The coronavirus disease 2019 (COVID-19) pandemic has challenged the core of our health care system. People are dying (frequently alone) at alarming rates, and there are shortages of vital resources including personal protective equipment, ventilators, medications, and trained staff. We must deliver care differently than what we are used to; there are too many patients, limited beds, and limited trained personnel. 1-3 The pandemic has created new and perplexing ethical challenges for the health care team. It has required us to enlarge our usual patient-centered ethical framework to more intentionally include a public health ethical framework. Instead of grounding our actions exclusively on patient autonomy and engaging patients to balance the benefits and burdens of treatment on the basis of their values and preferences, triage teams are taking a more prominent role in decision-making as a result of extreme shortages of all resources. We are being asked to enlarge our ethical perspective to prioritize the common good of saving as many lives as possible with the resources we have. No longer is everything available or able to be applied indefinitely. As critical care nurses, we are challenged to find new ways to provide care to more patients, including some that are outside of our usual specialty area, with the resources that are available. 4 Many frontline clinicians are experiencing varying degrees of moral distress, moral injury, and moral outrage and these unresolved issues create moral residue. 5-8 This has challenged our ability to discern the ethically justified response and to find a place of integrity in the midst of the crisis. 5
For the past 2 weeks, Angelo, a 5-year veteran of the medical intensive care unit, has been working extra shifts and training nurses from units across the hospital to care for patients with COVID-19 who are clinically unstable and receiving mechanical ventilatory support. After 2 days off, Angelo reports to work and learns that he is being reassigned to a newly formed COVID-19 unit that is expecting an influx of patient admissions. Angelo starts his shift with 2 patients who are clinically unstable and on paralytics, vasopressors, and maximum ventilator support; 1 patient is in the prone position. The medical team just informed the family of one of his patients that despite all interventions, they do not expect the patient to survive the night. There are visitor restrictions to reduce risk of virus transmission, so none of the patient’s family is present. Angelo plans to connect the family with the patient via phone so they can express their love to the dying patient. A few minutes later, Angelo is told his assignment will be modified to admit another patient with COVID-19 from the emergency department (ED) who was just intubated.
To assist in exploring these issues, we will apply E-PAUSE—a tool designed to assist nurses in exploring ethical challenges, taking action, and reflecting on what has been learned to support ethical discernment. The elements of E-PAUSE are outlined in the Table.
Getting Started With E-PAUSE
Prior to using these steps in a specific situation such as Angelo’s, it is important to calm your nervous system so that you are able to see things clearly and to be able to respond rather than react to the stressful situation in front of you. Pausing with 1 deep inhale and an extended exhale can help bring the parasympathetic nervous system in balance when fear and stress has activated your sympathetic nervous system. Noticing where there is tension in your body and placing your attention on your feet on the floor with the support of the earth under them can help to disrupt the pattern of sympathetic overarousal.
“E”: Ethical Context—Name the Ethical Challenge or Issue
Operating in a complex, rapidly changing, and uncertain environment means that the anchors a nurse normally relies on can feel unstable or confusing. The usual standards of care may be shifting as the severity of the pandemic moves to contingency and crisis standards of care. 1, 5, 8 Generally, the ethical framework for caring for critically ill patients focuses on honoring the choices and preferences for the patients in a context of shared decision-making. Nurses are called to advocate for individual patients and to use professional competence, skills, and knowledge to benefit, or at least not harm, these patients. 9 In the midst of a pandemic, these obligations are not suspended but rather shifted as the ethical framework is expanded to more fully embrace a public health framework focused on communal good and fair, equitable allocation of resources. 10 Alongside these ethical responsibilities is the nurse’s accountability to use judgment and expertise to provide safe care. 9
For Angelo, there are competing demands for his nursing care that create additional ethical tensions. How can he safely provide individualized care to each of his patients? He is passionate about being a nurse, and he feels conflicted because he cannot provide the level of care to his patients that he feels they need. Everything is happening quickly and simultaneously; he has to prioritize which patient needs are most likely to benefit from his expertise and which needs will likely go unmet. He is experiencing moral distress created in the gap between what he thinks he ought to be doing and what he is actually doing. The distress is bumping him out of his resilience zone and causing indecision while he determines next steps and actions.
“P”: Perspective Taking—Who Is Involved and What Are Their Perspectives, Biases, and Assumptions?
Pausing to determine who is involved in the ethical tension and the impact on them engages both affective and cognitive attunement into the experience. This can happen in just a few moments. Angelo can pause long enough to assess the situation, including his patient’s needs and the needs of the system, without being on autopilot and reactive. As he considers his current patients, he is aware that the critically ill patient who is clinically unstable and receiving multiple treatments requires rapid assessment, expert clinical judgment, and skillful navigation and response to the rapidly changing situation. In contrast, the patient who is now dying requires different clinical expertise that allows Angelo to accompany the patient and family through the end of life. Because of COVID-19 visitation restrictions, the patient’s family has not been able to see the patient since he was admitted to the unit, and the family will not be able to be present at the bedside with the patient at the end of his life. They have just been informed by the medical team that the patient will not survive the night. The patient is alone, and the family is anxious and distraught.
For Angelo, the assignment burden is more than what is standard. His critical care unit is likely in the phase of contingency standards, which stretch the usual patterns to accommodate the rapid influx of patients without overwhelming the system. Typically, he may have 1 to 2 patients but now he has 3 to 4 patients. On this shift, Angelo will have 3 patients, all requiring frequent interventions and 1 who may not survive the night. The patient to be admitted from the ED will require dedicated attention from Angelo to rapidly assess and treat his symptoms and initiate monitoring and treatments. Angelo cannot be in several places at once and is pulled in competing directions. He is noticing that his chest feels tight and his breathing is shallow. He has several priorities; he feels overwhelmed and finds it hard to concentrate without being distracted. Angelo notices he is having difficulty with simple problem-solving.
Angelo may hold some biases and assumptions such as:
My charge nurse knows all the things that are happening with my assignment.
My charge nurse knows this is not right and will get me help.
I can figure it out on my own.
I can probably make it work.
They gave me this assignment because they think I can handle it.
I cannot safely continue with this assignment.
There are not enough resources.
Bringing your biases and assumptions into your awareness allows you to be able to examine their veracity and to decide which are relevant, which are not, where to focus your attention, and how to discover what else might be possible.
“A”: Ask Questions—What Is Unknown or Unclear in This Situation?
Asking questions can help create a mindset of inquiry and discernment. Noticing the patterns of your questions and what might be missing can help ensure that decisions are made on the basis of relevant information rather than assumption or opinion. Pausing to reflect can create more space around decision-making.
Angelo asks himself:
How can I allocate my time, attention, and skills equitably to my patients?
What are my nursing care priorities, and are they known to my charge nurse and coworkers?
How will my decisions impact the overall health of all the patients who are in need of critical care in my unit?
If I admit the new patient, will I be abandoning my dying patient?
If I spend my time with the dying patient and his family, will I abrogate my responsibilities to my colleagues?
What other options are there? What might I be missing?
Is it possible to delay the new admission from the ED for an hour so I can arrange a phone call for the family of my dying patient?
Is it possible for someone else to admit the patient from the ED?
Creating space to reflect on and answer some key questions can often reveal new insights that can help to loosen the grip of feeling overwhelmed in the midst of a rapidly changing situation.
“U”: Utilize Resources
When in the grip of a high-stakes situation, it is easy to overlook available resources. This step invites you to pause and remember previously challenging experiences. Think about a time when you were able to balance your priorities in a way that benefited your patient; what made that possible? What resources did you use? How might you access them now? Angelo might begin by asking: What reasoning skills or ethical frameworks do I use? Prior to the pandemic, Angelo may have focused on respecting the patients’ autonomy to choose the treatments they desire and advocated for their wishes. Now his ethical framework is enlarged to include consideration of the greater population of patients who need critical care resources and the common good of the broader community. That said, nurses are still obliged to respect the decisions of patients, to the extent possible under constrained circumstances. Outside of a crisis standard of care, nurses would rely on patients or their surrogates to help the health care team balance the benefits and burdens of treatments and to engage patients and families in making decisions that are aligned with their values and preferences. 10
Angelo might ask himself:
To what extent are patients and their families informed of the limitations on treatment options imposed by the pandemic?
How are the values and preferences of patients and their families being weighted in the current situation? What directions might their advance directive give?
Concerns of fairness and equity become more pronounced when resources become scarce. Nurses make allocation decisions every day all day, whether they are aware of it or not. Being intentional about your choices, especially in the midst of a pandemic, can support your confidence to do the best with what is available.
Again, Angelo might ask:
How should I allocate my time, attention, competence, and compassion so that I maximize the benefit for all?
Who is most likely to benefit from my expertise? Whose needs are most urgent? Who is most likely to be harmed? Is it possible to minimize those harms?
Am I treating my patients in the same way I treat other patients who are in similar situations?
Additionally, Angelo may consider what he needs to help him navigate the moral distress of this assignment. Is he able to clearly articulate the source of his distress? In weighing the options that are available, which option aligns best with his professional values? What outcome could he live with under these circumstances? Are his basic needs being adequately addressed? Does he need a moment for hydration, nourishment, or a physical break? He may want to use some simple self-care practices such as mindfulness in the moment, stretching, or connecting to his purpose. What inner resources have carried him through difficult situations in the past? Remembering a time when one was able to confront adversity and find a place of integrity in the midst of a complex and challenging situation can help shift one’s attention from fear and paralysis to what is possible; and we may be able to do the same now. 11
Angelo might also consider how to access external resources:
What resources are available to help me with my current assignment?
Can anyone on the team help?
Is the social worker or chaplain involved? Can they help provide information to the family, spiritual guidance, or care to the dying patient?
Is the triage team available to discuss the situation?
What other resources are available?
Is there peer-to-peer support available? Can I reach out to colleagues as thinking partners to acknowledge the ethical issues and the toll it is taking on me?
Are there grief counselors or services that can help me debrief the situation and offer suggestions?
Are there ethics consultants available to provide consultation or services to help manage the ethical conflicts of the situation?
“S”: Stand Up and Speak Up
Once Angelo identifies the ethical problem, the next step is to determine how to act. Considering all the information that is available in the current context, what ought to be done, and what actions are possible? What actions should be taken? What actions are aligned with his values? There is often a range of options for how to respond to situations like Angelo’s. There are ethical trade-offs associated with each of them. Angelo can raise his voice to speak up and bring his concerns to the charge nurse or nurse manager and escalate it up the chain of authority if needed. He could put his energy toward doing what he can for the patient in front of him with competence and compassion while acknowledging his limitations. Alternatively, he could enlist the support of others to implement an alternative plan to cover the needs of his patients. At the end of the day, the question that Angelo has to answer is whether he can find a place of integrity in the midst of the constraints on his usual decision-making. In a pandemic, there are no universal answers. However, reorienting to the foundational values of the profession (such as respect for persons, benefiting those we serve, avoiding harm, and providing fair, equitable care) can offer a grounding that provides reassurance that we are consciously choosing in spite of the inevitable trade-offs that we confront.
The next step is effective communication. Under stress, Angelo might resort to unproductive communication as his nervous system becomes more rigid and fear overcomes his self-regulation. He may be more likely to react rather than respond or become defensive and blame others for the situation he finds himself in. There are productive phrases Angelo could use to speak up.
What Angelo says and how he says it is more important than ever before:
To his colleagues, he could say:
I know we are all stretched, but I’m feeling overwhelmed by my assignment. May I talk with you about whether there is anything else we can do? Is there anyone else who can admit my patient from the ED so I can help the family of my dying patient to get the care they need? Or could we wait an hour to admit the new patient from the ED so I can manage the situation with my dying patient and his family? Any help you can offer would be greatly appreciated.
What can he say to the patient who is approaching the end of their life—the person in front of him? First, he can take a moment to gather his attention so he can be present for his patient. Angelo can attune to what is happening in his body, emotions, and thoughts. He can remember why his work matters. To this patient, he can say:
Unfortunately, you are very sick from the virus. It is very powerful, and the treatments we have are not helping you get better. I know this is hard to hear and hard for us to tell you. I’m going to get your family on the phone so they can spend some time with you. It is not possible to have them visit in person because of the virus. I am here with you. I’ll do everything I can to help keep you comfortable.
Angelo may be communicating a narrative to himself and his colleagues:
I cannot take this anymore (versus I am taking care of myself so I can take care of my patients; I support my team, and they support me).
There is an opportunity for Angelo to shift from a hopeless, defeated narrative to one of possibility and hope:
I am remembering that each patient is lonely. I am providing the last thread of compassion, and that gives me comfort that I am helping (versus I am just going through the motions because I am numb).
I can regain my balance and gather my attention to be totally present with this patient in these next moments as I speak with him and comfort him.
“E”: Empower My Practice
The final step in E-PAUSE is to pause to review the decisions that were made, how they were made, and what can be learned for future patients. In the busy intensive care unit setting, this step is often overlooked or dismissed as unnecessary. Although doing so in the current environment can prove difficult, it is vital to discuss how the situation has impacted you personally and professionally. Without these pauses, you can end up with a heavy moral residual that weighs you down to the point that it is detrimental to you and others. Unprocessed moral distress can lead to burnout. 12 Critical care clinicians are already at risk for burnout, and the pandemic has only intensified the risk by adding stress to an already stressed and stressful environment. 12 Carving out even 10 minutes to reflect on some key questions is an important step toward healing the residual of a morally distressing situation.
There are some things Angelo might consider in self-reflection:
What did I learn about myself and others from this situation?
Rather than judging myself as failing, can I recognize the compassion I provided and let go of unrealistic expectations of myself and others?
Is it possible to change the narrative to what is possible with the resources that were available?
It is important that I remember I did not abandon my patient and I found solutions within the constraints that were present.
What good came from my care, presence, and actions?
What will I take forward from this situation into the next?
What do I need to preserve or restore my integrity?
Using E-PAUSE and reflecting on these questions can allow critical care nurses and the health care team to find a place of understanding. This algorithm can be used as a guide to consider new questions to inform future choices. In unprecedented times like these, we must acknowledge and realize that we are all interconnected, and our actions impact not only our patients, families, and colleagues but also ourselves.
The authors declare no conflicts of interest. E-PAUSE is a copyright of Johns Hopkins University and is used with permission.