COVID‐19 pandemic experiences, ethical conflict and decision‐making process in critical care professionals (Quali‐Ethics‐COVID‐19 research part 1): An international qualitative study

Abstract

Aim and Objectives The aim of this study was to explore the sources of ethical conflict and the decision‐making processes of ICU nurses and physicians during the first and subsequent waves of the COVID‐19 pandemic. Background Depside several studies exploring ethical conflicts during COVID‐19 pandemic, few studies have explored in depth the perceptions and experiences of critical care professionals regarding these conflicts, the decision‐making process or which have analysed the complexity of actually implementing the recommendations of scientific societies and professional/healthcare institutions in interdisciplinary samples. Design A descriptive phenomenological study. Methods Thirty‐eight in‐depth interviews were conducted with critical care nurses and physicians from five hospitals in Spain and Italy between December 2020 and May 2021. A thematic content analysis of the interview transcripts was conducted by two researchers. Consolidated criteria for reporting qualitative research (COREQ) were employed to ensure the quality and transparency of this study. Results Two main themes emerged as sources of ethical conflict: the approach to end of life in exceptional circumstances and the lack of humanisation and care resources. The former comprised two subthemes: end‐of‐life care and withholding and withdrawal of life‐sustaining treatment; the latter comprised three subthemes: the impossibility of guaranteeing the same opportunities to all, fear of contagion as a barrier to taking decisions and the need to humanise care. Conclusions Professionals sought to take their decisions in line with professional ethics and bioethical principles, but, nevertheless, they experienced moral dilemmas and moral distress when not being able to care for, or to treat, their patients as they believed fit. Relevance to Clinical Practice Further education and training are recommended on the provision of end‐of‐life and post‐mortem care, effective communication techniques via video calls, disclosure of bad news and bioethical models for decision‐making in highly demanding situations of uncertainty, such as those experienced during the COVID‐19 pandemic.

Nurses Response to the Physical and Psycho-Social Care Needs of Patients with COVID-19: A Mixed-Methods Study

“…Over time, however, tiredness set in, and the staff’s personal availability partially decreased. Especially in the initial stages of the pandemic, there was a lot of fear of being infected and of infecting family [ 44 ].…”

“…On the other hand, accompanying patients until they died in solitude, with closeness and bodily contact, made it difficult for nurses not to empathize with them. Being close to the dying patient was also a profound need of the nurses themselves [ 5 , 44 ]. This closeness with patients also made it difficult to passively accept the rules in the department that obliged nurses not to resuscitate serious patients, against which some nurses tried to rebel, knowing that they no chance of changing things but felt they should advocate for those patients.…”

“…This closeness with patients also made it difficult to passively accept the rules in the department that obliged nurses not to resuscitate serious patients, against which some nurses tried to rebel, knowing that they no chance of changing things but felt they should advocate for those patients. This was just one of the many examples of ethical conflicts or moral distress experienced by nurses and other healthcare workers during the pandemic [ 5 , 44 , 45 ].…”

“…Factors experienced as barriers to the quality of care instead included the necessary standardization of many activities (i.e., giving at least the minimum to everyone) and the lack of adequate intensive care skills of many nurses, who could only support the work of their more expert colleagues and were not directly in charge of critically ill patients. This situation was a source of psychological stress and moral distress [ 5 , 44 ]…”

Protective factors of ethical conflict during a pandemic—Quali‐Ethics‐COVID‐19 research part 2: An international qualitative study

“…The qualitative study we report here forms part of a larger study examining ethical conflicts in the ICUs of Italy and Spainamong the first European countries to be hit by the emergencyduring the first wave of COVID-19. In the first part of this study we describe the ethical conflicts directly attributable to the health emergency and how decisions were taken in response (Falcó-Pegueroles et al, 2023). In the second part, we examine the factors that proved useful in preventing these conflicts during the • Nurses and physicians used ethical words such as justice, demanding, dedication and moral distress to describe their experiences during the sanitary crisis, demonstrating the complexity of the situation faced.…”