From the Frontlines of COVID-19 (JNA)

VOL.1 Patients dying alone: The dilemma between infection control and medical ethics
In April 2020, when Coronavirus disease (COVID-red zone with infected people for more than one hour at19) had its first rapid spread in Japan, nurses ata time. But the nurses were not able to leave their

hospitals caring COVID-19 patients faced both toughpatients' sides as everything just took time. They

working conditions and issues with medical ethics.

couldn't feel a patient's pulse because multiple layers ofThis is the story of the nurses’ ethical conflicts

gloves blocked the sense of touch in their hands. They

associated with COVID-19, but found solutions tocouldn't get too close to a patient's face to read theirsome of their challenges.

expressions, or hear what they were saying. They had areally hard time as they could not care for their patients

Kawasaki Municipal Tama Hospital is located in theas a nursing professional should."

northern part of Kawasaki City in Kanagawa Prefecture,

In April, the nurses' dilemma came to a head. One

and is classified as a core hospital responsible for acuteelderly patient who had transferred from anothermedical care in that area. It has been accepting COVID-hospital passed away.

19 patients with moderate symptoms.

Since that patient had requested no life-sustaining
treatments, the hospital was tasked with end-of-lifecare for the patient without any further advanced
medical care even if the disease became critical. We
had a procedure manual for end-of-life care for
COVID-19 patients, but the nurses said that some of thecontents were not ethically acceptable.
Ms. Sato says, "End-of-life care in normal times
involves staying close to patient’s heart andunderstanding to their every need as well as providing
grief care for families. That process is simply ingrained

A meeting in the infection ward：Zoning of the area
behind the blue wall is a red zone with infected
peopleAt its peak of COVID-19 outbreak in April and May,
some elderly patients with dementia were admitted tothe hospital as well as those with intellectual
disabilities, the frontline situation became quite severe.
At that time, Yoshiko Sato, Deputy Director of hospitaland Director of Nursing, saw the nurses struggling
between medical ethics and infection control.

Ms. Sato explains, "To minimize the nurses'
exposure time, I instructed them to try not to be in thein our staff, but with COVID-19 patients, they were notable to do so. Some nurses even spoke out, saying 'thisis not real end-of-life care?!'"In addition, nurses felt difficulty that the patient
frequently removed his ECG monitor and oxygen mask.
Then, the patient had to be physically restrained, and hedied in his restraints. The nurses normally try to avoid
using physical restraints, so that was a huge shock forthem. At the death conference (debriefing) held 10 days
after the patient's death, many nurses expressed theirheartbreak. Some nurses even shed tears and said,"What is nursing?"

From the Frontlines of COVID-19 (JNA)

Ms. Maki Fujii, the Certified Nurse Specialist in
Family Health Nursing *1, who was working to support
the nurses, listened to their complaints at the death
conference, and suggested that nurses should share notonly the things they couldn't do, but also the things they
did for patients, or what went well. There were thensuch comments as, "I was able to show the patient anemail from his grandchild" or "I was able to talk withhis family." More positive comments were heard, suchas solutions including "finding what I can do in thesetough times" or "thinking about what I might be able todo next time."
Ms. Fujii and the nurses began a discussion about
what they could do if they were ever in the same
situation again, such as enabling conversations between
patients and families when they couldn't see each other

PPE checks were carried out in pairs（Last updated: Aug. 2020)

directly, including conversations through the wall orusing information and communication technology.
They also launched weekly “Sharing meetings”
which enabled regular communication among staff*1 Certified Nurse Specialist in Family Health Nursing:members. This led to a dramatic improvement in team

These specialists undergo specialist nursing training at

morale in the infection ward.

a graduate school, and then pass the credentialing

In parallel with these efforts, Ms. Sato made aexamination given by JNA. They take on the principal

proposal at the hospital's COVID-19 Task Force, toroles of managing relationships between patients,

create an ethical guidelines for healthcare professionals

families and medical professionals, providing grief carein the hospital as a whole.

for families and helping patients and their families

As a result, the new Ethical Guidelines for Treatment

improve self-care and empowerment.

of COVID-19 Patients was compiled, based on the Four
Principles of Health Care Ethics, and set out theSee the following website for more information

hospital's position under the eight points. Today, withabout Certified Nurse Specialists:

no end in sight to COVID-19, the nurses continue theirhttps://www.nurse.or.jp/jna/english/nursing/educati

work while facing the difficult balance between

on.htmlinfection control and medical ethics.