When the demand for care, supplies, and lifesaving equipment exceeds availability, these necessities must be carefully allocated. During such times, decisions about care will likely be made rapidly under a triage system. The traditional ethical foundation for decision-making during triage is utilitarianism, which aims for outcomes that provide the greatest good for the greatest number of people.1,2,3,4
In ordinary circumstances, nurses are duty-bound to provide beneficent care for their patients. This foundational duty remains, even in situations where crisis standards of care and triage are necessary. However, in these situations the duty to perform only well-intended actions for the patient must shift from a focus on the individual patient to a focus on the general public. 1,2,3,4
Few clinicians, and very few patients and their families, have expertise in the nuanced ethics of triage. During the COVID-19 pandemic, clinicians may be forced to make heartbreaking decisions under circumstances they have never faced before. In actuality, normally expected standards of care cannot be met in every situation or for every patient in times of crisis. The implementation of triage systems under the umbrella of crisis standards of care will fluctuate depending on resource availability and demand.1,5 Because of this, some decisions made in dire circumstances may feel unfair or immoral to the healthcare team and the public. Skilled communication is key in educating the healthcare team and the public about how and why decisions are made.6
Even when nurses and other members of the healthcare team are working under crisis standards of care, it is important that all patients receive compassionate end-of-life care.1,3 This is necessary for the well-being of patients, patients’ families, and those caring for them. The communicability of COVID-19 makes end-of-life-care especially challenging. Every effort to alleviate physical and emotional pain and provide other comfort must be made, even if this can only be a compassionate presence and recognition of the personhood and value of that patient. Nurses have always cherished their roles as advocates for patients and their families. Now, because of isolation requirements that restrict all visitors, they may also be called upon to offer final words of comfort and serve as caring witnesses at the end of a patient’s life.
Healthcare institutions have a duty to ensure that decision-making under crisis standards of care be fair, ethical, legal, transparent, and compassionate. Institutions must also ensure that decision-making in triage situations is shared so no clinician bears this burden alone. Effective communication is crucial at all times.6 Institutions must institute guidelines and education about triage and end-of-life care so nurses and other members of the healthcare team fully understand considerations and consequences. Nurses must strive, as always, to provide patients with the best end-of-life care possible, especially in these unprecedented times.
Recommended Actions for Healthcare Institutions
Every organization must:
- Recognize the Three Ethical Duties of healthcare leaders in responding to COVID-19:
- Duty to plan—Manage uncertainty, especially regarding staff, space, and supplies.
- Duty to safeguard—Support workers and protect vulnerable populations.
- Duty to guide—Use contingency levels of care and crisis standards of care to guide fair allocation of resources.2
- Ensure that vulnerable populations are treated fairly under a triage system.1,2,3,4,5 A decision support framework may help with this.7
- Use crisis communications strategies to provide clear and understandable explanations for healthcare teams, patients, and patients’ families regarding how triage is considered and conducted.4
- Incorporate palliative interventions for end-of-life care into the planning and implementation of crisis response plans.
- Offer palliative care education for clinicians serving in unfamiliar situations who may not have developed end-of-life care skills.
- Provide debriefing and support for all clinicians at regular intervals to help them deal with the moral distress of decision-making in triage and crisis situations.
- Put systems in place to guarantee that all clinicians operating under crisis standards of care or triage systems are operating within legal and regulatory parameters.
- Maintain ready availability of ethics consultants and triage teams to ensure the burden of decision-making is shared.
- Establish policies for respectful care for the dead, and ensure that patients’ loved ones are informed of that care.8
Recommended Actions for Nurses
- Hone communication skills regarding decision-making under crisis standards of care in order to better explain those decisions to patients and their families.9
- Be honest and transparent in all communications to patients and their families regarding the plan of care and other relevant information.4,7
- Use cell phones, tablets, letters, and other methods to build relationships and help family members stay in touch or say good-bye to a loved one. Remember that family members may not be emotionally prepared to see their loved-one. If there has been a sudden physical decline, consider using nonvisual communication.10
- Apply palliative and end-of-life care knowledge and skills to provide patients with the comfort, compassion, and dignity they deserve.11
- Embrace flexibility and creativity. Even those who are well versed in palliative and end-of-life care will likely find that best practices are not possible in a crisis.10
AACN has a webpage on Palliative & End-of-Life Care to provide nurses with articles and other support materials.
- National Academy of Medicine. Crises standards of care: a systems framework for catastrophic disaster response. Washington, DC: The National Academies Press, 2012.
- Berlinger N, Wynia M, Powell T, et al. Ethical framework for health care institutions & guidelines for institutional ethics services responding to the coronavirus pandemic: managing uncertainty, safeguarding communities, guiding practice. The Hastings Center. March 16, 2020. Accessed April 13, 2020. https://www.thehastingscenter.org/ethicalframeworkcovid19/
- American Nurses Association (2015). Code of ethics for nurses with interpretive statements. Silver Spring, MD, 2015 Retrieved from http://nursingworld.org/code-of-ethics
- Repine TB, Lisagor P, Cohen DJ. The dynamics and ethics of triage: rationing care in hard times. Mil Med. 2005;170(6):505-509.
- American Nurses Association. Crisis standards of care COVID-19 pandemic. https://www.nursingworld.org/~496044/globalassets/practiceandpolicy/work-environment/health--safety/coronavirus/crisis-standards-of-care.pdf
- Barden C, Cassidy L, Cardin S, eds. AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence. 2nd ed. Aliso Viejo, CA: American Association of Critical-Care Nurses; 2016. Accessed April 13, 2020. https://www.aacn.org/nursingexcellence/standards/aacn-standards-for-establishing-and-sustaining-healthy-work-environments
- White DB. A model hospital policy for allocating scarce critical care resources. University of Pittsburgh School of Medicine. Published March 23, 2020. Accessed April 13, 2020. https://www.ccm.pitt.edu/sites/default/files/ UnivPittsburgh_ModelHospitalResourcePolicy.pdf
- Minnesota Department of Health. Crisis Standards of Care Ethical Checklist. April 2020. Accessed April 13, 2020. https://www.health.state. mn.us/communities/ep/surge/crisis/checklist.pdf
- Vital Talk. COVID ready communication playbook. Accessed April 13, 2020. https://www.vitaltalk.org/guides/covid-19-communication-skills/
- Norieka D. End-of-life care in the time of COVID-19. VCU Health Continuing Education. Virginia Commonwealth University. April 6, 2020. Accessed April 13, 2020. https://vcu.cloud-cme.com/default.aspx?P=0&EID=17987 [click “Tests” box].
- American Association of Colleges of Nursing. ELNEC support for nurses during COVID-19. Accessed April 13, 2020. https://www.aacnnursing.org/ELNEC/COVID-19