Table 1.

Ethical principles of relevance

Ethical Principle(s)	Application in the COVID-19 Palliative Care Setting
Minimize harm and maximize well-being	• Predictable harms related to visitation within the COVID-19 context should be limited, including: - Transmission between healthcare workers, families, and patients. - Patient outcomes with regards to psychosocial and spiritual distress or those impacted by unmet physical needs. - Family caregiver outcomes with regards to psychosocial and spiritual distress and the risk of prolonged grief disorder. - Healthcare worker outcomes with regards to psychosocial and spiritual distress, including moral injury. • Every effort should be made to facilitate digital communication wherever possible (Association for Palliative Medicine of Great • Britain and Ireland 2020).
Equity and respect	• Compassionate, patient-centred care addressing physical, psychological, social, and spiritual needs should be offered to all patients, with or without COVID-19, in all settings as they approach death (Scottish Academy of Medical Royal Colleges 2020; Arya et al. 2020). • Visitation restrictions should be based upon a logical and consistent public health message. Where possible, consistent procedures should be utilized within and between healthcare services. • Providing additional access to visitors for people who are dying supports an equitable approach to care, recognizing heightened needs and a limited timeframe for meaningful connection. • Prioritizing the needs of people who are close to dying through additional support for visitation may create concerns of disadvantage and risk among others which will need to be responded to with clarity, sensitivity, and compassion. Of note, the equitable distribution of PPE for various triaged purposes in times of short supply should be carefully considered.
Honesty and transparency	• There should be transparency regarding the potential for public health needs to be prioritized over the personal autonomy of patients and their caregivers. This should be communicated clearly and compassionately (Rogers 2004). • Visiting restrictions, their rationale and guidance for how to “live with” the rules or make an appeal in special circumstances should be clearly documented and communicated to patients and families (Rogers 2004). This communication should occur when a patient is being transferred from one care setting to another and include how restrictions may change if the patient deteriorates, enters terminal phase or if their COVID-19 status changes (Yardley and Rolph 2020). Clear timeframes should be provided for an expedited appeals process, given the importance of time in end-of-life care. • Visiting restrictions should be included in advance care planning discussions to enable patients and families to make informed decisions regarding ongoing care and preferred place of care or death. Advance care directives made before the COVID-19 pandemic should be reviewed. • The usual practice of notification when a patient rapidly deteriorates, to allow family to be present, should continue.
Flexibility and proportionality	• Where risk and surge levels fluctuate, policies should be reviewed in conjunction with clear guidance at a state and national level (Scottish Academy of Medical Royal Colleges 2020; Arya et al. 2020). For example, in the context of low infection rates, adequate staffing and sufficient personal protective equipment (PPE), it may be feasible to safely facilitate and supervise visitation for all patients. In contrast, during times of high infection rates and high demand on healthcare services it may be necessary to forfeit visitations for most patients. • The potential risks associated with a patient with suspected or confirmed COVID-19 requires proportionate steps to mitigate these risks, relative to patients who are COVID-negative. • The granting of exceptions to communicated rules should be discouraged as it places unreasonable decision-making burden on individual staff members. Furthermore, the ensuing negotiations may damage therapeutic relationships and disrupt health professional teamwork in the delivery of care. • It may be that individual cases do warrant exceptions based on specific circumstances, in recognition of the need for proportionality (Rogers 2004). Here, the risks should be weighed, with focus on the benefits to the patient as the primary focus of care. Ideally, planning should be undertaken in anticipation of needs rather than in a reactive manner. • Support to families, alongside the maintenance of therapeutic relationships and health professional teamwork should be high priorities, underpinned by expert communication skills. In some cases, conversations with individual patients and families about visitation restrictions are best conducted by a staff member not directly involved with the care of the patient, in order to protect those providing clinical care from conflict of interest (Andrist, Clarke, and Harding 2020). Ultimately, the healthcare service should take responsibility for making, communicating, and enforcing the rules and providing accessible support to staff (Rogers 2004).
Capacity and consent	• Patients with decision-making capacity should provide consent to receive each visitor, and where this is not possible, their preference should be sought where possible and respected along with their previously known wishes and the view of a proxy decision maker (Association for Palliative Medicine of Great Britain and Ireland 2020). • Efforts should be made to establish that each visitor understands the risk of exposure to the virus for themselves and their household contacts (Scottish Academy of Medical Royal Colleges 2020).
Community interests and personal autonomy	• A balance must be struck between the best interests of the community, those of individuals, and individual preference to accept personal risks. The need for enforcement of mitigation strategies such as quarantine should be given due importance when weighed against the potential risks for the broader community, including the general local community, the healthcare community (staff and other patients) and the nation.