A 55-year-old man, ‘Dunphy,’ is in the hospital with acute respiratory distress syndrome. Dunphy has been living with asthma before being diagnosed with acute respiratory distress syndrome. The patient has been receiving supportive care including ventilator support. Due to the severity of his condition, Dumpy had been hospitalized for one month before being sent home with a tracheostomy. Even though his condition had improved, Dumpy started having breathing problems and had to be rushed back to the hospital for emergency ventilation support. Unfortunately, Covid-19 has ravaged the nation and made all hospitals, particularly, the intensive care unit to be over-packed. Three patients in the intensive care unit have recovered from Corona and are discharged. Dumpy is brought in at the hospital. After that, four young patients, aged 23-26 years, with critical breathing issues due to Covid-19 arrive a few minutes later. The nurse in charge of the unit is conflicted about prioritizing the patients with Covid-19 or withholding treatment for Dunphy.
The Covid-19 pandemic impacted all nations globally. Some nations, such as the US were severely affected. While healthcare professionals struggled to handle the rising cases of Covid-19 infections, the healthcare system was still plunged with patients suffering from various chronic conditions, with some requiring intensive care. According to Douplat et al. (2020), many healthcare teams faced the challenge of withholding treatment during the pandemic. The decision to withhold treatment is not intentional. Instead, the pandemic resulted in a scarcity of resources and time to cater for those with underlying conditions alongside those infected with Corona. Bearing in mind the severity of the Coronavirus and its high infection rate, most health workers chose to focus on those affected by the pandemic at the expense of patients battling other types of medical conditions. For instance, Ehni et al. (2021) explain that the pandemic caused a scarcity of resources for artificial ventilation in intensive care units. Consequently, patients with acute respiratory disorder were severely affected as the resources were too scarce to care for them. When encountered with such scenarios, nurses are faced with an ethical dilemma about the right course of action to take. Difficult decisions had to be made about resource allocation and treatment.
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Relevant Ethical Principles or Values
The ethical values of beneficence, non-malfeasance and respect for autonomy are the most applicable to this ethical scenario. Butts and Rich (2016) describe the ethical principle of beneficence and non-malfeasance to involve promoting the health and wellbeing of people and doing no harm by being kind and merciful. Based on this principle, providers have the ethical duty to engage in actions that promote the well-being and health of patients. On the other hand, respect for autonomy refers to allowing a person to make a decision, as long as they do not harm others. As such, this principle advocates for patients to be given the independence of deciding to refuse treatment for the sake of other persons who are critically ill.
Quality of Life Approach
The quality of life approach is the most relevant to the ethical issue related to withholding treatment during the Covid-19 pandemic. First, the prospects of a return to normal life for a patient with Covid-19 are minimal, especially without treatment. Gibson et al. (2020) indicate that Covid-19 is a novel disease that can mutate and infect-non-immune populations. Many nations have reported high numbers of deaths since the beginning of the pandemic. Fortunately, the prospects of returning to a normal life with treatment are higher. Most patients who isolated and followed the treatment procedures returned to a normal life. There were a few cases of the disease recurring. Gibson et al. (2020) indicate that the probability for recovery for critically ill patients with Covid-19 is minimal in comparison to those with ARDS. This makes patients with Covid-19 to be given a higher priority.
The social, mental and physical deficits a patient is likely to go through after the treatment of Covid-19 does well are plenty. Mentally, a patient might experience trauma due to the fear of having a recurrent infection or from the experience of having Coronavirus. Patients might also experience social isolation after the successful treatment of Covid-19. The fear surrounding the virus has resulted in people isolating themselves from others due to the fear of infection. On the other hand, there are no mental and social deficits after successful treatment of ARDS. A patient will resume normal life without any hindrance. Physical deficits might be experienced in terms of lung damage.
Yes, some partialities might prejudice a provider of a patient’s value of life. Unlike ARDS, Covid-19 is a new virus that has adversely affected the whole world. There is minimal research on this virus, thus impacting the ability of providers to make an accurate assessment of the recovery options of a patient. Additionally, the high rates of death caused by Covid-19 have generated fear among public and healthcare providers. This might cause providers to view all of Covid-19 cases as lethal. On the other hand, providers have extensive experience with patients suffering from ARDS. There is also in-depth research about this disease alongside its treatment option. Healthcare providers are not likely to be biased when evaluating the quality of life of a patient with ARDS.
The present and future conditions of patients with Covid-19 and ARDS might determine the probability of continued life. .According to Matthay et al. (2019), the mortality rates for patients with acute respiratory distress syndrome are 30-40%. Moreover, most patients who survive after undergoing treatment become susceptible to functional or psychological sequelae. Most patients with Covid-19 develop ARDS. The mortality risk of the Covid-19 increases with age (Ehni et al., 2021). However, Covid-19 has severe outcomes in comparison to ARDS (Gibson et al., 2020). On the other, even though the acute respiratory disorde r is infectious, it does not mutate. Thus, the patient's present and future condition in terms of the age and criticality of the disease might determine if continued life is undesirable. Younger patients are most likely to survive and recover from Covid-19. On the other hand, many people with severe ADRs do not survive, particularly older people.
There is no plan to forgo treatment for Covid-19 patients, as they will only get worse or infect others in the home setting. The only plans for the comfort of palliative care include ventilator support. On the other hand, there is a plan to forgo treatment for the 55 years old patient, due to his age. Plans for palliative care include continuous neuromuscular blocking agents, high-dose corticosteroids, and recruitment manoeuvers (Gibson et al., 2020). Provision 4 of the ANA Code of Ethics states that “ The nurse has authority, accountability and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to provide optimal patient care” (ANA, n.d. p. 1). Based on this provision the nurse has the authority to make the decision based on their clinical judgment. This decision involves maximizing the benefit of care by providing treatment to young patients with Covid-19.
Humanistic Theory
The humanistic nursing theory translates to engaging in authentic dialogue with patients. The nurse-patient interactions should be guided by a nurse and be based on the existential experiences of the patient and the nurse ( Butts & Rich, 2016) . This theory believes that patients have a unique understanding of the world and should be given the freedom to make choices. Based on this theory, the nurse with the dilemma of whether to withdraw treatment should reason with the 55-year-old patient about the situation within the intensive unit. Furthermore, the nurse can explain the young ages of the four patients who are more likely to survive the treatment in comparison to the 55-year-old patient with acute respiratory distress.
Ethical Scenario
I once worked in a non-profit medical-based organization as a volunteer. I had hoped to utilize my nursing knowledge in providing medical services to the people of the remote village where I had been assigned. The non-profit organization had been experiencing challenges in garnering donations and sponsorship to support the purchase of medical equipment. I was almost done with my shift one evening and was seated at the bedside of an elderly woman suffering from dementia. A patient, who was 30 years old, came in while complaining of intense stomach pain. The patient was in extreme agony, and I suspected a case of food poisoning. As I was checking for symptoms in an attempt to diagnose the patient, a mother rushed in with a 10 years old boy who had been involved in an accident. The body was profusely bleeding from the head injury he has sustained. The 30-year-old patient looked at me and asked me to finish up with him because he had traveled for quite a distance to reach the clinic. I had two options: two finishing diagnosing and treating the 30 years old patient with stomach pains or to attend to the 10 years old boy first, as the former patient waited.
The strategy that would help to advocate for the patients is to make a clinical analysis to determine which the most crucial situation between the two was. Secondly, it would be prudent to analyze the harm that would come to each patient if left for 20minutes as I attended to the other patient. However, I assessed the situation and determined that the boy was in a critical condition as he was losing a lot of blood. Attending the 30-year patient would have put the boy at risk of losing a lot of blood. This might have hindered the boy's ability to recover or would have resulted in brain damage. The principle of non-maleficence urges nurses to not harm ( Butts & Rich, 2016) . There was also the possibility that the boy was hemorrhaging.
Overall, the case scenario about withholding treatment during Covid-19 highlights the ethical dilemmas providers encounter in healthcare settings. There is a gap between what is legal and what might be considered ethical. The concept of withholding treatment to a patient might be deemed illegal. However, considering the critical situation of other patients, such as those with Coronavirus, might deem the decision to withhold treatment ethical. Using the Four Approach method significantly changed my decision-making. The approach allowed me to critically evaluate the ethical dilemma and make the best decision that would lead to more benefit. I do not believe this is a unique case as healthcare providers face situations that require one to decide providing or withholding treatment. this analysis has impacted my nursing practice as it has enlightened me on the different strategies to utilize in addressing an ethical dilemma. A nurse should not be led by biases when choosing the best course of action. Instead, critical analysis using ethical principles and values is required in making a decision. Diseases are evolving, such as SARS and Covid-19. This might force providers to re-evaluate their principles based on the situation at hand.
References
ANA. (n.d.). American Nurses Association Code of Ethics for Nurses . https://nursing.rutgers.edu/wp-content/uploads/2019/06/ANA-Code-of-Ethics-for-Nurses.pdf
Butts, J. B., & Rich, K. L. (2016). Nursing ethics across the curriculum and into practice . Boston, MA: Jones and Bartlett.
Douplat, M., Jacquin, L., Frugier, S., Tazarourte, K., & Le Coz, P. (2020). Difficulty of the ethical decision–making process in withholding and withdrawing life-sustaining treatments in French EDs during COVID pandemic. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine , 28 (1), 1-2. https://sjtrem.biomedcentral.com/articles/10.1186/s13049-020-00772-3
Ehni, H. J., Wiesing, U., & Ranisch, R. (2021). Saving the most lives—A comparison of European triage guidelines in the context of the COVID‐19 pandemic. Bioethics , 35 (2), 125-134. https://doi.org/10.1111/bioe.12836
Gibson, P. G., Qin, L., & Puah, S. H. (2020). COVID-19 acute respiratory distress syndrome (ARDS): clinical features and differences from typical pre-COVID-19 ARDS. Med J Aust , 213 (2), 54-56. https://www.mja.com.au/system/files/issues/213_02/mja250674.pdf
Matthay, M. A., Zemans, R. L., Zimmerman, G. A., Arabi, Y. M., Beitler, J. R., Mercat, A., ... & Calfee, C. S. (2019). Acute respiratory distress syndrome. Nature Reviews Disease Primers , 5 (1), 1-22. https://www.nature.com/articles/s41572-019-0069-0?fbclid=IwAR1TOMplW3IupWiqGn6evud5Ry5vfezlxQxdV-0AjPIIsGyHlX07nuaJm4M
