distress persists or affects your functioning, speak with an appropriate colleague or health professional. This reflection does not decide whether the clinical decision was correct.

Sources and limitations

What the evidence does not establish

This produces no score, classification, or recommendation, and does not assess or diagnose anything about the person completing it. It reaches no judgement about whether the decision was correct.
Separating outcome, decision, and conditions is a way of thinking, not a finding. Real situations rarely divide cleanly, and a decision can be sound and still cause harm.
Moral distress is described in the literature as strain arising when a clinician cannot act on professional values because of external constraints. Recognising that pattern in your own account is not a determination that it applies to you.
Nothing here addresses whether the conditions you worked inside were acceptable, or what should change about them. That is a question for the people accountable for those conditions.
A worksheet cannot substitute for supervision, a trusted colleague, a physician health programme, or clinical care.

The sources behind the structure

Mackel et al. — Moral distress and moral injury among attending neurosurgeons (Neurosurgery, 2022) ↗Defines moral distress as the strain a clinician faces when unable to uphold professional values because of external constraints, and reports its frequency and consequences in a surveyed physician population.
Olson — Physician's occupational distress: burnout or moral injury? (Mayo Clinic Proceedings, 2024) ↗Examines why the distinction between burnout and moral injury matters, including what each implies about where a remedy belongs.
Djukic, Ranney and Maguen — Physician moral injury during the COVID-19 pandemic (Journal of General Internal Medicine, 2025) ↗Qualitative study identifying insufficient resources and conflict between patient needs and institutional constraints among the main sources of physician moral injury.

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