An Ethics Oasis in Our Pandemic Journey

Come, be heard, you are not alone with the discomfort, we are here with you.

Apatient rips off their mask, yelling at the doctor that COVID is a hoax. A masked doctor wonders if their nearly deaf patient, no longer able to read lips, really understands the procedure they consented to. In the hours prior to intubation, a COVID patient is not allowed to see their loved ones. A clinical team weighs one life against another to determine who receives ECMO when demand exceeds capacity. Healthcare workers are no strangers to moral distress, the painful experience of the gap between what we think should happen and what we can make happen. Since the arrival of COVID-19, we are getting toxic doses. How often do we wonder if we’re doing the right thing, or know we cannot? This comes at a time when we are increasingly distanced from the support of our colleagues —break rooms closed, masks covering our expressions, hugs not allowed. It’s enough to make anyone’s moral compass spin. One way to realign to our moral north star is to speak our experience. Our moral fibers, wounded by our experiences on the wards and clinics, can be strengthened by giving them voice. When we articulate out loud the conflict between how we want things to be versus how they actually are, we bolster our integrity and values. But who can we talk to? Our loved ones might not understand our work experiences. Coworkers are busy. What about HIPAA and liability issues? When

By Mary Anderson, MD, Nancy O’Connor, MD and Joan Henriksen

Mary Anderson, MD Nancy O’Connor, MD Joan Henriksen

we cannot air our thoughts, our struggles are compounded by loneliness. However, no caregiver is alone in experiencing ethical tensions. We are all familiar with that anguish in various ways, and that makes us uniquely qualified listeners. We ourselves are an underutilized community ready to support one another, if only we could find each other. In our organization, we created the Ethics Oasis to allow for that human connection. It is a twice a week meeting hosted online via Zoom. It lasts 50 minutes. No RSVP, special invitation, or registration is needed. It is open to all patient-facing caregivers. Topics of discussion are determined by those who attend. Conversations are confidential, peer-protected, non-judgmental, and moderated by an ethicist and a clinician. Participants voice their first-hand experiences of their ideals conflicting with their reality—all in the unique fellowship shared by healthcare workers. Ethics Oasis is not about critiquing care or performing an ethics consult. It’s not even meant for problem solving per se. We don’t have curriculum or didactic sessions. We ask that all speak solely from their own experience and avoid patient identifiers. All voices and perspectives are respected. We ask for presence—by minimizing distractions, using the video function of Zoom, and respecting silence as time for reflection. The Ethics Oasis model has many strengths. Being online, we are immune to social-distancing mandates. The online venue also dodges the challenges of finding physical meeting space. On Zoom we can see faces (with expressions, honesty, vulnerability) that are otherwise hidden by masks. We hope that attending from home lets participants feel safer and more comfortable, while also reducing the barriers of time and distance. We are pleased and gratified by the widespread support the Ethics Oasis has received across our organization. Ethics Oasis was initiated by a professional clinical ethicist with expertise in moral distress. Additional start-up energy came from the Clinical Care Committee, which

was tasked with managing scarce resources during the pandemic. Its subgroup, the Moral Experience Team, provided a wonderful cadre of committed volunteer facilitators. Essential support then came from the Practitioner Health and Wellness Committee, which endorsed peer-protected confidentiality. Person-power and ideas poured in from the Employee Assistance Program, the Resiliency and Physician Satisfaction Committee, and the Spiritual Care team. Our media services published an informational webpage and created a QR code. The Zoom account came through the Ethics department funding. And sure enough, morally distressed partners have come to the oasis. The breadth of topics discussed is a testament both to the challenges of being a caregiver and to the elastic nature of Ethics Oasis absorbing most anything that attendees bring. Here is a sample of the topics discussed so far: • Guilt for leaving things undone. • Fear of transmitting COVID to others. • Families firing their doctor. • Responding to structural racism. • Struggling to set limits on patient care to make room for self-care. • Exhaustion from enforcing mask and visiting policies. • Witnessing patients and families making irrational and futile care decisions. • Feeling loss of empathy and dehumanization with an angry patient at the end of the day. • Change fatigue. • Feeling vulnerable when patients threaten violence. • Uncertainty when you reach the limits of your expertise. If only we could say “if you build it, they will come.” But we’ve had significant struggles with low attendance. Those who are burned out and exhausted (perhaps most in need of an Ethics Oasis) are particularly unlikely to have the time and energy to attend “yet another meeting.” Getting the word out is also a challenge. We’ve tried every tool of promotion we could think of; a write-up in the company-wide newsletter, word of mouth, posters in break rooms, handing out business cards with a QR code, and enlisting team managers to endorse attendance. We’ve discussed Ethics Oasis at nurse shift-change meetings, huddles, and doctor group meetings. We offered different times of the day and even a weekend meeting time. We wonder if people feel too intimidated to share personal and difficult feelings both online and with an unknown group of people. Another possible barrier seems a little ironic—perhaps it is too easy to attend. Does no RSVP also mean no commitment? Does little effort to attend translate into little value? Despite challenges, we believe the Ethics Oasis does have significant value. Even when COVID has left the headlines, our clinical experiences will continue to generate ethical tensions. We have shown Ethics Oasis is a sustainable way to honor and heal our moral ideals. Our time reflecting together helps give us peace between our internal values and our external workplace. As a result, we are stronger, more resilient, and happier physicians. We are optimistic that when a tool is helpful it will be adopted. But we are realistic about the difficulty of any change, even a positive one. The trouble recruiting attendees to the Ethics Oasis is more likely a reflection of the slow pace of cultural change, rather than a sign that ethical tensions don’t exist or don’t need addressing. Right now, experiencing moral distress is an expected part of our job, but dealing with it isn’t. We envision a future with Ethics Oasis where it’s normal in our medical culture to acknowledge and heal from moral distress.

Mary Anderson, MD practices Internal Medicine as a Hospitalist at Allina Health’s Abbott Northwestern Hospital. She lives in Minneapolis with her husband. Nancy O’Connor, MD is a family physician in Shakopee. She is interested in the intersection of medical humanities and healing the Healers. Joan Henriksen serves as a full-time clinical ethicist at Allina Health’s Abbott Northwestern Hospital.

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