Distress, defined as anxiety, sorrow, and/or pain, among nurses is a pervasive problem. When elevated or uncompensated, distress may contribute to deleterious consequences for the nurse, patient outcomes, the nursing profession, and society as a whole. Caregiver appraisal, or the cognitive process individuals use to mediate emotional reactions to any situation, may be positive, negative, or neutral. Associations between nurses' distress and caregiver appraisal when withdrawing life-sustaining treatment (LST) is being considered. Internal appraisal factors and nurses' distress are substantiated in multiple studies, and this information could ultimately contribute to interventions for nurses working with terminally ill patients. Guided by Cognitive Adaptation Theory, this study explores distress and caregiver appraisal patterns in nurses who provide LST in a Pediatric Intensive Care Unit (PICU) setting.