Analysis of the interviews revealed five major themes. Two of the themes arose from participants’ descriptions of how virtual visits helped ameliorate ethical dilemmas that arise in the ICU: ‘fulfilling a moral instinct to connect families’ and ‘promoting autonomy’. Three themes identify unanticipated ethical issues which may be exacerbated by the use of virtual visits depending on how they are conducted and resource availability, such as ‘preserving dignity and privacy’, ‘managing emotional distress’, and ‘providing equitable access’ to virtual visiting technologies.
Fulfilling a moral instinct to connect families
Participants described a sense of moral satisfaction arising from providing patients and families with an opportunity to connect at a time when this would not have otherwise been possible. They explained how the role aligned with the overarching duty of their profession to make people “feel better” and caused them to feel privileged to be in their role as healthcare workers.
“That’s one of the reasons I went into medicine was to try and make people feel better when things are bad. It was just an incredible opportunity” (Participant 7).
“I think that that is such privilege and the amazing thing about this whole project, I guess. So, yeah…The human connection you get is amazing and so rewarding” (Participant 4).
Participants also described instinctual actions they took to enhance the connection between families and patients virtually, such as surrogate hand holding (where the participant would hold the hand of the patient on behalf of a family member).
“she just kept saying, “I’m holding your hand. I’m holding your hand.” And so then I held the patient’s hand and said, “It’s okay, I’m holding her hand for you” and then the parents were just crying and crying and they were like, “We’re so grateful. We’re so grateful” (Participant 1).
Promoting autonomy
Often, participants described how the virtual visits allowed adjustments to be made so that patients.
who were too unwell to speak over the telephone could still express their thoughts and personalities non-verbally. This supported patients’ autonomy by facilitating self-expression.
“the delight on their face as they could communicate with him–for the patient to be interacting and.
sort of joking around as well, like saying some things like “ohh, it’s like a hotel in here”, Like writing.
it on a board. It’s just quite sweet. That’s when it’s really worthwhile” (Participant 4).
For patients receiving end-of-life care, participants described how virtual visits facilitated families’ autonomy in deciding how to spend their final moments with the patient.
“the patient wasn’t able to speak because of the trache, but he was mouthing responses. So I.
remember the last thing he said was she told him that she loved him, and he just mouthed with.
whatever strength he could that he loved her…I think not long after, he passed away.” (Participant 1).
“It didn’t matter how different the people were or how they used the call or, you know, whether or not they sang or got a priest or talked to their relative or whatever…” (Participant 2).
Preserving dignity and privacy
Participants described their thoughts and concerns regarding how the privacy of patients and their family members could be preserved while conducting virtual visits. For example, when patients were too weak to hold the video call device, it was held for them. The virtual visit would be set up so that only the patient was in the family member’s field of view and the participant holding the video call device could not be seen, however they were still witness to the conversation.
“in our role, we’d hold the tablet, and we’d swap the camera so that from the relative’s point of view, they can only see the patient. So for them they kind of forget that you’re there.”(Participant 7).
Participants reported feeling unsure whether the relatives realised their conversations were audible to staff, especially as some conversations were personal to families and patients. The physical dependence of heavily sedated or unconscious patients during video calls, along with the helplessness of families relying on staff to facilitate these interactions, underscored the importance of protecting both from vulnerability. Participants highlighted the need to be mindful of preserving the dignity and levels of exposure for patients and families during video calls.
“Obviously being on loudspeaker, everyone can hear what is being said and everyone can hear the.
content of it.” (participant 3).
“in the community, you never see them cry. Like these really strong men would then fall apart on the phone and, again, like I said at the beginning, about them not realising that they could see– that you could see them.”(Participant 2).
Consent for virtual visits was either taken before a patient lost capacity due to their illness or consent.
was granted by a family member or member of the ICU team in the patient’s best interests. Some participants reflected on the act of facilitating a virtual visit between a heavily sedated patient and their family, being in line with what they would have wanted as a patient.
“They were unconscious, and sometimes you think, would I like my loved ones to see me like that?
With all the tubes? But then you think, I can’t imagine them not being there with you” (Participant 7).
Managing emotional distress
On occasions when a family member became distressed, participants expressed regret that they could not reassure them the same way they would with an in-person visit. Video calling placed greater emphasis on verbal reassurance. Finding the correct words was challenging for participants when families were distressed.
“you want to comfort them, but what can you say over a video call? “I can see you’re really upset. I hope you’re okay” But clearly they’re not okay because they’re crying…” (Participant 3).
Participants described how, at times, the helplessness they felt when unable to reassure families during the calls, impacted upon their own well-being. As family members joined calls from their home environment, participants gained insight into the patient’s and family member’s social context and private life. Though this aided rapport building, it also made it more difficult for participants to manage their emotions. Despite experience working in the ICU setting, participants described how video calls could cause them to experience emotional breakdowns in the workplace for the first time.
“she was crying saying “please sir, please, please help me. Help my daughter” And she said “I cannot lose another one” And, uh, I found out that her husband passed away in January and, uhm, it was, I– after that call and not being able to help. Feeling so helpless in hearing somebody that wouldn’t be older than my grandmother to beg down the phone like that. And, uh, I think it was the first time in my life that I’ve ever walked into the corner of a ward and just cried.” (Participant 1).
When a video call had to be ended abruptly to provide emergency care, participants often struggled with how to communicate this to the family. They described making quick decisions in the moment that they later regretted. Compared to an in-person visit, during which a family member might pick up on cues from the staff and ICU environment that their relative is deteriorating, during virtual visits, this responsibility fell entirely on the participants. As a result, virtual visits placed a greater emphasis on competency in verbal communication skills, with clear and sensitive explanations crucial for conveying the need to interrupt a video call due to the severity of the patient’s condition.
“I was just about to press the button to turn the camera around so they can see him and he went into, like, real bradycardia all of a sudden.And then the nurse kind of made the signal like, “Cut the call, cut the call”. So I had to just make up this excuse on the spot about how the ward round had come and hang up the call. I felt awful afterwards…”(Participant 4).
Equitable access to virtual visiting technology
During the pandemic, the number of patients who required virtual visits surpassed the resources and time available to the virtual visiting team. The critically unwell state of patients, combined with the dependence of families on virtual visiting technology, highlighted the need for clinical and ethical guidance on how virtual visiting should be integrated into clinical services. Virtual visiting guidelines were perceived as vital to prevent staff from feeling isolated in their decision-making.
“…There were times where we were doing like 50 odd calls a day. And that was between a team about 5 or 6 of us.”(Participant 4).
“I’ll always remember– There was this patient who got admitted and it was right at the end of the day and I’d done the whole ward and it was already past the time that I was supposed to go home, and I just thought I’ll have to do that first thing in the morning and then I came in again the next day and the patient had died. And I just felt terrible that I’d never done it.” (Participant 2).
One participant described language barriers and the family member’s confidence in using technology affecting how well they could connect with a patient. They identified strategies used to overcome such barriers.
“I managed to speak to this guy and explain exactly how to set up the app and then finally got like his– he spoke to the wife, and then finally, I’ve got the wife on the call and it was just this amazing moment because it’s taken me a whole week to finally get this lady. And I’m there and I was like, “Maria, you’re here,” and she was like, “I’m so happy I can see you,” or words to that effect in broken English”. (Participant 3)
link
.jpg "New Stroke Prevention Guidelines Emphasize Power Of Lifestyle Changes")
