Ethically Protecting Yourself and Patients

How Nurses Make Hard Decisions During a Health Crisis

By Jeanie L. Sauerland, MA, BSN, RN

AT FIRST GLANCE, traditional patientfocused care models may seem to conflict with public-health focused care models. Changing focus from one to the other, even when the change appears ethically supportable, may lead to moral distress. Nurses may face a dilemma, particularly if there are scarce resources available and the standard of care cannot be provided to all those who might benefit.

Health care leaders have an ethical obligation to develop policies and guidelines for use during a public health emergency. These duties include (1) a duty to plan and manage uncertainty; (2) a duty to safeguard and support workers and protect vulnerable populations; and (3) a duty to guide and develop contingency and crisis standards of care.

COVID-19 presents a unique set of challenges to nurses and other health care workers. Nurses, on the front lines fighting for patients, are also among the highest risk group for contracting the disease, particularly if there are shortages of personal protective equipment (PPE). 2 In this unique position, nurses need to protect themselves and the public through advocacy for the allocation of appropriate PPE and developing crisis standards of care.

CONFRONTING ETHICAL DILEMMAS

In an ethical dilemma, nurses face a problem in deciding between two moral

In the context of COVID-19, protecting oneself is protecting the patient and other community members.

priorities without an obvious solution. COVID-19, at first glance, may appear to present such a dilemma. The American Nurses Association (ANA) Code of Ethics for Nurses contains two provisions that may initially appear in conflict. 3 Provision Two states that the nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population. Provision Five of the ANA Code of Ethics states that the nurse owes the same duties to self as to others, including the responsibility to promote health and safety.

Some nurses may hesitate in providing care due to the risk to self, potentially placing the remaining nursing staff at greater risk. 4 Other nurses may be highly motivated to provide care, despite the risks to self. Whether or not the nurse has a moral obligation to act in a crisis is dependent on if:

• The patient is at significant risk of harm, loss, or damage if the nurse does not assist;

• The intervention or care is directly related to preventing harm;

• Care will probably prevent harm or loss; and

• The benefit the patient will gain outweighs any harm the nurse might incur and does not present more than an acceptable risk to the nurse. 5

In the context of COVID-19, protecting oneself is protecting the patient and other community members. A nurse exposed to COVID-19 while caring for a patient risks not only harm to self, but also spreading the virus to vulnerable populations, including other patients and family members.

Nurses must evaluate the risk-to-benefit ratio before engaging in care of CO- VID-19 patients. The duty to care remains in place and can be pursued safely if the nurses use the appropriate infection control measures, including the proper use of PPE.

TAKING LIFE-SAVING MEASURES

In April, the American Heart Association published interim guidance for life support for COVID-19. 2 “It is essential that providers protect themselves and their colleagues from unnecessary exposure. Exposed providers who contract COVID-19 further decrease the already strained workforce available to respond and have the potential to add additional strain if they become critically ill.” Strategies include donning appropriate PPE before entering the scene and limiting the number of personnel on the scene.

Perhaps the most effective measures that nurses can take in protecting themselves and others from the dangers of COVID don’t take place in the work environment.

• Hold leaders accountable to supply appropriate PPE and ensure staff members adhere to guidelines issued by the Centers for Disease Control and Prevention, the American Heart Association, etc.

• Encourage family members and the public to abide by public health policies to control disease transmission such as hand-washing and social-distancing.

• Advocate for early goals of care discussions regarding patient preferences during the COVID pandemic—particularly for people in high-risk populations.

• Acknowledge the physical and emotional toll of caring for others during a pandemic and seek out opportunities for self-care.

Supporting one another and advocating for our needs will protect both nurses and the public who depend upon our care.

While it is impossible to provide specific ethical guidance for every situation the nurse may encounter during the pandemic, nurses have the ability to draw upon their clinical training, critical thinking skills, and the support of peers and colleagues during this time. Supporting one another and advocating for our needs will protect both nurses and the public who depend upon our care.

REFERENCES

1. Berlinger, N., Wynia, M., Powell, T., et al. (2020). Novel Coronavirus SARS-CoV-2 (COVID-19) Guidelines for Institutional Ethics Services Respond to COVID-19. Managing Uncertainty, Safeguarding Communities, Guiding Practice. The Hastings Center.

2. Edelson, Sasson, Chan, et al. (2020). Interim Guidance for Basic and Advanced Life Support for Life Support for Covid-19. American Heart Association.

3. American Nurses Association (2015). Code of Ethics for Nurses with Interpretive Statements.

4. McNeill, C., Danita, A., Nash, T., Chilton, J., Swanson, M., (2020). Characterization of nurses’ duty to care and willingness to report. Nursing Ethics, 27(2), 348-359.

5. ANA Center for Ethics and Human Rights. (2015). Position Statement on Risk and Responsibility in Providing Nursing Care. American Nurses Association.