Table 1

Clinical ethics questions and illustrative cases

Ethical questionCase
Should we decrease patient care in order to conserve PPE? 1.David is a nurse caring for a patient who has been hospitalised with suspected COVID-19. The patient is in a single room, awaiting the COVID-19 test result. This patient has a chronic condition and has had many admissions over the years. In order to conserve the limited PPE at his hospital, David and his nursing colleagues have been minimising entering the patient’s room. The patient is unhappy and is complaining that the level of nursing care is so different to past admissions.
What should I do when the PPE provided is inadequate for the task? 2.John is a physiotherapist, working in a small regional town. He is on call for the emergency department in the regional base hospital. John has been asked to assist with Celia, a 16-year-old patient with cystic fibrosis, who has come in to ED, feeling increasingly unwell, with increased cough and increased secretions compared to her baseline. John has been asked to review Celia for urgent airway clearance which for Celia normally involves nebuliser therapy and PEP therapy to clear secretions. John is feeling anxious about the level of PPE available to him. He has only been given a gown and a standard surgical mask. An N95 mask is recommended for aerosol-generating procedures such as airway clearance, in a patient with respiratory symptoms who has not been cleared of COVID-19. John also does not have access to goggles.
Should I abstain from working to protect my family? 3.James is an infectious diseases registrar scheduled to work in the COVID-19 screening clinic tomorrow. James is fit and healthy, married and has a 6-year-old son. When being briefed about the clinic, he is advised that staff have not worn face shields this past week as they are currently not available but that they are scheduled to be delivered in 2–3 days’ time. James does not wear glasses and is worried about patients gagging or coughing when the swab is being taken. When he tells his wife, she asks him to call in sick.
Can I use more PPE than recommended, to protect my vulnerable family member at home? 4.Jennifer is an intern working on the wards in a large metropolitan hospital. She lives at home with her mother and elderly grandmother. She has read in the paper that in some countries that were previously affected by SARS, all doctors routinely wear masks for every interaction with every patient. She is about to review a patient with multiple sclerosis who was tested for COVID-19 on admission and is recovering from a bacterial pneumonia. The patient still has a mild intermittent cough. Jennifer wants to wear a mask as she is worried about her grandmother who has heart failure. However masks are not recommended when seeing this type of patient and are not easily accessible on the ward.
Is wearing the PPE ethically required when it is inhibiting my relationship with a low-risk patient? 5.Louise is a paediatrician who works with children with autism at a paediatric hospital. Her organisation has mandated the wearing of face masks by clinicians in her clinic. Louise’s view is that the mask is impacting negatively on the care she can provide to patients and isn’t really needed. She knows she has to follow hospital policy but she is worried that the mask will impact on her therapeutic relationship with patients and families, particularly that it will make it more difficult to establish rapport with the children she treats who often find interpersonal interactions challenging. She doesn’t think that the infection risk to her or to her patients is sufficient to justify wearing the mask.
Should we delay resuscitation to don PPE? 6.Emily is a 45-year-old consultant in the emergency department. She is well but her husband has rheumatoid arthritis and is on immunosuppressants. Emily is part of the emergency department planning team. They are planning their approach to resuscitation in the ED, when the patient’s COVID-19 status is unknown. They are considering the scenario of a busy ED where a 50-year-old patient of unknown COVID-19 status arrests shortly after arrival. All ED staff are wearing surgical masks, but resuscitation is considered a high-risk activity for transmitting COVID-19 infection and full PPE is recommended. The team are concerned and unsure if the first staff member present should begin resuscitation, or delay to don additional PPE. Community transmission is currently low, with most confirmed COVID-19 cases from returned travellers.
  • The cases are based on our experiences in Australian hospitals but do not describe specific individuals.

  • PEP, Positive Expiratory Pressure; PPE, personal protective equipment.