The AAS Ethics Committee held its first annual Artwork and Essay Contest in 2021 – the topic for the essay contest was “What is the most challenging ethical issue, personal or professional, you have encountered in the COVID era?” The winning essay and artwork were selected by the Ethics Committee and will be published in the October issue of the Journal of Surgical Research. But we also want to share many of the powerful entries we received for this contest, so look for more of these essays to post as blog articles between now and the 2022 ASC – thank you to everyone who participated in the contest!
Krista Haines, AAS Committee Chair & JJ Jackman, AAS Executive Director
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He was only 70 but flirting with death upon arrival to our ICU. Like so many other relatively young and otherwise healthy Hispanic people, he had chosen to wait until his agonizingly labored breathing had forced him past the doors of a community hospital emergency room. Because he worked all day. Manual labor. To support his family. The physicians there provided exceptional care and initiated all the appropriate therapies in as timely a manner as possible. But he was more than that small hospital could handle, already bursting at the seams with so many more just like him. And so his path and mine crossed. When I first met him, it was from above my N95 mask and through my thick face shield. He was intubated, sedated, paralyzed, and on maximal ventilatory support to barely maintain an adequate level of oxygenation. My physical exam was rather limited. He had marked conjunctival edema, his face and neck appeared engorged and, although there was air entry bilaterally, it certainly was faint and far away. The next few days proceeded like they too often do. His wife and numerous family members attempted to visit, but were denied the opportunity to do so in person for their own safety as well as for that of everyone else. Only his wife was allowed a few minutes of staring at the man she loved from the antechamber of his room. She asked him not to die. And then she left. For most of the week, his respiratory status made no progress whatsoever. He developed progressively worsening acidosis and acute kidney injury, and his hemodynamic status also worsened. He was eventually started on CRRT, after numerous conversations with his wife (who had also just tested positive for COVID-19 herself) regarding both his wishes and his very poor prognosis. Our Chaplain was there for most of these heartbreaking discussions, bridging the language gap, attempting to somehow fill the ever-growing emotional void, and alleviating some of the mounting desperation. He expired five days later.
Much like this gentleman, so many COVID-19 patients are transferred to us in such dire condition that we are often forced to engage in a balancing act between beneficence, non-maleficence, and patient autonomy. Families expectedly want us to “do everything” to save their loved one, which we do. With passion and dedication and, over time, at great personal cost. The extent of what we do to these patients over sometimes weeks to months is beyond what I can portray in words. Which makes it incredibly difficult to admit one day that we have reached the point of medical futility. And given the often protracted course of this disease, how do we truly even know that we have? And if we have and don’t realize it, to how many other potentially salvageable people are we denying care by persevering on that one case? And are we even possibly causing harm, either physical or psychological, by so persevering? It may not be immediately evident, but COVID-19 patients who have reached the point of requiring paralysis and proning as a heroic effort to maintain oxygenation are so fragile and labile that even the act of turning them can lead to extreme hemodynamic changes and cardiac arrest. In a COVID-19 room. With a limited number of doctors and nurses who will then put themselves at risk during subsequent attempts at resuscitation. In this day and age, almost anyone can be kept “alive” for nearly any length of time. Whether we should and whether doing so would be concordant with the individual’s wishes and with the just distribution of scarce resources is a different issue. As Surgeons, this balancing act is also one that we perform routinely, advocating for patient autonomy and the fair distribution of resources and against non-beneficial surgical care and interventions. I want to believe that, as physicians, the core ethical principles proposed by Beauchamp and Childress are deeply ingrained in us and guide our everyday practice. As much as this pandemic has made glaringly obvious some of the health disparities that still plague our society, it has also emphasized people’s empathy and selflessness, as well as the acquired art of cultural sensitivity and competency and that of communicating to families where the limit of medicine is. Yet there is still more to be done. Perhaps by understanding and addressing the less tangible but equally important spiritual needs of our patients and their loved ones. At our institution, our Chaplains are not only available but remarkably involved with COVID-19 patients and their relatives, regardless of their religious beliefs or background. They provide opportunities for so-called video visits between COVID-19 patients and their family members and friends. This has been instrumental in lessening the sense of isolation and fear, especially among our Hispanic population, who anecdotally appears to be affected more frequently and more severely by this virus. I make this observation with no hard data to support it, but I worry about the biases that keep certain groups of people away from our care until it is nearly too late. In my albeit limited experience, we routinely go to extreme measures to weather the COVID-19 storm, fairly and equally for all patients, and we make deliberate efforts to recognize when our efforts are failing. We welcome the opportunity to care for anyone who needs us, and I wish that that was common knowledge.
I have no eloquent answers to the questions above. What I do know is that, as Surgeons and Intensivists, we face these challenges every day. We face medical challenges as well as those of cultural competency and communication. Which does not even compare with what families must endure and with what it means to die alone, two sets of glass doors removed from the rest of the world. And so I would argue that the ethical solution is in everyone’s hands. Do no harm. Wear masks. Socially distance. Protect yourself, the ones you love, and those whom you may have not yet met.