Micro triage decisions and moral distress during the COVID - 19 pandemic in critical care providers: A cross-provincial case study

Moral distress in the workplace is thought to be a driving force behind the burnout and workforce attrition that plagued health care providers (HCPs) during COVID-19. Moral distress occurs when a HCP knows the morally right course of action, but is unable to act upon this due to an institutional constraint. For example, a HCP tasked with determining the allocation of scarce, life-saving medication amongst several patients might experience the effects of moral distress. The HCP would want each patient to have equal access to receive medical treatment, but under the constraints of resource scarcity, this would not be possible. In response to the many challenges brought about by the COVID-19 pandemic, the medical community in Canada devoted considerable attention to the possibility of triaging access to ventilators and other necessary medical attention. However, in most places, these triage decisions with life-endangering consequences did not transpire. Instead, insufficient resources and infection control policies rendered HCPs in the difficult position of having to make an array of small-scale triage decisions. For example, when personal protective equipment was scarce, HCPs had to decide when to enter patient rooms and when to communicate remotely, extend time between doses, or deviate from the standard of care. Collectively, the aforementioned challenges are examples of the ethical decisions which we have termed micro-triage. We posit that the accumulation of micro-triage decisions may manifest as moral distress. In this research project, we will document the routine ethical decisions that HCPs faced during the pandemic, with the objective of developing educational strategies that will serve to better prepare HCPs to make micro-triage decisions in the future.