Ethical and Social Issues for Health Care Providers in the Intensive Care Unit during the Early Stages of the COVID-19 Pandemic in Japan: a Questionnaire Survey

This questionnaire-based observational study was conducted in July 2020 with the aim of understanding the ethical and social issues faced by health care providers (HCPs) registered with the Japanese Society of Intensive Care Medicine in intensive care units (ICUs) during the coronavirus disease (COVID-19) pandemic. There were 200 questionnaire respondents, and we analyzed the responses of 189 members who had been involved in COVID-19 treatment in ICUs. The ethical and social issues that HCPs recognized during the pandemic were difficulties in the decision-making process with patients’ families, limitations of life-sustaining treatment, lack of palliative care, and inadequate mental support for patients’ families and HCPs. Regarding decision-making on issues of clinical ethics during the pandemic, more than half of the respondents thought they had failed to provide sufficient palliative care to patients and responded that they experienced moral distress. The free-text responses on moral distress revealed issues such as unusual treatment and care, restricted visits, challenging situations for HCPs, and psychological burden. Additionally, 38.1% of respondents experienced episodes of social prejudice or discrimination and 4.7% experienced a shortage of medical resources. Our study result shows that the moral distress of HCPs was caused by difficulties in patient-centered decision-making and insufficient medical care to patients and their families. These were caused mainly by a lack of communication due to the stronger implementation of infection control measures. We believe that it is important to address ethical and social issues during a pandemic in order to provide appropriate medical care and prevent burnout among HCPs. Supplementary Information The online version contains supplementary material available at 10.1007/s41649-021-00194-y.

Additional file 1 Table S1. Questionnaire items Q1: What is your profession?

1) Physicians 2) Nurses 3) Clinical engineers 4) Physical and occupational therapists 5) Pharmacist 6)
Other Q2: How long have you been working? 1) 1-2 years 2) 3-5 years 3) 6-10 years 4) 11-20 years 5) More than 21 years Q3: What is your work experience in the intensive care unit? 1) Currently working full-time in the intensive care unit 2) Currently working concurrently in the intensive care unit 3) Worked in the intensive care unit in the past and currently indirectly in intensive care unit work 4) Worked in the intensive care unit in the past and not currently involved in intensive care unit work 5) Has not worked in the intensive care unit in the past, but currently involved indirectly in intensive care unit work 6) Has not worked in the intensive care unit in the past and no current involvement in intensive care unit work Q4: How many years of experience do you have in the intensive care unit? 1) 1-2 years 2) 3-5 years 3) 6-10 years 4) 11-20 years 5) More than 21years 6) No experience Q5: What is the type of your hospital? 1) University hospital 2) Public hospital 3) Other Q6: How was your intensive care unit operated before the COVID-19 epidemic? 1) Open intensive care unit † 2) Semi-closed intensive care unit † † 3) Closed intensive care unit † † † † Intensivists are the patient's primary attending physician. † † Mandatory critical care consultation (intensivists are not the patient's primary attending physician, but every patient admitted to the intensive care unit receives a critical care consultation) or elective critical care consultation (intensivists are involved in the care of the patient only when the attending physician requests a consultation.) † † † No critical care physician (intensivists are unavailable).

Q27: Did your hospital have a problem with the allocation of medical resources necessary for life support?
1) Shortage of medical resources (to the extent that the necessary treatment and care could not be provided) 2) Although medical resources seemed to be in short supply, it was possible to request support such as transfer from another facility or government.
3) Although medical resources seemed to be in short supply, it was possible to deal with it by increasing medical resources. 4) Although medical resources seemed to be in short supply, it was possible to utilize existing medical resources. 1) I did not feel it.
2) I did not feel it, but I sometimes hesitated to interact with others directly.
3) I had experienced an episode of prejudice or discrimination. but it did not become a mental burden. 4) I had experienced an episode of prejudice or discrimination, which was a mental burden.

5) Other
Q34: Please give us your opinion on ethical and social issues in the ICU during the COVID-19 pandemic.  Fig S2. Points on which healthcare providers felt that they could not provide sufficient support for patients and their families (multiple-choice questions).