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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There is little doubt that the pandemic has changed humanity and medicine, the scope and far-reaching impacts of the coronavirus yet to be fully appreciated. Just as the virus has created novel challenges for society, so too has it created unprecedented ethical dilemmas. The initial waves of the pandemic created a number of well-publicized moral quandaries for health care organizations and providers. Over time, these ethical challenges evolved, particularly as organizational policies were established to protect patients, healthcare workers, families, and communities at large. As the consequences of system-wide policies came to bare impact at a clinical level, it was the unintended effect of one these policies that resulted in the most challenging ethical dilemma that I have ever experienced – the lessons from which, I continue to carry forward.
I was working in the surgical intensive care unit when the initial waves of COVID had shallowed. After months of restricted hospital visitation, a new policy was established allowing the activated healthcare power of attorney (HCPOA) of an incapacitated adult the chance to visit their loved one. Incapacitated adults without a formally documented HCPOA were omitted from the policy; however, a notable exception existed allowing loved ones the prospect of visitation if the patient was deemed imminently dying – the exemption intending to facilitate a compassionate transition for patients pursuing comfort-focused cares. This policy had been born of beneficence and was not exclusionary in intent. Rather, its purpose was to establish a boundary; to maintain a form of a visitor restriction – thereby mitigating the pervasive threat of viral spread – while celebrating engagement in joint decision-making. The demarcation centering on an HCPOA seemed balanced and natural.
As the hospital adjusted to the new policy, I watched as SICU patients came to bare its effects. Patient A was a man in his 70s who had had a challenging hospital course. A large retroperitoneal fluid collection of unknown etiology had ravaged his body, precipitating renal failure and a decline in his mental status. Next door, Patient B was a comorbid man in 70s, battling the effects of a perforated viscus, his hospital course also complicated by encephalopathy and renal failure. The two patients, with similarities in hospital course, separated by mere feet, had one significant difference: Patient A did not have a formally recognized HCPOA, while Patient B had completed the necessary documentation prior to his admission.
The new policy was initiated and the wife of Patient B was allowed visitation in order to help pilot his cares. Struggling from a difficult hospital course, with the prospect of a meaningful recovery yet undetermined, Patient B was transitioned to comfort-focused cares. He passed peacefully with his family at his side and the decision had been shared; it was carried out with the utmost respect for his wishes and his peaceful passing was viewed by family with both sadness and solace. The wife of Patient A, meanwhile, remained unable to visit, navigating goals of care from afar. It was apparent that she had become increasingly fatigued by the distant visage of the ICU however – having been informed of the policy, and without the capacity to utilize videoconferencing technologies, the inability to see her husband had taken its toll. Perhaps believing he was suffering, but most assuredly missing her loved one, Patient A’s wife requested full cessation of cares despite what had been gradual, sustained improvements in his health.
Simply put, ethical implications of the policy lay exposed. Although benevolent in its intention, the policy had placed remaining ethical principles in dispute. While the bias that had been created was unintentional, the implementation of the policy created a partiality that compromised patient justice. Because there was now conflict of interest, was it possible to respect surrogate autonomy? In the ICU, where seeing propagates understanding, had the policy inadvertently damaged the integrity of informed consent? Could joint decision-making take place in honesty? Lastly, the policy had compromised nonmaleficence; by not allowing families to see their incapacitated loved ones during points of critical decision-making, we had unintentionally incentivized the withdraw of life-supporting therapies so that families could see, touch and hold their family members before they passed.
The policy was eventually amended, allowing legal and non-legal appointees one-time visitation for life-altering decisions; unfortunately, the reformed policy would no longer prove applicable to Patient A by the time it was enacted. After thorough discussions, I conveyed to the wife that Patient A was continuing to recover – his trajectory had improved and he was safely transferring out of the ICU. Convalescence had been slow but we were no longer making life-altering decisions in his care; no longer was there a persistent fear that he was imminently dying. All this to say, his wife remained unable to visit, the policy change coming far too late.
When Patient A passed suddenly and unexpectedly days later, our team was left devastated…defeated. Weeks of dedication to his cares – of standing bedside, diligently pursuing both his recovery and the right to have his wife at his side – had resulted in a man, unable to see his wife, alone and unaccompanied by his loved ones in the waning weeks and months of his life. The initial policy had unsustainable clinical implications; it had failed the patient and it had failed his family. I shared in their pain, as the response to the imperfect policy had proved to be inadequate and untimely.
The last few months of Patient A’s life were framed by the shadows of the pandemic and his hospital course proved to be ethically challenging on both personal and professional fronts. In reflection, I offer this experience not in criticism, but as an opportunity for growth. Unquestionably, the ethical dilemmas presented gifted me the chance for personal development, strengthening my resolve to advocate for what is just. Professionally, this experience is an opportunity to learn from mistakes, to always consider the clinical implications of our decisions, and perhaps, to better prepare – and more quickly respond – to future challenges yet to come.