Problem
The COVID-19 pandemic has altered the delivery of patient care. Patients with severe COVID-19 pneumonia are managed with endotracheal intubation and mechanical ventilation and have a high case fatality rate. During the pandemic, symptom management at the end-of-life has required revisions due to logistical challenges such as medication shortages and preservation of personal protective equipment. Due to the high risk of infectious transmission, family members may not be permitted to see loved ones who are hospitalized. Furthermore, family meetings are primarily virtual. Meanwhile, health care providers are struggling from high physical workload demands while simultaneously experiencing moral and psychological distress. Clinicians working with patients with COVID-19 voice concerns about the risk of infecting self and family and stress due to constant change as health care systems evolve to meet patient needs during a pandemic situation. Patients without COVID and hospitalized for other reasons are required to endure the same restrictions regarding family visitors as those with COVID. This has resulted in some procedures being postponed or limited and has altered the way nursing care and interventions are carried out. Patients must endure the loneliness of undergoing surgery or other procedures without the support of having family with them.
Case Scenario
You work as a staff nurse in an oncology surgery unit. K.M. is a 37-year-old woman who is one day postoperative from a mastectomy for an invasive ductal carcinoma of her left breast. There is an outbreak of COVID-19 within your community. K.M. does not have COVID-19 and the surgical unit where you work has been designated to manage patients without COVID-19; nonetheless, a no visitor policy is enforced throughout your hospital and K.M. may not receive any visitors. When you enter K.M.'s room to perform your baseline assessment, you find her crying. She says to you, "This is terrible. When my sister had a mastectomy 3 years ago, she was able to have breast reconstruction done at the same time. I did not have that choice because only the mastectomy was considered essential-the reconstruction was considered elective! I have to wait before I can have that done and go through surgery all over again! It is so unfair! And it is so unfair that my husband had to drop me off at the curb and cannot be with me! He is worried sick!" K.M. is not the only patient you have cared for during this pandemic who has faced obstacles receiving what had previously been considered standard care. Additionally, many of your patients have voiced anger, frustration, anxiety, and fear because their loved ones are barred from being able to visit them postoperatively.
Discussion
Access to health care resources can drastically change during a pandemic. Resources may be scarce not only for patients who are directly infected by the pathogen responsible for the pandemic, but for all patients. For instance, access to the services rendered by health care personnel (e.g., surgeons), facilities (e.g., surgical centers, operating rooms), pharmacologic agents, medical devices, to name a few, may all be disrupted or delayed because of societal needs to divert maximum resources to mitigate the effects of the pandemic. Diversion of these resources can result in a scarcity of resources considered as standard therapy during other times. The COVID-19 pandemic has caused disruptions to and delays in access to care for many patients with breast cancer, as well as patients with other cancers.
Task
A. Describe the ethical principles that are in conflict in this case.
B. K.M. feels that she should have been eligible to have reconstruction done at the same time as her mastectomy. Her availability of choices and her personhood were arguably threatened by not being able to select her preferred surgical procedure. She might have elected to wait to have her mastectomy until such time as the breast reconstruction could have also been done; however, her risk of an adverse outcome related to her cancer would have been greater. Is it just to enforce these types of resource delays during a pandemic?
C. K.M. expresses frustration at not being able to see her husband postoperatively. Are visitor prohibitions during a pandemic so much a threat to beneficence that they should not be enforced? Or are these types of universal prohibitions justifiable?
D. What resources might you mobilize to assist you in caring for K.M. and other patients in similar circumstances?
E. How can you assure that your professional need to deliver quality care to your patients is not threatened? I can assure that my professional need to deliver quality care to my patients is not threatened by ensuring I follow protocol. I would make sure that I know and understand the safety polices. I would practice patient-centered care to help the patient achieve their goals with a positive outcome.
F. How can you preserve your own sense of self-worth?