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Ethics and personal safety on the frontlines of COVID-19

Author(s): Eileen Weber, DNP, JD, PHN, RN

To: Ethics Inbox   

From: Concerned ED nurse

Subject: Becoming ill with COVID-19

I’m an emergency department (ED) nurse and worry about becoming critically ill from coronavirus disease 2019 (COVID-19). Despite years of pandemic anticipation and months of awareness that a new coronavirus had pandemic potential, the American healthcare system was massively unprepared to detect infection, protect frontline healthcare workers, or develop a safe, reliable vaccine. What happens to me if I get COVID-19?

From: ANA Center for Ethics and Human Rights

The American Nurses Association (ANA) supports all nurses as they respond to cases of COVID-19 and is tirelessly advocating for the best scientifically based protection, increased testing capacity, and rapid vaccine development. We are deeply saddened by reports of nurses and all other healthcare professionals who have become infected with COVID-19 and, even worse, who have died. It is both a moral and strategic imperative for our nation’s leaders to do everything possible to arm and protect nurses and other critical responders in addition to maintaining a supply of medical supplies and life-saving equipment.

Crisis standards of care

Conventional standards of care govern our usual practice to prioritize evidence-guided care reflecting each patient’s understood needs, values, and preferences. What happens when medical supplies are limited? In a scenario where ventilator scarcity crosses a pre-determined threshold, such as 15% or 20% of a region’s available supply, crisis standards of care (CSC) might be triggered. In this scenario, CSC prioritizes communal benefit, sometimes stated as “the greatest good for the greatest number.”

Should a nurse become critically ill, his or her care depends on which CSC triage framework for allocating resources governs that care. Some authorities argue that logic and fairness dictate that healthcare workers should receive priority for life-saving treatment. These authorities assert that the frontline worker deserves the ventilator for two main reasons: the need for such workers in the continued fight against the pandemic until we get a vaccine and the reciprocal obligation owed workers who have been involuntarily exposed to extraordinary risk of harm.

Other authorities argue that only prognosis should govern triage, and should be determined by random selection, like a lottery, that gives each patient an equal chance of being rescued. These authorities argue that workers given a ventilator may not recover well enough or quickly enough to assist in the prolonged fight against COVID-19, so prioritizing them isn’t justified. If a triage team determines that several people have roughly the same prognosis, getting priority treatment is up to chance.

Duty to care

Does an ED nurse have a duty to sacrifice his or her own health and personal safety? According to several authorities, nurses have a duty to care, but nurses’ employers also have a duty to prepare for crisis situations, especially foreseeable ones like the COVID-19 pandemic.

Self-sacrifice is unsustainable. Our Code of Ethics for Nurses with Interpretive Statements (the Code), and recent guidance, Nurses, Ethics and the Response to the COVID-19 Pandemic, agree. The Code states, “the nurse’s primary commitment is to the patient,” but also that “the nurse owes the same duty to self as to others.” ANA’s pandemic guidance asserts, “Nurses must continue to advocate for systems and protocols that protect their ethical obligations as nurses, as well as ensure equity and fairness to all concerned in times of pandemics.” Nurses should ask employers and policymakers how that equity and fairness will be extended to them after the extraordinary risk they have been forced to shoulder.

— Response by Eileen Weber, DNP, JD, PHN, RN, member of ANA’s Center for Ethics and Human Rights Advisory Board

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