The issue of moral distress is nothing new in healthcare, but the COVID-19 pandemic has amplified the problem.
“Very few people have had the time to consider what shifting standards of care will look like during a pandemic. We are by necessity doing things very differently. That does not mean it is wrong,” says Lucia D. Wocial, PhD, RN, FAAN, HEC-C, a nurse ethicist at Fairbanks Center for Medical Ethics at Indiana University Health.
Clinicians know that good end-of-life care does not mean excluding family members from being with patients.1 “Even if a video connection can be set up, it is a poor substitute for direct contact with a family member,” Wocial says.
Visitor restrictions mean some patients are dying alone. “There have been real tragedies where people are literally brought to the emergency room by family who never see the person alive again,” Wocial says.
Some clinicians found themselves working in unfamiliar locations and without enough supplies. “You have to get up to speed really fast, and the stakes are high,” Wocial notes.
In the context of all this, there may be clinicians who believe they cannot meet ethical obligations to patients. “The stress on clinicians is enormous. Everybody is working harder than they’ve ever had to work in the past,” Wocial observes.
It is counterintuitive for healthcare providers to slow down during an emergency. “Yet we need them to do that,” Wocial offers. “There are difficult ethical questions every moment of every day, and that’s exhausting.”
Ethicists can support clinicians with moral distress in specific ways, according to Wocial:
• Emphasize that protecting themselves is not unethical. Clinicians are choosing between patient care and their own safety. Ethicists can help clarify what is at stake.
If a clinician intubates someone without proper PPE, it might have been helpful for that one patient. But there is a bigger picture. “You put yourself at risk. If we lose you, that’s one more person we’ve lost on the front line,” Wocial says.
• Explain the ethical justification for refusing CPR. Emergency department providers have asked ethicists what they should do if an actively dying patient arrives. They ask this specific question: If the physician can make a reasonable judgment that the patient cannot recover, is it ethically permissible for him or her to not perform CPR, even if the family wants the team to try?
“With limited PPE and looming ICU [intensive care unit] shortages, that is an ethically permissible position to take,” Wocial says.
Refusing to perform CPR in this situation may feel unethical. “It doesn’t mean you’ve done anything wrong,” Wocial explains. “It means you had to make a tough choice in an ethically challenging situation.”
Still, there are clinicians who may struggle with the decision. “Ethicists can say, ‘What you’re doing is good, and here’s why, from an ethics standpoint,’” Wocial suggests.
• Give a name to what clinicians are feeling. Simply learning what “moral distress” means, and understanding that many others are suffering from it as well, is comforting. “We expect people to experience it because these are very ethically challenging times,” Wocial says.
• Encourage clinicians to make self-care a priority. “Failing to take care of ourselves will not serve us or our patients well in the long run,” Wocial notes.
Staff at the University of Rochester (NY) Medical Center did not have to make allocation decisions. The hospital never was overwhelmed with COVID-19 patients, reports clinical ethicist Marianne C. Chiafery, DNP, PNP-BC. Nurses also had enough PPE to be protected while at work, so that was not an issue. However, clinicians experienced moral distress over these specific concerns:
• Staff worried about bringing the virus home. “Our hospital supplied staff with scrubs that they can change out of before going home, which helped,” says Chiafery, associate professor of clinical nursing at University of Rochester’s School of Nursing.
Still, nurses were conflicted between meeting their professional obligation to not abandon patients in need and possibly harming their own family members. “The tension between personal safety concerns and professional obligations weighs heavily,” Chiafery says.
• Staff struggled with caring for critically ill patients who were isolated from loved ones. Ethicists explained that there are no “good” options in this situation. If nurses allowed visitation for COVID-19 patients, others would be put at risk. “We acknowledge that while not allowing visitors feels wrong, the least bad option is to restrict visitors,” Chiafery says.
Next, ethicists pointed out there are ways to mitigate harm, and help patients and families in this awful situation. Nurses make more frequent phone calls to family, and offer patients computer and phone access 24/7. “Staff spend more time at their bedside just being with them,” Chiafery reports.
Palliative care colleagues found a way to help, too, by developing scripts to use for goals of care discussions. “These are hard even when everyone can talk face to face,” Chiafery says. “Losing that in-person contact made it more challenging.”
• Staff struggled with comforting patients and family. Not being able to physically comfort patients is “a painful realization” for many staff, Chiafery says.
One physician noted that in talking to a new mother about her premature baby, he normally would reach out with a comforting touch to the shoulder. Not being able to perform this simple gesture bothered him greatly. “To this physician, it violated his sense of who he is a healthcare provider, and how he demonstrates that concern to those in his care,” Chiafery says.
Just hearing other colleagues express the same concern was reassuring. Ethicists also stressed the importance of eye contact as a way to connect. They also recommended that staff convey their feelings. Chiafery explained it this way to staff: “It’s OK to say to a patient or family, ‘I understand your frustration with this situation, because I feel the same. I wish things were different.’”
- Wakam GK, Montgomery JR, Biesterveld BE, Brown CS. Not dying alone - Modern compassionate care in the Covid-19 pandemic. N Engl J Med 2020; Apr 14. doi: 10.1056/NEJMp2007781. [Epub ahead of print].