Lucia Wocial, 60
Title: Nurse ethicist, Charles Warren Fairbanks Center for Medical Ethics at Indiana University Health
Location: Indianapolis
Wocial is part of a resource team that helps patients, their families and fellow nurses grapple with difficult ethical issues. She supports them through education and training.
As told to Ruben Castaneda, as part of U.S. News & World Report’s “One Pandemic Question” series. Responses have been edited for length and clarity.
Q: How did the COVID-19 pandemic affect you and the nurses you work with?
Nurses faced ethical issues every day before the pandemic, and the number of challenges has increased dramatically with COVID-19.
Nurses are identified as the most trusted profession. In fact, we take care of people at their most vulnerable. During the peak of the pandemic, we were put in a position where we had to balance compassionate care with the underlying concern of not having enough resources. How do we do that when we must restrict access to family members? It was difficult to navigate when people were dying alone.
[Read: A Day in the Life of an ICU Nurse During the COVID-19 Pandemic.]
Many people understood the need to protect patients and families from exposure to the novel coronavirus, yet having people die alone felt like a bridge too far.
When hospitals locked down and restricted visitors because of COVID-19, it was not uncommon for families and staff to ask for compassionate exception, to allow visits. Not just families — everybody. Nurses, physicians and social workers asked for this. The most common example when it comes to asking for compassionate exception involves situations around the end of life.
Imagine a couple married for 50 years, and the husband is sick with COVID-19 and isn’t going to make it. The wife is never going to see him again, but she can’t see him in the hospital because we can’t let her in; she might get sick. Imagine how that feels — not only for the wife but for the clinical team caring for the patient.
For end-of-life situations, health care best practices include allowing the family to be present with the patient, providing opportunities for them to make memories, to say goodbye. People who work in hospitals know that one of the best ways to show compassion is to support both the patient and family during the dying process. We couldn’t do that with COVID-19 patients. There are no good places to die. Studies show that people do not want to die in hospitals, hooked up to machines. Many people do not have the support or resources to care for a family member in their home who is dying.
In the end, we made the best use of technology — video calls when possible — and, honestly, a lot of people went above and beyond to be with patients so they would not die alone. I met with our nursing professional practice council to examine the ethical complexities of the situation and encouraged them to voice their concerns and offer concrete suggestions to hospital leadership. With additional input from our ethics committee and chaplain service, when families had to make difficult decisions, we made an exception for at least one family member to come to the hospital for those discussions and even let one family member be with the patient as they died.
There has been a lot of death with COVID-19. One of the most challenging situations was caring for COVID-19 patients who don’t believe they have COVID and don’t believe they’re dying. How do you help someone who isn’t ready to be helped? The ethics of that are straightforward: care for the patient with compassion. It is still very distressing.
[See: A Look at Hospitals, Health Care Workers Fighting the Coronavirus Pandemic.]
At some point, those patients will lose their ability to communicate and you talk to their family members, who are completely ill-prepared, and everybody’s just completely devastated.
We in health care in the U.S. leave no stone unturned to help patients. We don’t ask for your insurance card if you’re critically ill, we treat you. This approach is resource-intensive, and not just when it comes to equipment.
Typically, in a busy hospital you might do three or four intubations in a 24-hour period, maybe five or six. During the pandemic, in one 24-hour period, you do 30. From a nursing care standpoint, if you have someone who needs to be on a ventilator, they probably need multiple medications that you need to keep track of. Their kidneys may start to fail and you have to start dialysis. That takes a lot of skill, concentration and time.
You have a patient who needs more and more care and you know that patient is not going to survive, and you keep asking me to do more and more for this patient. That means there are five other patients in my care who will get less attention. They might survive, but their ability to survive is compromised if I have to pay more attention to patients who likely won’t.
[Read: Unsung Heroes Fight the COVID-19 Pandemic.]
I talk about these ethical dilemmas with nurses. Nurses ask: ‘What is the right thing to do?’ Very few people have had time to think about how they will practice in a pandemic. The help people need is reconciling the shift in the standard of care. Part of what we recommend is acceptance of doing the best you can with limited resources; identifying what is possible, not focusing on the ideal. When you hear nurses say if only, we can help them identify all the good things they are doing that represent compassionate care even if that is not what they would do under normal circumstances.
We can get another ventilator or more personal protective equipment, but how are you going to clone a nurse so they can give more time and attention to other patients down the hall?
In some ways, the experience of the last year has fired me up. We have to fix the health care system in the United States, which focuses on critical illness and fails to provide resources to keep people healthy. It’s hard to know how to fix it when frankly people are just trying to keep up with taking care of their patients.
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