Supporting cancer care clinicians to ‘hold’ their patients during and beyond the COVID‐19 pandemic: a role for reflective ethics discussions

Abstract

The COVID-19 pandemic has placed an overwhelming burden on healthcare delivery globally. This paper examines how COVID-19 has affected cancer care clinicians' capacity to deliver cancer care in the Australian context. We use the lens of 'holding patients' (drawing from attachment theory, psychology and from Australian Indigenous knowledge) to conceptualise cancer clinicians' processes of care and therapeutic relationships with patients. These notions of 'holding' resonate with the deep responsibility cancer care clinicians feel towards their patients. They enrich ethical language beyond duties to benefit, avoid harm, respect patients' autonomy and provide just treatment. We consider the disruptive effects of COVID-19 on care delivery and on clinicians themselves. We then show how models of clinical ethics and other similar reflective discussion approaches are a relevant support mechanism to assist clinicians to process and make sense of COVID-19's disruptions to their professional ethical role of holding patients during and beyond the pandemic.

Support for clinicians with moral loss after the pandemic

“…14 For example, delaying cancer surgeries and stopping cancer screening services because of government mandated restrictions was frustrating and distressing for staff who believed the long term consequences and burdens for these patients were greater than the benefits of preventing covid infections. 15 Staff were redeployed, their responsibilities were changed, and in some situations they lost professional control over care decisions. 1 3 5 6 12…”

“…Protecting their own safety at work became a pressing concern4 and an ethical imperative to preserve the health workforce 7. Governments and hospital leaders imposed constraints related to infection control, including personal protective equipment,35 visitor restrictions for inpatients,3 and disruptions to established and evidence based clinical care pathways 14. For example, delaying cancer surgeries and stopping cancer screening services because of government mandated restrictions was frustrating and distressing for staff who believed the long term consequences and burdens for these patients were greater than the benefits of preventing covid infections 15.…”

“…Governments and hospital leaders imposed constraints related to infection control, including personal protective equipment,35 visitor restrictions for inpatients,3 and disruptions to established and evidence based clinical care pathways 14. For example, delaying cancer surgeries and stopping cancer screening services because of government mandated restrictions was frustrating and distressing for staff who believed the long term consequences and burdens for these patients were greater than the benefits of preventing covid infections 15. Staff were redeployed, their responsibilities were changed, and in some situations they lost professional control over care decisions 135612…”

“…These studies highlight that being required to care for patients in ways that conflicted with fundamental health ethics values of patient centred care was distressing for clinicians, inducing feelings of shame and guilt and a loss of moral identity 1416. When clinicians are prevented from doing what they believe is right for their patient by a workplace authority (eg, health administrators or governments) their moral distress may lead to an erosion of trust in self and in leadership,17 feelings of professional powerlessness,5 and loss of professional integrity to be able to perform their role in accordance with their values 1.…”

COVID-19 recovery: implications for cancer care clinicians

“…Burnout has become more than a profession-based reported statistic and a frequently dismissed element of a doctor’s job [ 9 , 13 ]. It has become a lived experience for many clinicians [ 7 , 13 , 14 ].…”