Accountable Healthcare - Shifting Ethics in a Crisis: Responding to COVID-19
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April 23, 2020

Shifting Ethics in a Crisis: Responding to COVID-19

As nurses, we often encounter ethically troubling patient care situations. In a pandemic, when there is supply rationing, crisis standards of care and the looming potential for triage protocols, we need to apply a different lens to determine what course of action is ethically appropriate

Crisis response is often defined in three stages, and we can anticipate ethical problems at each stage:

  1. Conventional:
    Our duty is to provide safe and ethical care for our patients and their families. We provide patient-centered care, which relieves suffering and respects patients’ references regarding their plan of care. We may experience distress when those preferences do not align with our own professional values.
  2. Contingency:
    At this stage, resources are limited but still present, and the supply can meet the demand. We make decisions about the care we provide in accordance with patient preferences as much as possible while also managing resources carefully. For instance, we might limit family visitation to conserve personal protective equipment.
  3. Crisis:
    At this point, the demand for resources exceeds the supply, and new rules apply. Healthcare teams shift to a utilitarian approach, doing the greatest good for the greatest number of people. The number of resources is fixed, so instead of basing decisions on patient wishes, decisions are based on an objective determination of how resources are best used. This stage is referred to as triage.

Shifting from the conventional stage to a crisis stage is likely to damage our moral integrity. Strategies that we usually rely on to resolve moral problems in the conventional phase may be less applicable during a crisis. Consider the following steps when you anticipate a shift in phases.

  • Get the facts – Communicate with all involved and clarify assumptions and biases. Review your hospital’s policies, and talk to clinical leaders so you understand the crisis standards of care and how triage decisions will be made. In some cases, an objective clinician or others not directly engaged in caring for patients assist with triage. Find out who will help you navigate your ethical concerns. 
  • Collaborate and communicate – Seek input and perspective from a trusted source, a mentor or the ethics committee in your organization. Bring together others who are similarly concerned. Share the facts you’ve learned and allow time for others to share what they know.
  • Speak up – Ask questions and raise concerns. We need to advocate for systems and protocols that protect our ethical obligations, ensure equity and preserve human rights. 
  • Be courageous and act boldly – Ethical practice takes courage and conviction. It isn’t easy.

The ANA Code of Ethics is the framework that guides our practice as nurses. We know that our primary commitment is to our patients. However, other provisions in the code of ethics speak to the duty we have to ourselves (provision 5) and to social justice (provision 9). During this time of crisis, these two provisions may be more applicable when you and your team are faced with crisis standards of care and scarce resources.

Remember, feeling morally compromised in a crisis situation is not a sign of weakness, but rather a clear demonstration of the strength of your moral integrity.

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