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Moral Distress in Nova Scotia’s Healthcare System During COVID-19

By:

Marika Warren, PhD 
Health Care Ethicist, NSHEN 
Assistant Professor, Department of Bioethics 
Dalhousie University 

 

 

Moral distress, defined as not being able to align your actions or practice with your moral obligations and commitments, is an entirely reasonable reaction to a situation wherein the pandemic and our responses to it have radically shifted how we provide health care.  

Below I describe some of the things that are unique to moral distress during COVID and the effects that has in health care.  In closing I offer some reflections on describing situations causing moral distress as moral dilemmas instead, which shifts the focus from an individual “falling short” to the fact that it’s.an untenable situation.

What are some differences in the experience of moral distress during COVID?

•    COVID is pervasive – we’ve all been deeply affected personally as well as professionally.  Conversations with loved ones and colleagues often provide essential support for managing moral distress, and COVID has diminished these opportunities significantly by increasing isolation and limiting our ability to connect with others.  

•    Patients and families, often stressed and vulnerable when seeking health care even in the best of circumstances, have heightened anxiety during COVID and this is often expressed in challenging behaviours.  Health care providers are called on to respond to these behaviours empathetically when everyone’s compassion is in short supply.  

•    COVID has affected us cognitively as well; the phenomenon of “COVID-brain” is well-documented and the stresses associated with being in “survival mode” long-term deplete our mental energy.  

•    COVID has also exacerbated many pre-existing challenges in health care related to resource constraints, which are a common contributor to moral distress, and has created fear of both known backlogs and existing wait lists and an backlog of uncertain volume caused by delays in seeking or being able to access care.  

•    Even carefully planned and well-managed system changes can give rise to moral distress, and we’ve been living through constant, significant, and unpredictable changes throughout the health care system for the last 20 months (and counting).

•    Finally, because COVID-19 is a novel pathogen there is extensive uncertainty around how it will react in response to our behaviour, and this means that the goalposts that might signal the end of the pandemic keep on moving.

Effects of moral distress during COVID

We see the effects of moral distress throughout the health care system; moral injury is prevalent given the relentless and widespread experience of being ethically compromised.  Health care providers are doing all they can to continue providing the best care they can but are hitting breaking points both individually and as teams and services.  In Nova Scotia we see examples of this in decisions to pause referrals for MAiD, individuals leaving the health professions even in the absence of alternative employment, and emergency department closures.  Health human resources are dangerously depleted, in Nova Scotia and elsewhere, and there are no reserves that we can draw on either individually or as health care systems

Moral distress or moral dilemma – shifting perspectives

The definition of moral distress – that you know what the “right” thing to do is and would do that thing if not for some impediment – assumes that it is possible to provide care in ways that meet our ethical obligations. So even though this is the terminology that has been used to capture feelings of moral failure during COVID, it strikes me as inaccurate.  If the care that we feel we should be providing is some version of what we did in the “before times”, this is no longer feasible.  For example, encouraging loved ones to visit frequently and become involved in care was endorsed as good, patient and family-centred care with a high likelihood of benefit to patients.  Now, however, the likelihood of harm to patients, health care providers, and others in health care facilities means that even though welcoming visitors seems possible because we remember doing it not long ago, the current situation is importantly and relevantly different such that extensive visiting is likely to be the “wrong” thing to encourage when COVID is active in the community.  

It might be clearer to describe the situation of health care workers as being in a constant moral dilemma, where there are two equally undesirable options available to us and neither choice will feel comfortable. This framing can help us focus on the fact that we are all doing the best we can within an impossible set of circumstances.

NSHEN remains committed to providing health ethics resources during the COVID-19 pandemic.

Please visit our COVID-19 resources page for ethics related items  that we update as new information becomes available.


http://www.nshen.ca/index.php/covid-19-resources/ 
Twitter
Our Twitter feed (@NSHEN1) is a great resource for updated health and news information on the current COVID-19 pandemic. We upload not only our own ethics resources but other information that is we feel is pertinent to our followers.  
Facebook
Our Facebook page (@NSHealthEthicsNetwork) is a great resource for updated health and news information on the current ethics news from NSHEN and other ethics resources that is we think you may find interesting.  

New NSHEN Ethics Resource 


Podcast

 

It's Complicated: A Podcast About Healthcare Ethics in Practice 

Presented by NSHEN

NSHEN is excited to announce our new resource, a podcast called “It’s Complicated: A Podcast About Healthcare Ethics in Practice” with episodes coming every two months from the NSHEN Team and special guest speakers, on a variety of healthcare topics that have ethical overtones. We will also feature our book reviews and featured article summaries.

Our first episode, “Meet the NSHEN Team” is now available for your listening pleasure here:

Meet the NSHEN Team - Episode 1

New Ethics Afer Hours 


Netflix

 

Diagnosis-

A Question of Trust


‘A Question of Trust’ is the fifth episode in the Netflix documentary series Diagnosis, which based on Dr. Lisa Sanders’ column in the New York Times. In this episode we meet Lashay, a 17 year old girl who is not able to hold down anything she eats or drinks. Dr. Sanders turns to crowdsourcing for advice regarding a possible diagnosis given Lashay’s symptoms. The crowd’s suggestions point toward a diagnosis that Lashay has already been given by her own doctors, but Lashay and her family are leery of the crowd’s advice. The way Lashay’s possible diagnosis was communicated to her has left her feeling judged by her medical providers and the family’s reluctance to accept the diagnosis appears to be due to a lack of trust in the medical profession. 

Diagnosis– Netflix

 

Read more with discussion guide on this Netflix movie

Fireside Chat Video Series

New interview available!

Ethics in Vaccine Research

with


Scott Halperin, MD, Professor of Pediatrics and Microbiology & Immunology Director, Canadian Center for Vaccinology
 

Latest Featured Article Summary


Our Next Pandemic Ethics Challenge? – Allocating “Normal” Health Care Services
 

by Jeremy R. Garrett, Leslie Ann McNolty, Ian D. Wolfe, and John D. Lantos. Hastings Center Report, 2020.
 

Abstract

The pandemic creates unprecedented challenges to society and to health care systems around the world. Like all crises, these provide a unique opportunity to rethink the fundamental limiting assumptions and institutional inertia of our established systems. These inertial assumptions have obscured deeply rooted problems in health care and deflected attempts to address them. As hospitals begin to welcome all patients back, they should resist the temptation to go back to business as usual. Instead, they should retain the more deliberative, explicit, and transparent ways of thinking that have informed the development of crisis standards of care. The key lesson to be learned from those exercises in rational deliberation is that justice must be the ethical foundation of all standards of care. Justice demands that hospitals take a safety-net approach to providing services that prioritizes the most vulnerable segments of society, continue to expand telemedicine in ways that improve access without exacerbating disparities, invest in community-based care, and fully staff hospitals and clinics on nights and weekends.
 

NSHEN Article Summary:
Our Next Pandemic Ethics Challenge? – Allocating “Normal” Health Care Services

 

Read More

Ethics Nova Scotia Health presents:

Informed Choice Subject Guide


This subject guide outlines five aspects of informed choice. It is intended as a quick reference guide for health care professionals.

Informed choice involves supporting patients* in making choices about their care. It is one of the cornerstones of good health care practice. Professional ethics and legal requirements impact what is important to address.
 
Informed Choice by NS Health
Download and print a copy of the Informed Choice subject guide here.

National Health Ethics Week 2021

National Health Ethics Week is a time Canadian health institutions, schools and universities, research and clinical ethics committees, healthcare professionals, community organizations, businesses, and members of the general public set aside to host and take part in educational events that explore health ethics that affect Canadians.

The goals of National Health Ethics Week are to:


Encourage events across the country to raise awareness and promote dialogue about bioethics ethics issues facing our communities;

Facilitate networking between individuals interested in bioethics;

Provide greater visibility for the services offered by the Canadian bioethics community, including research ethics boards and clinical ethics committees;

Offer an opportunity for Canadians to get engaged in discussions that have important policy-making implications in the health arena.


CBS Event: Mandatory Vaccination Policies: Ethical Considerations


To recognize National Health Ethics Week, CBS is hosting an event.  On November 2nd at 12:30 (EST) Al-Noor Nenshi Nathoo (Alberta Health Services) will be joined by Jocelyn Downie (Dalhousie University) and Bashir Jiwani (Fraser Health Ethics Services) to explore the ethics dimensions of mandatory vaccination policies.  Please see the poster below for more details.

BOOKS, BOOKS and MORE BOOKS

Did you know NSHEN has a book library?  Well, we do! Have a look at our current listings and if there is something you are interested in reading, we will loan it to you! 


Check the list often, we are always adding new titles!

https://www.nshen.ca/index.php/nshen-book-library/nshen-library-reserve-a-book/

Recent additions to our library include:

-About Us: Essays from the New York Times' Disability Series
-The Power of Ethics: How to Make Good Choices in a Complicated World 
-Already Toast: Caregiving and Burnout in America 
-Neglected No More: The Urgent Need to Improve the Lives of Canada's Elders in the Wake of a Pandemic
NSHEN Case Database & Resources

Plain Language Definitions – Ethics Health Care Terms

Straightforward Definitions of Terms in Health Ethics

Talking about values and principles in health care ethics can be confusing, especially if some of the words are unfamiliar.  NSHEN created a plain language definitions document which have short definitions to help make it clearer what some of the words that we use in ethics work mean.

Click on the link below to download the file.

NSHEN Plain Language Definitions -Ethics Health Care Terms

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