Ethical Obligations on COVID-19

My name's Marian Altman. I'm a clinical practice specialist with the American Association of Critical-Care Nurses. It is my pleasure today to have a conversation with Dr. Connie Ulrich, who is a fellow in the American Academy of Nursing. She is the professor of nursing at the University of Pennsylvania, where she is the Lillian S. Brunner chair of med-surg nursing. She's also a professor of bioethics at the Perelman School of Medicine, where she was the first nurse bioethicist. Dr. Ulrich's research examines ethical challenges that we healthcare providers face in our work with patients and their families.

Dr. Ulrich, I really want to thank you for taking your time to share your expertise with AACN's membership during this unprecedented time where nurses are practicing in such difficult circumstances.

Well, thank you so much, Marian. It's just a pleasure to be here, and it's a pleasure to speak to the ethical challenges that many nurses are facing on the frontline. So thank you for having me. I really appreciate it.

Nurses are very stressed because they are caring for their patients, but yet they also have that concern of, am I going to take this virus home to my families, my loved ones, the people that I live with? The American Code of Nurses have an ethical framework that guides all of our practice, but how do we apply that code of ethics during the COVID-19 pandemic?

I do think that as this crisis has hit us in a pandemic, this document has become foundational, and a foundational guideline for us to support us during this time. I don't believe, and I've said this before, that the code really tells us exactly what to do in a pandemic, but I do believe that the guidelines keep us grounded in what we ought to do and how we ought to conduct ourselves with patients and families and the community. I believe if you look at the statements, the statements that the code professes are very profound because I do think they help us think about how should we cope with this crisis? As you indicated, Marian. Because the code indicates several things. First of all, it tells us our primary commitment is to the patient; it is to the family; it is to the community.

And so we are to treat everyone under our care with respect and dignity for their worth and to advocate for and to protect the health and safety of our patients during that time. And we have seen that in so many ways today with the nursing profession. And I am just so proud to be a nurse, and I'm very proud to see how nurses are caring for COVID-19 patients. I mean, it could simply be by holding someone's hand, wearing protective gear at the end of life when that patient is isolated and alone in an intensive care unit, right? That is showing dignity and worth and respect for that particular patient and doing all that they can, recognizing that the family member can not be there in that intensive care unit. So I think that the statements are really profound.

And one of the other statements that I think is really important here is that we are also called to speak to the ethical environment of our employment or our institution and the conditions of that employment that provides safe care to our patients. So within that ethical environment, we are really called to be advocates. And I think that means not only advocating for our patients but also advocating for ourselves. Why should we, as nurses, expect that our institutions are there to protect us and to provide us with the adequate resources that are needed for quality and safe care delivery? I think that is an expectation, and that's a moral and ethical expectation that we should have of our institutions.

And we have every right to voice our concerns when we are not protected and need to be protected for our patients and their families.

Dr. Ulrich, the code of ethics, it discusses the benefits to the patients, but it also discusses the risk to the nurse. And one of the codes specifically addresses that we need to take care of ourselves, just like we have an obligation to take care of our patients. We do have that obligation to take care of ourselves. So what advice do you have for nurses on how they need to weigh the benefits to the patient versus the risks to themselves?

The American Nurses Association does outline four criteria that need to be met with respect to caring for patients. And here they argue that we have a moral or ethical duty to care for patients if all four of these criteria are met. And those criteria include that the patient, for example, is at significant risk of harm or loss or damage if the nurse does not assist with regards to that patient care, or that the nurse's intervention or care is directly relevant to preventing a harm to the patient, the nurse's care will probably prevent harm, loss or damage to the patient, and the benefit that the patient will gain outweighs any harm that the nurse might incur and does not present more than an acceptable risk to the nurse. Because how do you define acceptable risk? I think that's the challenge that we have.

So I also think that we have to work with our colleagues, we have to work with our institutions, on the policies that might guide these decisions. And certainly, nurses need to be part of these discussions. Nurses have to be at the table because they are the individuals who are implementing these particular policies. I think nurses also, if there is this concern about the risk and how we're thinking about the risk to the nurse, they certainly should seek out other resources that might help them work through that risk, such as an ethics consultation, to discuss the risk level that one might occur and how to balance that with the resources that one might need to be available to protect themselves, and also certainly to speak to clinical leaders on the unit and other types of resources that might help you work through what you believe that risk actually is to you.

What recommendations do you have for a nurse if they feel that the systems to protect them are failing, and yet they also they feel that obligation that's in the code of ethics to their patients and to their families? What do you recommend for a nurse to do other than contact some of the resources that you just described?

The nurses do have a professional and ethical duty to speak out by using their voice if there is something that is concerning to them and represents a safety concern on their particular unit or within the hospital or institution in which they work. Unfortunately, I think sometimes that there is a disconnect between administration and those on the front lines of care delivery. I think we need to do better at trying to closing that communication gap through honest and transparent communication on what nurses and others clinicians are actually experiencing and the types of support that they need.

Sometimes, I think it might be a matter of education, educating those individuals who do not have the background that nurses and physicians have by including them, for example, in rounds, in clinical rounds, so that they can see firsthand what those ethical challenges are and how to move forward when differences or conflicts arise within that particular institution or related to a patient or a family, whatever that ethical issue might be. We should not be afraid to say that, "I believe there is a problem here, and what can we do about that particular problem? How can we work to resolve this ethical issue, and what resources are available to me to do so?" And I think we need to be better at having those kinds of conversations.

I mean, I also think certainly looking at the literature is helpful as the issues change every day, and the top scientists and ethicists and nurse bioethicists are trying to address these issues for their respective constituencies, which I'm trying to do as well. So I think we have to work collaboratively with our physician colleagues and others to discuss these issues we're facing and to develop strategies and plans on how to address them. Nurse bioethicists such as myself are really here to advocate for the concerns of nurses across the country, to shed light on their ethical concern so that we can build a stronger system in the future and the support that our nursing colleagues need in the process to better care for patients and their families.

Is there any other information that you'd like to share?

I do hope that we can learn lessons going forward. We absolutely have to address the moral failures, and we know there were moral failures such as the lack of personal protective equipment and we using equipment or, in some instances, as I said, buying our own safety gear to bring to work, such as goggles and other types of equipment. But I think we also have to think about, what are the moral successes here that we can point to? We have saved many lives, and that is terrific and a wonderful thing. We have stayed with our patients. we've seen nurses stay with their patients during very frightening times for them as well as for their patients.

They've never given up, they've worked through the exhaustion, they've worked through the pain, they've worked through the suffering that so many have experienced. So for this, I think we absolutely have to be grateful, and we have to think about their needs, and we have to hear their voice in the future so that we can build a better system.