During the COVID-19 pandemic, evidence-based resources have been sought to support decision-making and strategically inform hospitals’ policies, procedures, and practices. While greatly emphasizing protection, most guiding documents have neglected to support and protect the psychosocial needs of frontline health care workers and patients and their families during provision of palliative and end-of-life care. Consequently, the stage has been set for increased anxiety, moral distress, and moral injury and extreme moral hazard. A family-centered approach to care has been unilaterally relinquished to a secondary and nonessential role during the current crisis. This phenomenon violates a foundational public health principle, namely, to apply the least restrictive means to achieve good for the many. Instead, there has been widespread adoption of utilitarian and paternalistic approaches. In many cases the foundational principles of palliative care have also been neglected. No circumstance, even a global public health emergency, should ever cause health care providers to deny their ethical obligations and human commitment to compassion. The lack of responsive protocols for family visitation, particularly at the end of life, is an important gap in the current recommendations for pandemic triage and contingency planning. A stepwise approach to hospital visitation using a tiered, standardized process for responding to emerging clinical circumstances and individual patients’ needs should be considered, following the principle of proportionality. A contingency plan, based on epidemiological data, is the best strategy to refocus health care ethics in practice now and for the future.

Notice to CE enrollees:

This article has been designated for CE contact hour(s). The evaluation demonstrates your knowledge of the following objectives:

  1. Analyze the harms that restricted visitation during a pandemic brings to patients, their loved ones, and staff.

  2. Identify and explore the practices and processes aimed to maintain safety with visitation.

  3. Describe steps to fairly approach visitation restrictions to preserve staff’s moral integrity and restore patient- and family-focused care.

To complete the evaluation for CE contact hour(s) for this article #A21602, visit www.ajcconline.org and click the “CE Articles” button. No CE evaluation fee for AACN members. This expires on July 1, 2023.

The American Association of Critical-Care Nurses is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation, ANCC Provider Number 0012. AACN has been approved as a provider of continuing education in nursing by the California Board of Registered Nursing (CA BRN), CA Provider Number CEP1036, for 1.0 contact hour.

Although it was once considered unthinkable, many hospitalized patients are now dying alone.1  In response to the COVID-19 pandemic, hospitals worldwide have tightened their visitor policies following public health recommendations.2  For example, in May 2020 at St Boniface Hospital in Winnipeg, Canada, the family of a 66-year-old patient with cancer was prevented from being with her at the end of her life.3  This occurred despite the province of Manitoba’s having one of the lowest COVID-19 caseloads in Canada at the time (290 cases, 7 deaths, and 35 723 tests performed as of May 21, 2020).4 

These unprecedented circumstances have created a cascade of reactive changes in hospitals’ delivery of care. Visitation restrictions have become a standard of pandemic protocols and are driven by a broadly utilitarian approach.5,6  In turn, these restrictions have led to changes in how health care workers care for people who are dying, with serious repercussions for families.7  During the pandemic, missed opportunities for families to be with gravely ill patients are a haunting reminder of how unilateral policies fail to respond compassionately, with the practice of restricted visitation already questioned during the severe acute respiratory syndrome (SARS) epidemic of 2002 to 2004.8,9  We suggest that the same psychosocial collateral damage described then is occurring again now, and on a much larger scale, because of policies that discount the value of family-centered care.1 

“These unprecedented circumstances have created a cascade of reactive changes in hospitals’ delivery of care.”

Patient- and family-centered care is touted as the hallmark of high-quality health care in hospitals,10,11  and compassion is considered an essential element of high-quality care.12,13  However, strict, one-size-fits-all policies that completely bar visitors or allow only 1 visitor (even at moments close to death) have become the norm and have rarely been questioned during the current pandemic.1,7  Hence, family-centered care became one of the pandemic’s first victims owing to a return to paternalistic approaches.6  In fact, these restrictions may not even be explicitly justified by research evidence.14  Adult patients are being treated uniformly (ie, left alone and isolated from family members), regardless of SARS-CoV-2 status. The approach in pediatric facilities has been to allow only 1 family member to visit per day.8,15 

Many health care workers initially agreed with increased visitor restrictions. Tensions grew as the role of asymptomatic carriers became clear.16  Health care workers’ compassion yielded to a dire need to be protected from infected individuals who had not yet shown symptoms.17  Every visitor increased their risk of infection.18  As the pandemic progressed, health care workers witnessed how rules meant to protect played out. They identified the conflict between their patients’ need for compassion and their own need for protection.1  Do constraints on visitation mean that the fiduciary obligation to provide patient-and family-centered care becomes supererogatory? No. The logistical challenges to visitation do not excuse us from fulfilling our obligations to patients and families; there is still something owed. Health care workers and hospital administrators owe transparency and rationale. They must investigate what can actually be done and explore what is safe to try. Leaders in health care need to create opportunities to explicate the ethical rationale for eliminating visitation.14 

In this review, we aim to identify practical approaches to hospital visitation for patients in palliative or end-of-life care circumstances. We identify and examine foundational concepts, the current evidence, and special factors and provide an example of a responsive visitation protocol. We present a stepwise approach to decision-making for visitation and offer implementation guidelines. We advocate for a considered and compassionate approach to help fill the gaps in current best practice documents and enhance the quality of care during a pandemic. This approach may reduce triggers of anxiety,19  limit moral distress,20,21  and prevent moral injury.22  For patients, families, and health care workers, the current visitation restrictions were enacted with best interests in mind but have failed to protect.23 

Literature Search

In May 2020, we conducted an in-depth search of the MEDLINE, PubMed, Embase, Scopus, and Web of Science databases using the Medical Subject Headings terms palliative care/end-of-life, moral hazard/injury, and advance directives/moral distress and pandemics/COVID-19. We limited the search results to English-language articles published between 2015 and 2020. This review also draws on additional articles that were subsequently collected (eg, references from the reference lists of the articles found in the literature search, new publications, valuable research published before 2015, and current news media) and analyzed by consensus among the authors. The concepts of moral distress, moral injury, and moral hazard are described in Table 1.

Findings

Currently, the best available evidence for controlling the spread of SARS-CoV-2 includes frequent, thorough handwashing (hand sanitizing), physical distancing (maintaining a minimum distance of 1.8 m, or 6 feet), quarantine or isolation of contacts,31  and using an N95 respirator with a face shield when performing aerosol-generating procedures.17,32  These measures have been shown to be effective.31,33,34 

However, COVID-19 has presented unique challenges related to (1) understanding the prevalence of the virus, (2) recognizing the needs of distinct patient populations (eg, older adults, obstetric patients, and pediatric patients) with and without positive SARS-CoV-2 status when admitted to the hospital,18  and (3) responsibly allocating scarce resources.35  Such circumstances create a place of moral hazard for health care workers and add to an already heavy psychological burden during the pandemic (eg, anxiety, reduced self-efficacy,36  depression, anxiety, poor-quality sleep or insomnia).23  These challenges are specifically relevant to decision-making during the pandemic.

Understanding Prevalence

Variations in prevalence of COVID-19 in different regions of the world, and even within a single country, are remarkable. In Canada, for instance, Ontario and Quebec have experienced a disproportionate number of cases and deaths compared with other large areas of the country.4  New York City, with a relatively dense population, saw a very high prevalence compared with other US cities. And the north of Italy was much more affected than the south, despite the country’s relatively small size.37 

Testing

Polymerase chain reaction–based testing materials have been scarce, response times vary significantly, and some brands lack sensitivity and specificity.32  Also, large-scale testing has been a worldwide problem, particularly in (already) underresourced communities.38  Hence, adequate screening of health care workers, patients, and visitors with accurate and timely polymerase chain reaction testing has been difficult.39,40  The use of verbal screening (inquiring about recent travel, contacts, and current symptoms) became routine. Isolation of COVID-19–positive patients is usually discontinued once the patient is asymptomatic and/or after a set time limit (eg, 14 days)17 ; however, testing of asymptomatic individuals varies widely. These factors all affect isolation practices, policies, and health care workers’ exposure protocols.18  Furthermore, recent studies indicate that health care workers are more likely to acquire COVID-19 from contacts in the community than from their workplaces.41 

Different Patient Populations

Children have been largely spared from this pandemic, constituting only 1% to 5% of the total population testing positive,42,43  with just 2% requiring intensive care unit admissions.43,44  Despite the emergence of novel multisystem inflammatory syndrome,45  the number of children hospitalized for severe COVID-19 remains small. Hence, the separation of parents who live in the same household from hospitalized children who are COVID-19 negative lacks support. In fact, the importance of parental presence for hospitalized children is undeniable.46 

Scarce Resources

Many hospitals have struggled to procure supplies, from sedatives and opioids to ventilators and personal protective equipment (PPE).47,48  Stockpiling supplies has been advocated as an essential component of any prepandemic preparation, although a worldwide event would inevitably bring shortages and competition between countries.38  The scarcity of PPE has led to international conservation strategies, including visitation restrictions, even in communities seemingly unaffected by the pandemic with adequate surge resources.49 

Importance of Information and Communication

Throughout the pandemic, an abundance of conflicting information has been circulated via the media, causing confusion and uncertainty about how to stay safe.49-51  Fears of the unknown, anxiety about risks, and uncertainty about liabilities are very real driving forces behind decision-making. However, hospital administrators generally are not the individuals who must bear witness to negative outcomes from one-size-fits-all protocols. Table 2 provides examples of personal experiences during COVID-19. Perhaps more than ever, evidence-based information is fundamental when creating and implementing practices that protect the health and well-being of health care workers and the public.

During the SARS outbreak, it became very clear that frequent, transparent, and flexible hospital communication was invaluable.36,57  Communication about appropriate provision of supplies and equipment, particularly in the face of potential shortages, needs to be evidence-based and reassuring, including alternatives to protect patients and health care workers.10,32  To facilitate communication and decision-making, it has been recommended that a hospital (or group of hospitals) organize a command center to work with local or regional public health authorities. This group drafts an escalation plan of strategies, according to disease prevalence in their region or community, with predetermined, specific criteria (contingency levels) set for each stage of the pandemic.6  It is crucial that hospitals’ measures align with these community plans and public health directives.

“It is clear that the strong ethical obligation to be present with dying patients has been directly challenged during this pandemic.”

An important component of such contingency planning is proper consultation and communication.36  First and foremost, a consultation with stakeholders, including frontline health care workers, is mandatory to establish trust and increase adherence. Finally, open and ongoing communication with patients and families is required, including broadly sharing visitor policies on traditional and social media alongside individualized information sharing at each facility (eg, via pamphlets, mobile applications, and/or use of navigators).58  Essentially, institutions cannot expect busy frontline health care workers to be the primary source of information for patients and families.59 

A Precedent-Setting Example

One hospital yielded to the call to have visitors return to the bedside. At Seattle’s Virginia Mason Medical Center, a new role of “support companion” was created to guide families and patients with COVID-19 at the end of life. The support companion acts as a designated person available to guide visitation. At Virginia Mason, registered nurses fulfill the support companion role to help visitors throughout the process, relieving frontline staff of this task. The availability of both PPE and staff allowed this institution to be flexible, responsive, and supportive of patients and loved ones as they said their final good-byes—a vital part of a “good death.”60 

Stepwise Approach, Guidelines, and Questions

After reviewing the literature and considering the program described above, we devised a practical stepwise approach to enhance evidence-based decision-making to support visits for patients receiving palliative or end-of-life care (Table 3). It follows the ethical principle of proportionality, which demands that “the risks of compromising standards in a given instance should be weighed against the need to do so to optimize benefits to patients, caregivers, and the community.”61  In contrast to utilitarianism, the delivery of valuable goods should be the goal, including the best opportunities for patients to be well cared for while supporting health care workers’ safety. Any allocation of resources needs to be checked by the question “Are we doing more harm than is needed?”6,14  Criteria for each step should be explicitly disclosed in advance to stakeholders to ensure fairness, maximize transparency, and build capacity for consistent decision-making.62  Visitation policies must have practical implementation guidelines (see Figure) and build in opportunities for regular reevaluation to guide appropriate goals of care.

Discussion

There is a general consensus that a pandemic brings extenuating circumstances to the usual modus operandi of an organization. This situation may require the use of international directives such as the Siracusa principle (which delineates situations when civil liberties may ethically be limited),63  in which the collective good is held as the highest ethical standard. However, there is a need for creative contingency planning that includes a tiered, standardized approach for pandemic hospital visitation to avoid moral and psychological damage, which will continue to accumulate.25  Early and responsive organizational action will reduce opportunities for hasty crisis-level reactions (without accounting for context and circumstances) and relieve pressure on individual clinicians. Such planning also helps to responsibly allocate resources,14  from critical care beds to complex therapies such as extracorporeal membrane oxygenation.64,65 

Maves et al35  predicted that the first or subsequent waves of COVID-19 would see critical levels of demand for resources that might outstrip supply. Indeed, this has already occurred. Further, broadly restrictive visitation policies are depriving patients of an invaluable resource and denying families opportunities that cannot be replaced. Families of dying patients often have psychosocial needs similar to those expressed by health care workers (ie, hear me, protect me, prepare me, support me, and care for me),19  but under pandemic restrictions their needs may go unmet.66  As dedicated health care workers, we share the common value of human connection at the end of life and recognize the need to involve family whenever possible as a baseline ethical obligation. Some hospitals have enlisted volunteers to accompany dying patients as an innovative approach.67  It is clear that the strong ethical obligation to be present with dying patients has been directly challenged during this pandemic.68,69 

Traditionally, we define a “good death” as one that is relatively free of unnecessary suffering for all involved and consistent with patient wishes and goals (eg, clinical, ethical, cultural, spiritual).60,70,71  According to Schaepe and Ewers,72  having family at the bedside facilitates the sharing of information about the patient that is grounded in their intimate knowledge of the patient’s needs and preferences. The presence of family at the end of life may require several visits, as the timing of a person’s death remains difficult to predict. Thompson et al73  reported that at the end of life, families usually engage in a range of rituals to comfort the dying patient and to start their own grieving process. Evidence from palliative care research shows that holding a dying loved one’s hand, stroking their arm, or playing with their hair are all typical gestures.74  These simple acts let the patient know that they are valued and loved. Often, dying patients and their loved ones reconcile past wrongs, impart words of wisdom, and share last wishes.73  Research indicates that when they cannot be at the bedside during the dying process, families often experience excessive feelings of guilt and failure, as death is a rite of passage that is important to witness in many cultures.71  Some authors have argued that witnessing patients dying alone brings taxing emotions to health care workers. Many who see this as inhumane take it upon themselves to fill the void.7,19  End-of-life care is the most often cited source of moral distress in nonpandemic situations, and health care workers’ witnessing patients dying alone is a major contributor to moral distress experiences.1,69 

“Visitors are ultimately part of the care team and an essential and irreplaceable aspect of a hospital’s pandemic triage algorithm.”

During the SARS outbreak in 2003, measures were put in place to mitigate the psychosocial impact on health care workers.75  Studies identified frequent and proper communication,58,69  without being unduly reassuring, as very helpful.57,76  Hospital-level leadership, infection prevention and control services, and other supervising bodies need to be transparent and flexible, acknowledge shared uncertainty, and provide clear evidence-based plans that will bolster health care workers’ trust, confidence, and sense of self-efficacy.77  This information includes direction about hospital protocols, policies, and processes. It is very important for health care workers78  and the public to know that proper protection from the virus is a priority, hence the limits to free visitation.5 

Circumstances in which health care workers are unable to do their jobs effectively owing to limited resources are the second most cited source of moral distress among health care workers.79,80  During this pandemic, health care workers have “gone to war without ammunition”; the lack of proper PPE has sparked copious complaints and is one reason health care workers have approached the media to express their frustration.5,81  Another fundamental resource lacking for patients dying alone is proper palliative care (eg, health care worker training, availability of chaplains and social workers, medications to alleviate or manage symptoms).7,69,73  These circumstances have also been noted as triggers for moral distress among health care workers.20 

From an ethics perspective, all health care workers carry an obligation to explore the difficult questions surrounding end-of-life care, to implement a workable responsive approach, and, subsequently, to communicate it effectively. Whether an institution can support visitors at the bedside during the peak of a pandemic is ultimately specific to that institution. Explicit and transparent processes help health care workers, patients, and families understand the rationale for the choices made, even if they do not agree with them. Also, each plan must contain triggers to reevaluate previous guidelines, should conditions change.

Finally, visitors are ultimately part of the care team and an essential and irreplaceable aspect of a hospital’s pandemic triage algorithm. They are not an unnecessary risk to safety. The costs of unfairly and unilaterally restricting visitation are simply too high. Again, the implementation of crisis standards of care should not change our obligation to maintain compassion. Turning to algorithms and crisis protocols that lack sensitivity to humanity and create emotional dissonance among frontline health care workers is neither safe nor ethically supportable. Such circumstances often lead to the need for work-arounds and place stakeholders in a position of moral hazard and at high risk for moral distress and moral injury.26,82  With the stepwise protocols for decision-making and implementation offered here, we hope to start conversations to discover new and feasible alternatives to a one-size-fits-all policy.

Conclusion

The pandemic resulted in broadly restrictive and often unfair protocols, largely owing to misinformation, trial and error, and crisis demands on resource conservation. Policies and procedures were devised with the best intentions at the time. However, we recommend that a robust evidence-based protocol for visitation, guided by ethical principles, be immediately incorporated into hospitals’ contingency plans.

ACKNOWLEDGMENTS

We are grateful to Wendy Austin, Doug Diekema, David Ferris, Dana Nelson-Peterson, and Amy Ninetto for their contributions. We dedicate this work to all who have lost their lives to COVID-19 and their families, for teaching us ways that we can do better.

REFERENCES

1
Curley
MAQ
,
Broden
EG
,
Meyer
EC
.
Alone, the hardest part
.
Intensive Care Med
.
2020
;
46
(
10
):
1974
-
1976
.
2
Booth
R
,
Pidd
H
.
UK hospitals tightening restrictions on visits—even to dying patients
.
The Guardian
.
March
30
,
2020
. Accessed May 15, 2020.
3
von Stackelberg
M
.
Cancer patient dies alone in Winnipeg hospital after family denied palliative visits
.
CBC News website
.
May
13
,
2020
. Accessed May 21, 2020.
4
Tracking the coronavirus
.
CBC News website
.
2020
. Accessed June 16, 2020.
5
Parodi
SM
,
Liu
VX
.
From containment to mitigation of COVID-19 in the US
.
JAMA
.
2020
;
323
(
15
):
1441
-
1442
.
6
Hick
JL
,
Hanfling
D
,
Wynia
MK
,
Pavia
AT
.
Duty to plan: health care, crisis standards of care, and novel coronavirus SARS-CoV-2
.
NAM Perspectives
.
National Academy of Medicine
.
March
5
,
2020
. Accessed July 10, 2020.
7
Yardley
S
,
Rolph
M
.
Death and dying during the pandemic
.
BMJ
.
2020
;
369
:
m1472
.
8
Rogers
S
.
Why can’t I visit? the ethics of visitation restrictions— lessons learned from SARS
.
Crit Care
.
2004
;
8
(
5
):
300
-
302
.
9
Bernstein
M
,
Hawryluck
L
.
Challenging beliefs and ethical concepts: the collateral damage of SARS
.
Crit Care
.
2003
;
7
(
4
):
269
-
271
.
10
Kitson
A
,
Marshall
A
,
Bassett
K
,
Zeitz
K
.
What are the core elements of patient-centred care? a narrative review and synthesis of the literature from health policy, medicine and nursing
.
J Adv Nurs
.
2013
;
69
(
1
):
4
-
15
.
11
Luxford
K
,
Safran
DG
,
Delbanco
T
.
Promoting patient-centered care: a qualitative study of facilitators and barriers in health-care organizations with a reputation for improving the patient experience
.
Int J Qual Health Care
.
2011
;
23
(
5
):
510
-
515
.
12
Entwistle
VA
,
Watt
IS
.
Treating patients as persons: a capabilities approach to support delivery of person-centered care
.
Am J Bioeth
.
2013
;
13
(
8
):
29
-
39
.
13
Sinclair
S
,
Beamer
K
,
Hack
TF
, et al
.
Sympathy, empathy, and compassion: a grounded theory study of palliative care patients’ understandings, experiences, and preferences
.
Palliat Med
.
2017
;
31
(
5
):
437
-
447
.
14
Berlinger
N
,
Wynia
M
,
Powell
T
, et al
.
Ethical framework for health care institutions and guidelines for institutional ethics services responding to the coronavirus pandemic: managing uncertainty, safeguarding communities, guiding practice
.
The Hastings Center
.
March
16
,
2020
. Accessed July 15, 2020.
15
Wunsch
H
.
The outbreak that invented intensive care
.
Nature Briefing
.
April
3
,
2020
. Accessed May 10, 2020.
16
Bai
Y
,
Yao
L
,
Wei
T
, et al
.
Presumed asymptomatic carrier transmission of COVID-19
.
JAMA
.
2020
;
323
(
14
):
1406
-
1407
.
17
Wiersinga
WJ
,
Rhodes
A
,
Cheng
AC
,
Peacock
SJ
,
Prescott
HC
.
Pathophysiology, transmission, diagnosis, and treatment of coronavirus disease 2019 (COVID-19): a review
.
JAMA
.
2020
;
324
(
8
):
782
-
793
.
18
Cheng
VCC
,
Wong
SC
,
Yuen
KY
.
Estimating coronavirus disease 2019 infection risk in health care workers
.
JAMA Netw Open
.
2020
;
3
(
5
):
e209687
. doi:
19
Shanafelt
T
,
Ripp
J
,
Trockel
M
.
Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic
.
JAMA
.
2020
;
323
(
21
):
2133
-
2134
.
20
Wall
S
,
Austin
WJ
,
Garros
D
.
Organizational influences on health professionals’ experiences of moral distress in PICUs
.
HEC Forum
.
2016
;
28
(
1
):
53
-
67
.
21
Dean
W
,
Talbot
SG
,
Caplan
A
.
Clarifying the language of clinician distress
.
JAMA
.
2020
;
323
(
10
):
923
-
924
.
22
Shay
J
.
Moral injury
.
Psychoanal Psychol
.
2014
;
31
(
2
):
182
-
191
.
23
Lai
J
,
Ma
S
,
Wang
Y
, et al
.
Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019
.
JAMA Netw Open
.
2020
;
3
(
3
):
e203976
. doi:
24
Garros
D
,
Austin
W
,
Carnevale
F
.
Moral distress in pediatric intensive care
.
JAMA Pediatr
.
2015
;
169
(
10
):
885
-
886
.
25
Epstein
EG
,
Hamric
AB
.
Moral distress, moral residue, and the crescendo effect
.
J Clin Ethics
.
2009
;
20
(
4
):
330
-
342
.
26
Rushton
CH
.
Moral resilience: a capacity for navigating moral distress in critical care
.
AACN Adv Crit Care
.
2016
;
27
(
1
):
111
-
119
.
27
Talbot
SG
,
Dean
W
.
Physicians aren’t ‘burning out.’ They’re suffering from moral injury
.
STAT News
.
July
26
,
2018
. Accessed June 16, 2020.
28
Marshall
MF
,
Epstein
EG
.
Moral hazard and moral distress: a marriage made in purgatory
.
Am J Bioeth
.
2016
;
16
(
7
):
46
-
48
.
29
Brunnquell
D
,
Michaelson
CM
.
Moral hazard in pediatrics
.
Am J Bioeth
.
2016
;
16
(
7
):
29
-
38
.
30
Krugman
P
.
The Return of Depression Economics and the Crisis of 2008
.
W W Norton & Co
;
2009
.
31
Nussbaumer-Streit
B
,
Mayr
V
,
Dobrescu
AI
, et al
.
Quarantine alone or in combination with other public health measures to control COVID-19: a rapid review
.
Cochrane Database Syst Rev
.
2020
;
4
(
4
):
CD013574
.
32
Perencevich
EN
,
Diekema
DJ
,
Edmond
MB
.
Moving personal protective equipment into the community: face shields and containment of COVID-19
.
JAMA
.
2020
;
323
(
22
):
2252
-
2253
.
33
Hsiang
S
,
Allen
D
,
Annan-Phan
S
, et al
.
The effect of large-scale anti-contagion policies on the COVID-19 pandemic
.
Nature
.
2020
;
584
(
7820
):
262
-
267
.
34
Anderson
RM
,
Heesterbeek
H
,
Klinkenberg
D
,
Hollingsworth
TD
.
How will country-based mitigation measures influence the course of the COVID-19 epidemic?
Lancet
.
2020
;
395
(
10228
):
931
-
934
.
35
Maves
RC
,
Downar
J
,
Dichter
JR
, et al
.
Triage of scarce critical care resources in COVID-19: an implementation guide for regional allocation: an expert panel report of the Task Force for Mass Critical Care and the American College of Chest Physicians
.
Chest
.
2020
;
158
(
1
):
212
-
225
.
36
Wu
PE
,
Styra
R
,
Gold
WL
.
Mitigating the psychological effects of COVID-19 on health care workers
.
CMAJ
.
2020
;
192
(
17
):
E459
-
E460
. doi:
37
Livingston
E
,
Bucher
K
.
Coronavirus disease 2019 (COVID-19) in Italy
.
JAMA
.
2020
;
323
(
14
):
1335
.
38
Rubin
R
,
Abbasi
J
,
Voelker
R
.
Latin America and its global partners toil to procure medical supplies as COVID-19 pushes the region to its limit
.
JAMA
.
2020
;
324
(
3
):
217
-
219
.
39
Woloshin
S
,
Patel
N
,
Kesselheim
AS
.
False negative tests for SARS-CoV-2 infection—challenges and implications
.
N Engl J Med
.
2020
;
383
(
6
):
e38
. doi:
40
Altamirano
J
,
Govindarajan
P
,
Blomkalns
AL
, et al
.
Assessment of sensitivity and specificity of patient-collected lower nasal specimens for sudden acute respiratory syndrome coronavirus 2 testing
.
JAMA Netw Open
.
2020
;
3
(
6
):
e2012005
. doi:
41
Burke
RM
,
Midgley
CM
,
Dratch
A
, et al
.
Active monitoring of persons exposed to patients with confirmed COVID-19— United States, January-February 2020
.
MMWR Morb Mortal Wkly Rep
.
2020
;
69
(
9
):
245
-
246
.
42
CDC COVID-19 Response Team
.
Coronavirus disease 2019 in children—United States, February 12–April 2, 2020
.
MMWR Morb Mortal Wkly Rep
.
2020
;
69
(
14
):
422
-
426
.
43
Parri
N
,
Lenge
M
,
Buonsenso
D
Coronavirus Infection in Pediatric Emergency Departments (CONFIDENCE) Research Group
.
Children with Covid-19 in pediatric emergency departments in Italy
.
N Engl J Med
.
2020
;
383
(
2
):
187
-
190
.
44
Shekerdemian
LS
,
Mahmood
NR
,
Wolfe
KK
, et al
.
Characteristics and outcomes of children with coronavirus disease 2019 (COVID-19) infection admitted to US and Canadian pediatric intensive care units
.
JAMA Pediatr
.
2020
;
174
(
9
):
868
-
873
.
45
Feldstein
LR
,
Rose
EB
,
Horwitz
SM
, et al
.
Multisystem inflammatory syndrome in U.S. children and adolescents
.
N Engl J Med
.
2020
;
383
(
4
):
334
-
346
.
46
Johnson
BH
,
Jeppson
ES
,
Redburn
L
.
Caring for Children and Families: Guidelines for Hospitals
.
Association for the Care of Children’s Health
;
1992
.
47
Emanuel
EJ
,
Persad
G
,
Upshur
R
, et al
.
Fair allocation of scarce medical resources in the time of Covid-19
.
N Engl J Med
.
2020
;
382
(
21
):
2049
-
2055
.
48
Daugherty Biddison
EL
,
Faden
R
,
Gwon
HS
, et al
.
Too many patients … a framework to guide statewide allocation of scarce mechanical ventilation during disasters
.
Chest
.
2019
;
155
(
4
):
848
-
854
.
49
World Health Organization
.
Rational use of personal protective equipment for coronavirus disease (COVID-19) and considerations during severe shortages: interim guidance, 6 April 2020
. Accessed May 15, 2020.
50
Chan
ALY
,
Leung
CC
,
Lam
TH
,
Cheng
KK
.
To wear or not to wear: WHO’s confusing guidance on masks in the covid-19 pandemic
.
The BMJ Opinion
.
March
11
,
2020
. Accessed July 15, 2020.
51
Dagens
A
,
Sigfrid
L
,
Cai
E
, et al
.
Scope, quality, and inclusivity of clinical guidelines produced early in the covid-19 pandemic: rapid review
.
BMJ
.
2020
;
369
:
m1936
.
52
Vargas
T
.
A father of four voted for the first time. Days later, he died alone because of a president’s failure
.
Washington Post
.
November
14
,
2020
. Accessed November 15, 2020.
53
Wakam
GK
,
Montgomery
JR
,
Biesterveld
BE
,
Brown
CS
.
Not dying alone—modern compassionate care in the Covid-19 pandemic
.
N Engl J Med
.
2020
;
382
(
24
):
e88
. doi:
54
Ramachandran
P
,
Swamy
L
,
Kaul
V
,
Agrawal
A
,
Narasimhan
M
.
Powerless in the ICU: perspectives from ICUs in the face of coronavirus disease 2019
.
Chest
.
2020
;
158
(
3
):
881
-
883
.
55
Nacoti
M
,
Ciocca
A
,
Giupponi
A
, et al
.
At the epicenter of the Covid-19 pandemic and humanitarian crises in Italy: changing perspectives on preparation and mitigation
.
NEJM Catalyst
.
March
21
,
2020
. Accessed July 15, 2020.
56
Andone
D
,
Murphy
PP
.
What it’s like for health care workers on the front lines of the coronavirus pandemic
.
CNN website
.
March
29
,
2020
. Accessed November 15, 2020.
57
Maunder
R
,
Hunter
J
,
Vincent
L
, et al
.
The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital
.
CMAJ
.
2003
;
168
(
10
):
1245
-
1251
.
58
Albashayreh
A
,
Archimbault
P
,
Arnold
B
, et al
.
COVID Ready Communication Playbook
.
VitalTalk
. Accessed June 16, 2020.
59
Cowper
A
.
Covid-19: are we getting the communications right?
BMJ
.
2020
;
368
:
m919
.
60
Burns
E
.
Palliative and end of life care for older people
.
British Geriatrics Society
.
March
1
,
2010
. Accessed November 15, 2020.
61
Jackson-Meyer
K
.
The principle of proportionality: an ethical approach to resource allocation during the COVID-19 pandemic
.
Bioethics.net
.
April
1
,
2020
. Accessed July 15, 2020.
62
Sprung
CL
,
Joynt
GM
,
Christian
MD
,
Truog
RD
,
Rello
J
,
Nates
JL
.
Adult ICU triage during the coronavirus disease 2019 pandemic: who will live and who will die? recommendations to improve survival
.
Crit Care Med
.
2020
;
48
(
8
):
1196
-
1202
.
63
Todrys
KW
,
Howe
E
,
Amon
JJ
.
Failing Siracusa: governments’ obligations to find the least restrictive options for tuberculosis control
.
Public Health Action
.
2013
;
3
(
1
):
7
-
10
.
64
Seethala
R
,
Keller
SP
.
Extracorporeal membrane oxygenation resource planning in the setting of pandemic respiratory illness
.
Ann Am Thorac Soc
.
2020
;
17
(
7
):
800
-
803
.
65
White
DB
,
Lo
B
.
A framework for rationing ventilators and critical care beds during the COVID-19 pandemic
.
JAMA
.
2020
;
323
(
18
):
1773
-
1774
.
66
Abbasi
J
.
Prioritizing physician mental health as COVID-19 marches on
.
JAMA
.
2020
;
323
(
22
):
2235
-
2236
.
67
Perry
S
.
At Harborview Medical Center, volunteers sit with the dying—and it changes lives
.
UW Medicine
. Fall 
2018
. Accessed June 16, 2020.
68
Hollander
JE
,
Carr
BG
.
Virtually perfect? telemedicine for Covid-19
.
N Engl J Med
.
2020
;
382
(
18
):
1679
-
1681
.
69
Neville
TH
.
COVID-19: a time for creative compassion
.
J Palliat Med
.
2020
;
23
(
7
):
990
-
991
.
70
Emanuel
EJ
,
Emanuel
LL
.
The promise of a good death
.
Lancet
.
1998
;
351
(
suppl 2
):
SII21
-
SII29
.
71
Granda-Cameron
C
,
Houldin
A
.
Concept analysis of good death in terminally ill patients
.
Am J Hosp Palliat Care
.
2012
;
29
(
8
):
632
-
639
.
72
Schaepe
C
,
Ewers
M
.
“I see myself as part of the team”— family caregivers’ contribution to safety in advanced home care
.
BMC Nurs
.
2018
;
17
:
40
. doi:
73
Thompson
G
,
Shindruk
C
,
Wickson-Griffiths
A
, et al
.
“Who would want to die like that?” perspectives on dying alone in a long-term care setting
.
Death Stud
.
2019
;
43
(
8
):
509
-
520
.
74
Donnelly
SM
,
Donnelly
CN
.
The experience of the moment of death in a specialist palliative care unit (SPCU)
.
Ir Med J
.
2009
;
102
(
5
):
143
-
146
.
75
Maunder
R
,
Hunter
J
,
Vincent
L
, et al
.
The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital
.
CMAJ
.
2003
;
168
(
10
):
1245
-
1251
.
76
Booth
CM
,
Stewart
TE
.
Communication in the Toronto critical care community: important lessons learned during SARS
.
Crit Care
.
2003
;
7
(
6
):
405
-
406
.
77
Hawryluck
L
,
Lapinsky
SE
,
Stewart
TE
.
Clinical review: SARS— lessons in disaster management
.
Crit Care
.
2005
;
9
(
4
):
384
-
389
.
78
Rambaldini
G
,
Wilson
K
,
Rath
D
, et al
.
The impact of severe acute respiratory syndrome on medical house staff: a qualitative study
.
J Gen Intern Med
.
2005
;
20
(
5
):
381
-
385
.
79
Wall
S
,
Austin
WJ
,
Garros
D
.
Organizational influences on health professionals’ experiences of moral distress in PICUs
.
HEC Forum
.
2016
;
28
(
1
):
53
-
67
.
80
Dodek
PM
,
Wong
H
,
Norena
M
, et al
.
Moral distress in intensive care unit professionals is associated with profession, age, and years of experience
.
J Crit Care
.
2016
;
31
(
1
):
178
-
182
.
81
Coronavirus: Lack of medical supplies ‘a national shame’
.
BBC News
.
March
28
,
2020
. Accessed April 15, 2020.
82
Rosenbaum
L
.
Harnessing our humanity—how Washing-ton’s health care workers have risen to the pandemic challenge
.
N Engl J Med
.
2020
;
382
(
22
):
2069
-
2071
.

Footnotes

 

FINANCIAL DISCLOSURES

None reported.

 

To purchase electronic or print reprints, contact American Association of Critical-Care Nurses, 27071 Aliso Creek Road, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; email, reprints@aacn.org.