Monthly Archives: December 2021

Family in the Covid ICU: A Different Approach

Attendant caring for patient in SIUT COVID ICU (Photo filtered to protect the identity of the patient)

Family in the Covid ICU: A Different Approach

Fakhir Raza Haidri
Associate Professor, ICU/CCU, Sindh Institute of Urology and Transplantation, Karachi, Pakistan

The COVID-19 pandemic began in February 2020 in Karachi and within a couple of months, the disease had already occupied a large number of beds in ICUs. SIUT, the largest transplant center in Pakistan started a COVID OPD, ward, and intensive care facility for the public as part of the national effort to contain the first wave of COVID. At the same time, the hospital continued to provide care to its own patients.

This variant of COVID was new. The disease process was being understood slowly over time, and treatment was evolving. Most of the medicines being prescribed had not been tested before and were mainly given emergency approvals by drug regulators. But I want to bring up a very different aspect of COVID-19: family involvement in the COVID ICU. In the initial stages of the pandemic, allowing relatives into the COVID ICU was unimaginable. But this is exactly the strategy we adopted at SIUT.

At the start of the first wave of COVID, global standards of care included strict isolation of admitted patients to control disease transmission. COVID-19 guidelines from Pakistan’s Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) discouraged the presence of family members, except in the case of paediatric patients. Families were not allowed to visit and the only way to see loved ones admitted with COVID was with a mobile phone. Even dead bodies were handled with great care and funeral gatherings were restricted. In the beginning, doctors were as afraid of COVID as everyone else in the community. We were wearing full-body gowns, masks, eye shields, goggles, foot covers, gloves – even respirators in some instances. We had to write our names on our dresses to identify each other. Attendants were strictly not allowed inside. Nurses were also afraid. And then came a time when nurses started getting COVID. Fear spread like wildfire, and nurses began opting out of ICU duties. Some demanded fewer working hours, and we had to negotiate their timings with them. At the same time, the number of patients was increasing.

A few attendants of our patients insisted on staying in the ICU, mainly wives, sisters and children. They wanted to stay with their loved ones for different reasons, the most important being cultural norms which made families duty bound to care for sick kin. Initially, we refused to let family members into the ICU but ultimately, after consultation between infectious disease physicians, intensivists, and the hospital administration, we decided to allow them in. Only family members who were young, healthy and not pregnant were allowed as attendants. In addition to other safety measures set in place, they had to wear complete personal protection equipment (PPE), just as the nurses were wearing.

The reason for this allowance was multifactorial. Families strongly wished to be with their sick relatives, but there was also a practical benefit because of the care family members could provide. Short of staff during peak COVID, we found the family helpful at the bedside. We found that pain, agitation and delirium – major concerns in the ICU – were best managed by involving family members. Mobilizing patients out of bed was also a task where the family was helpful. As time progressed and the fear decreased at all levels, we realized that the impact of family involvement in the COVID ICU was tremendous. We began to see miraculous improvement in patients’ outcomes.

One of the patients was Mrs. B, a young female from a poor socioeconomic status with a history of psychiatric illness. She came with severe COVID pneumonia, complicated by kidney failure. She received a few sessions of dialysis, but the pneumonia was severe. She underwent a tracheostomy procedure which developed complications. Later, she had massive gastrointestinal bleeding, for which she required surgery and endoscopies. She had severe infections and bedsores. Several times we gave up on her and thought she would not survive even 24 hours. But she did survive. What made her recover and leave the ICU alive was her older sister who cared for her as though she was her mother. She always knew what her sister wanted, and she tried her best to provide it to her.

Then there was Mr. S.A.H, a dialysis-dependent, older man with complicated vascular access. He developed COVID pneumonia and was put on a ventilator. One day, I saw his daughter standing beside him, not doing anything. I asked her why she was not helping her father get better. She took my message positively, and her healing touch made the difference. The father, who was on continuous infusions of different medicines to control delirium and agitation, entirely regained his senses in only three days. The next day he was discharged from the ICU, in his senses and talking.

We admitted Mr. H.A, a doctor who developed COVID pneumonia on top of an already bad chest. He remained on BiPAP, the noninvasive breathing support, for a long time. He developed clotting in his lung vessels and was ultimately oxygen dependent. Due to his chest wall deformity, he was not able to sleep on his belly which is the recommended position for COVID patients. His wife devotedly cared for him, day and night, finally stealing her living husband back from the ICU. He remained on oxygen for at least six months before getting back on his feet.

Three problems in the ICU are detrimental to the recovery of patients, independent of the primary illness: pain, agitation, and delirium. Our experience showed that family involvement in the COVID ICU helped with all three problems, helping patients get out of the ICU bed. The ICU is a jail from which patients must be liberated; the family has a definite role in this.

REFLECTION ON THE EVOLUTION OF MY ATTITUDES AND APPROACH TO TEACHING “MEDICAL ETHICS”

Winter sky, Benalla, Victoria, Australia - Contributed by Dominique Martin

Reflection on the Evolution of my Attitudes and Approach to Teaching "Medical Ethics"

Dominique Martin
Associate Professor in Bioethics and Professionalism, School of Medicine, Deakin University, Australia

As an undergraduate, I studied medicine and arts, majoring in philosophy and English at the University of Melbourne, Australia. After thoroughly enjoying my year of medical internship, I returned to university to complete an honours year in philosophy in the hope this would help me to decide whether to continue a career in medicine or pursue my passion for philosophy. After what felt like a lifetime of indecision as I struggled to balance the competing demands of my interests in the humanities and sciences, it was a relief to discover certainty within my heart during this honours year; I loved medicine, but a life of intellectual inquiry was the one for me.

Embarking on a PhD in applied ethics, and mindful of the limited job opportunities in this field, I nevertheless swore early on that no matter what, I’d never resort to “teaching ethics to medical students.” No doubt, I was influenced by the dismal “ethics” classes which I had experienced as a medical student, and the type of impoverished ethics teaching that I characterise as “pseudoethics.” My own intellectual snobbery was also influential; philosophical ethics seemed an obviously superior field to that of “medical ethics.” I felt that nothing could be less personally rewarding and less professionally impactful than summarising “the four principles” for a crowd of students who would rather be learning “real medicine.” I write this narrative in the hope of prompting reflection by others who may be in a similar position, and hesitant to invest time – if not their career – in ethics, for fear of such a desperate fate.

15 years later, I have the privilege and joy of leading one of the most robust ethics, law and professionalism programs for medical students in Australia. Over the past decade, I’ve had to navigate my own biases about ethics, medicine and teaching, as well as external challenges impacting my teaching plans and objectives, while striving to design, develop and deliver effective and appealing ethics curricula for medical students. If there’s one thing I’ve learned, it’s that there is no single formula that will guarantee success in teaching ethics to medical students; everyone must tailor their curriculum to their unique context. Even when you feel confident that you have a reliable learning activity or assessment task, cultural shifts between student cohorts, staff changes, or a pandemic can necessitate significant alterations to your curriculum and approach to teaching.

Early on in my teaching career, I worried most about what to teach medical students about ethics. It seemed irresponsible to leave out discussion of the grounding ethical theories, great thought experiments and ongoing debates about seminal issues, and indeed impossible to teach anything worth teaching without these components. All too soon, I began to understand the appeal – and hence the ubiquity – of the “four principles” approach to medical ethics teaching. Principlism is more easily distilled into a one hour “introduction to ethics” class and can be more readily applied in analysis of cases by students than a similarly abbreviated account of virtue ethics, for example.

However, when I joined Deakin University in 2016 and discovered a much more spacious ethics curriculum, I realised more time was useful, but not the solution to all my ethics teaching challenges. I began to focus more on how to teach, and how to design curricula in which teaching could have an impact. In particular, I worried how best to engage and retain the interest of medical students in the ethics program. For some medical students, ethics can seem a distraction from precious study time as they anxiously cram scientific knowledge and prioritise clinical skills development. With class attendance optional, I soon found little comfort in having curriculum time at the end of semester when many students stayed home to study for exams.

Paying greater attention to the quality of my teaching and learning resources, and focusing more on my broader engagement with students in the program has been valuable in several ways. I soon learned that investing hours of time in fancy slide sets or elaborate learning activities rarely had proportionate benefits in students’ satisfaction or achievement of learning outcomes. Instead, I found that taking the time to make curricula easy for students to navigate, clearly and simply communicating assessment expectations, and pre-emptive action to identify and address potential questions or concerns led to better engagement and satisfaction. Students also seemed happy with basic slides and simple case discussions, so long as the key learning points were clear, and the real-world relevance of learning was apparent.

When considering potential improvements to our program, I now reflect less on what and how I teach, and more on why we teach ethics to medical students. Every program will espouse goals of developing ethical and professional medical practitioners, fostering virtuous conduct and attitudes and so on. These are important goals, and a good ethics curriculum can and should play a key role in achieving them. However, so much of the formation of students’ characters has already occurred, and their experiences in the clinical environment as students and practitioners will typically exert a stronger influence on their values and behaviours than the classes formally dedicated to ethics. What, then, is the point of our ethics teaching?

What can we provide in our teaching and assessment of ethics that will offer more than the basic conceptual and theoretical knowledge that might be acquired through reading a textbook, and more than the practical application of such knowledge which may be more effectively demonstrated in the clinical setting – assuming of course that preceptors there are suitably competent? This vital question now informs the rationale for my own teaching – why do I teach ethics? – and from this, shapes the content and methods of much of my teaching.

The “why” will be different for everyone. Personally, I teach in order to equip medical students with what I believe are essential skills they need to practice medicine ethically, and to support ethical decision-making and action by others. These skills comprise critical thinking, reasoning, and the ability to identify ethical considerations and to communicate clearly when discussing ethics. With these skills, students may be more capable of continuing their ethics education and training as independent learners in the clinical environment, and may be less susceptible to the risks of the “hidden curriculum” of medicine.

Regardless of the foundational concepts, principles or issues being explored in a particular class or assessment task, I strive to stimulate engagement with and evaluation of these skills. While these skills may well be taught and learned in the clinical environment, an explicit focus on their development is less likely in that context. Furthermore, these are skills that educators with specific ethics training and experience are perhaps best equipped to teach at the foundational level. This, in short, is an opportunity for my teaching to have a real impact on students, and hence on the individuals and communities they will one day serve as doctors. I also find this way of teaching more aligned with my earlier career aspirations of engaging in and fostering intellectual inquiry.

I occasionally wince when marking student papers that glibly refer to ‘the four pillars of ethics’ and appear to show that we have, after all, merely taught them psuedoethics. Nevertheless, majority of our students frequently astound me with their insights and the rapid progression of their skills in ethics over the four years of our program. Rather than becoming resigned to teaching ethics to medical students, as I feared when I first obtained an academic job, I have become ever more delighted by this responsibility. Teaching has proven to be an intellectually rewarding experience, and one that I firmly believe has a real and positive impact in the world.

Bioethicslinks Online

The inexorable march to progress: Sadequain, Industry and Agriculture II, 1984. Section of mural on display in State Bank of Pakistan Museum, Karachi

Editor's Note

The Human Genome Project (HGP) was completed in 2003 and the subsequent push for genetic research has made human DNA a coveted material, the ‘gold’ of the twenty-first century. Increasingly, because of the ease with which research can be conducted in developing countries, a lot of genetic research is taking place in locations such as Pakistan and genetic testing is making its way into the clinical arena.

Our June 2022 newsletter brings together three perspectives of genetics in Pakistan, in the domains of clinical medicine and research: Farhat Moazam’s essay looks at the issue of genetic tests rapidly making their way into clinical practice in developing countries like Pakistan which, juxtaposed against a lack of genetic counseling, can lead to tragic consequences for families. Zainab Afshan Sheikh, in her article describing her ethnographic study on genetic research in Pakistan, comments on the analogy of a ‘gold mine.’ She discusses the impact of genetic research on both local investigators and participants, including therapeutic misconception and the perception of research as a way of accessing healthcare resources. Based on data from her Master in Bioethics thesis, Natasha Anwar writes about the lack of national and institutional ethical oversight for genetic research and publications in Pakistan.

Also included in the newsletter is a short report on the International Association of Bioethics’ 2021 “Award for Bioethics Service in the Face of Challenges,” given to human rights activist and teacher of bioethics, Amar Jesani. Other content includes write-ups by alumni, Melba Katindi and Amjad Mahboob, about their PGD Projects, and brief reports and images of CBEC events from January to June 2022.

Genetic Tests and Clinical Practice: A View from Pakistan

Farhat Moazam

A group of Karachi clinicians meet periodically to discuss issues related to healthcare. In a recent meeting, a troubled physician presented the case of a two year old child with deranged kidney functions seen in the clinic.

Genetic Research in Local Realities of Scarcity and Hope

Zainab Afshan Sheikh

How do people engage in genetic research in Pakistan – and why? Since 2015, I have been studying the development of genetic research in Pakistan with this question at the core.

King Solomon's Mines

Natasha Anwar

The biblical Solomon, a king of Israel and son of King David, was renowned for his wisdom, power and his fortune, often described as one of the largest in the ancient world.

Introducing Research Ethics to Community Paralegals in Kenya

Melba Katindi

From June 2021 to March 2022, I conducted teaching sessions to introduce basic research ethics knowledge to community paralegals supporting key populations in Kenya.

Bringing Pharmacy Students into the Bioethics Fold

Amjad Mahboob

CBEC’s Postgraduate Diploma in Biomedical Ethics (PGD) opened new venues for discussion on ethics in patient-physician interactions…

CBEC-SIUT Workshop: Basics of Academic Writing Karachi, June 23, 2022

Anika Khan

On June 23, 2022, CBEC organized a one day workshop focusing on academic writing skills for its faculty, alumni and healthcare professionals from the Sindh Institute of Urology and Transplantation (SIUT).

From our Archives

Teaching Ethics through the Arts

Amber Romasa Nagori

Kant famously said that the highest significance of beauty is to symbolise moral good, while for Schelling and Hegel the greatest revelation of beauty rested in the arts.

CBEC Events

Perspectives

A few of our alumni from both PGD and Master’s programs share short video commentaries on their bioethics experience by answering these three questions:

  1. How have you utilized your bioethics training in your professional work?
  2. What challenges have you faced?
  3. What future do you see for bioethics in your context?

What future do you see for bioethics in your context?

Mariam Hassan Chaudhry

Jamshed Akhtar

Elizabeth Anne Bukusi

Quratulain Omaeer

Faisal Rashid Khan

Caroline Kithinji

Journal Club

Discussing two poems by
Harris Khalique

Nida Wahid Bashir