ABSTRACT

Objective:

To analyze the scientific production on the decision making of health workers during the COVID-19 pandemic.

Methods:

Integrative review in the databases CINAHL, MEDLINE, Scopus, ScienceDirect, WoS, and BVS. Inclusion criteria: original articles available in full, in any language, related to the object investigated.

Results:

During this pandemic, health workers have been making decisions based on ethical/bioethical principles (utility, beneficence, non-maleficence, autonomy, justice, proportionality, flexibility, clinical prognosis, duration of the need, and fair health attention), values (solidarity, equality, equity, utilitarianism, relational autonomy, reliability, reciprocity, maximization of the benefits and resources, and prioritization of those in worse conditions), beliefs and personal motivation, protocols, directives, tools, algorithms, recommendations, and criteria.

Final considerations:

Decision making has never been so necessary as in this pandemic. This article is not a recipe for the professionals, since decision making is based on numerous factors. However, it provides them with a foundation that can be helpful in this difficult process.

Descriptors:
Decision Making; Ethics; Health Personnel; Pandemics; Coronavirus Infections

RESUMEN

Objetivo:

Analizar producciones científicas sobre la toma de decisiones de profesionales de salud frente al COVID-19.

Métodos:

Revisión integrativa en las bases CINAHL, MEDLINE, Scopus, ScienceDirect y WoS y BVS. Criterios de inclusión: artículos originales disponibles integralmente, en cualquier idioma, relacionados al objeto investigado.

Resultados:

Profesionales de salud en esta pandemia toman decisiones basadas en principios éticos/bioéticos (utilitarismo, beneficencia, no maleficencia, autonomía, justicia, proporcionalidad, flexibilidad, pronóstico clínico, duración de una necesidad y atención justa), valores (solidaridad, igualdad, equidad, utilidad, autonomía relacional, confianza, reciprocidad, maximización de los beneficios de los recursos y priorización de aquellos en peor situación), creencias y motivaciones personales, protocolos, directrices, herramientas, algoritmos, recomendaciones y criterios.

Consideraciones finales:

La toma de decisiones nunca fue tan necesaria como en esta pandemia. Este artículo no proporciona una receta lista a profesionales, pues la toma de decisiones envuelve múltiplos factores, aún presenta varias bases capaces de auxiliarlos en este difícil proceso.

Descriptores:
Toma de Decisiones; Ética; Personal de Salud; Pandemias; Infecciones por Coronavirus

RESUMO

Objetivo:

Analisar as produções científicas sobre a tomada de decisões dos profissionais de saúde na pandemia COVID-19.

Métodos:

Revisão integrativa nas bases CINAHL, MEDLINE, Scopus, ScienceDirect e WoS e na BVS. Critérios de inclusão: artigos originais disponíveis na íntegra, em qualquer idioma, relacionados ao objeto investigado.

Resultados:

Os profissionais de saúde nesta pandemia têm tomado decisões baseadas em princípios éticos/bioéticos (utilitarismo, beneficência, não maleficência, autonomia, justiça, proporcionalidade, flexibilidade, prognóstico clínico, duração de uma necessidade e atendimento justo), valores (solidariedade, igualdade, equidade, utilidade, autonomia relacional, confiança, reciprocidade, maximização dos benefícios dos recursos e priorização daqueles em pior situação), crenças e motivações pessoais, protocolos, diretrizes, ferramentas, algoritmos, recomendações e critérios.

Considerações finais:

A tomada de decisões nunca se fez tão necessária como nesta pandemia. Este artigo não fornece uma receita pronta aos profissionais, pois a tomada de decisões envolve múltiplos fatores, todavia apresenta várias bases capazes de auxiliá-los neste difícil processo.

Descritores:
Tomada de Decisões; Ética; Pessoal de Saúde; Pandemias; Infecções por Coronavírus

INTRODUCTION

On March 11, 2020, the World Health Organization (WHO) declared that the outbreak of COVID-19, caused by the new coronavirus (SARS-CoV-2), was a Public Health Emergency of International Concern (PHEIC), characterizing it as a pandemic(¹1 World Health Organization (WHO). Coronavirus disease (COVID-19) outbreak [Internet]. Geneva: World Health Organization; 2020[cited 2020 Jul 20]. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019
https://www.who.int/emergencies/diseases... ). Most countries failed to recognize the threat of coronavirus at first and did not know how to deal with the situation(²2 Iserson K. Healthcare ethics during a pandemic. West J Emerg Med. 2020;21(3):477-83. https://doi.org/10.5811/westjem.2020.4.47549
https://doi.org/10.5811/westjem.2020.4.4... ). There was insufficient knowledge about the means of transmission and about the behavior of asymptomatic people and its influence in the dissemination of SARS-CoV-2. This, coupled with the nonexistence of vaccines or specific therapeutic alternatives, was a challenge for researchers, health managers and governors in the search for non-pharmacological public health measures that could decelerate the spread of the virus(³3 Aquino EML, Silveira IH, Pescarini JM, Souza-Filho JA, Rocha AS, Ferreira A, et al. Social distancing measures to control the COVID-19 pandemic: potential impacts and challenges in Brazil. Cienc Saude Colet. 2020;25(suppl 1):2423-46. https://doi.org/10.1590/1413-81232020256.1.10502020
https://doi.org/10.1590/1413-81232020256... ).

The WHO, seeking to give a direction to health practices, elaborated restrictive measures such as blockades, quarantines, and social isolation, as well as diagnostic measures, such as the testing suspected cases. They also took measures to screen for contacts and isolate people with suspected or confirmed cases of the disease. They made an attempt to contain the propagation of the virus(¹1 World Health Organization (WHO). Coronavirus disease (COVID-19) outbreak [Internet]. Geneva: World Health Organization; 2020[cited 2020 Jul 20]. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019
https://www.who.int/emergencies/diseases... ,⁴4 Shah A, Aacharya RP. Combating COVID-19 pandemic in Nepal: ethical challenges in an outbreak. JNMA J Nepal Med Assoc. 2020;58(224):276-9. https://doi.org/10.31729/jnma.4959
https://doi.org/10.31729/jnma.4959... ), minimizing morbimortality indexes and reducing the overload of health systems(¹1 World Health Organization (WHO). Coronavirus disease (COVID-19) outbreak [Internet]. Geneva: World Health Organization; 2020[cited 2020 Jul 20]. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019
https://www.who.int/emergencies/diseases... ,⁴4 Shah A, Aacharya RP. Combating COVID-19 pandemic in Nepal: ethical challenges in an outbreak. JNMA J Nepal Med Assoc. 2020;58(224):276-9. https://doi.org/10.31729/jnma.4959
https://doi.org/10.31729/jnma.4959...

5 Jeffrey DI. Relational ethical approaches to the COVID-19 pandemic. J Med Ethics. 2020;46:495-8. https://doi.org/10.1136/medethics-2020-106264
https://doi.org/10.1136/medethics-2020-1... -⁶6 Solnica A, Barski L, Jotkowitz A. Allocation of scarce resources during the COVID-19 pandemic: a jewish ethical perspective. J Med Ethics. 2020;46:444-6. https://doi.org/10.1136/medethics-2020-106242
https://doi.org/10.1136/medethics-2020-1... ).

The health professionals in the front lines of the struggle against COVID-19 started to have difficulties regarding decision making (DM). This is a process that involves logical and psychological actions, attitudes, factors, phenomena and values, as it seeks to select the most adequate alternative among those available to reach the objective selected(⁷7 Marquis BL, Huston CJ. Administração e liderança em enfermagem. 8a ed. Porto Alegre: Artmed; 2015.).

In this regard, since the pandemic crisis affected the offer of assistance in health due to an increased demand for attention and to the scarcity of resources, health professionals started to raise questions about how to proceed in these situations they had never experienced. These were problems hard to solve(⁸8 Chan PS, Berg RA, Nadkarni VM. Code blue during the COVID-19 pandemic. Circ Cardiovasc Qual Outcomes. 2020;13(5):e006779. https://doi.org/10.1161/circoutcomes.120.006779
https://doi.org/10.1161/circoutcomes.120... -⁹9 Morley G, Grady C, Mccarthy J, Ulrich CM. Covid-19: ethical challenges for nurses. Hastings Cent Rep. 2020;50(3):35-9. https://doi.org/10.1002/hast.1110
https://doi.org/10.1002/hast.1110... ), required fast DM, and offered no space for in-depth reflection or the necessary planning(¹⁰10 Nicoli F, Gasparetto A. Italy in a time of emergency and scarce resources: the need for embedding ethical reflection in social and clinical settings. J Clin Ethics. [Internet]. 2020[cited 2020 July 27];31(1):92-4. Available from: https://pubmed.ncbi.nlm.nih.gov/32213700/
https://pubmed.ncbi.nlm.nih.gov/32213700... -¹¹11 Vincent J-L, Creteur J. Ethical aspects of the COVID-19 crisis: how to deal with an overwhelming shortage of acute beds. Eur Heart J Acute Cardiovasc Care. 2020;9(3):248-52. https://doi.org/10.1177/2048872620922788
https://doi.org/10.1177/2048872620922788... ). This led to doubts, dilemmas, and ethical and moral conflicts.

Among the questions raised by the professionals, stand out: Is not providing vulnerable people with the adequate assistance an ethical infraction or a crime of denial of assistance? Since the morbimortality is higher among elders, should I prioritize younger patients to the detriment of older ones(¹²12 Sanches MA, Cunha TR, Siqueira SS, Siqueira JE. Perspectivas bioéticas sobre tomada de decisão em tempos de pandemia. Rev Bioet. 2020;28(3):410-7. https://doi.org/10.1590/1983-80422020283401
https://doi.org/10.1590/1983-80422020283... )? When attending two patients who need mechanical ventilation, if there is only one ventilator, which patient to choose(¹¹11 Vincent J-L, Creteur J. Ethical aspects of the COVID-19 crisis: how to deal with an overwhelming shortage of acute beds. Eur Heart J Acute Cardiovasc Care. 2020;9(3):248-52. https://doi.org/10.1177/2048872620922788
https://doi.org/10.1177/2048872620922788... ,¹³13 Virani A, Singh G, Bewick D, Chow C-M, Clarke B, Cowan S, et al. Guiding cardiac care during the COVID-19 pandemic: How ethics shapes our health system response. Can J Cardiol. 2020;36(8):1313-6. https://doi.org/10.1016/j.cjca.2020.06.002
https://doi.org/10.1016/j.cjca.2020.06.0... )? In the absence of adequate personal protective equipment (PPE), do I have the moral obligation and the professional duty to provide assistance(⁹9 Morley G, Grady C, Mccarthy J, Ulrich CM. Covid-19: ethical challenges for nurses. Hastings Cent Rep. 2020;50(3):35-9. https://doi.org/10.1002/hast.1110
https://doi.org/10.1002/hast.1110... ,¹³13 Virani A, Singh G, Bewick D, Chow C-M, Clarke B, Cowan S, et al. Guiding cardiac care during the COVID-19 pandemic: How ethics shapes our health system response. Can J Cardiol. 2020;36(8):1313-6. https://doi.org/10.1016/j.cjca.2020.06.002
https://doi.org/10.1016/j.cjca.2020.06.0... )? How should patients be admitted to Intensive Care Units (ICUs) during a pandemic(¹¹11 Vincent J-L, Creteur J. Ethical aspects of the COVID-19 crisis: how to deal with an overwhelming shortage of acute beds. Eur Heart J Acute Cardiovasc Care. 2020;9(3):248-52. https://doi.org/10.1177/2048872620922788
https://doi.org/10.1177/2048872620922788... ,¹⁴14 Romanò M. Fra cure intensive e cure palliative ai tempi di CoViD-19. Recenti Prog Med. 2020;111(4):223-30. doi: http://doi.org/10.1701/3347.33185
http://doi.org/10.1701/3347.33185... )? How to allocate scarce resources, such as ICU beds, ventilators, and medication? How is it possible to address end-of-life issues, including the non-resuscitation of the patient(¹⁵15 Kramer JB, Brown DE, Kopar PK. Ethics in the time of coronavirus: recommendations in the COVID-19 Pandemic. J Am Coll Surg. 2020;230(6):1114-8. https://doi.org/10.1016/j.jamcollsurg.2020.04.004
https://doi.org/10.1016/j.jamcollsurg.20... )? Are the decisions I make in my professional practice ethical(¹⁶16 Rawlings A, Brandt L, Ferreres A, Asbun H, Shadduck P. Ethical considerations for allocation of scarce resources and alterations in surgical care during a pandemic. Surg Endosc. 2021;35(5)2217-22. https://doi.org/10.1007/s00464-020-07629-x
https://doi.org/10.1007/s00464-020-07629... )?

Considering the above, recommendations, DM models, protocols, guidance, and updated information have been continuously requested by professionals and offered by institutions and health systems, to make the DM process more transparent to society and bring safety to professionals and users of the health system. Therefore, this study provides a framework for the discussion and reflection about the decisions made by health professionals who work daily in the struggle against COVID-19 in several settings.

OBJECTIVE

To analyze the scientific production on the decision making of health workers during the COVID-19 pandemic.

METHODS

Ethical aspects

Due to the bibliographical nature of the research, it did not required evaluation by a Research Ethics Committee. However, the ethical aspects and the copyright of the works mentioned were considered.

Type of study

This is an integrative literature review, as it gathered and summarized the scientific knowledge produced about a certain area or phenomenon of interest through the search, evaluation, and synthesis of knowledge, contributing for the development of a practice based on scientific evidence(¹⁷17 Paula CC, Padoin SSM, Galvão CM. Revisão integrativa como ferramenta para tomada de decisão na prática clínica. In: Lacerda MM, Costenaro RGS. Metodologias da pesquisa para a enfermagem e saúde: da teoria à prática. Porto Alegre: Moriá; 2016. p. 51-76.).

Setting of the study

This revision was developed at the moment when the COVID-19 pandemic was assuming an alarming proportion, the health systems were overloaded, and the worldwide mortality rate was high.

Methodological procedures

For the development of this study, the following stages were followed: 1) the research question was formulated using the PICo acronym; 2) sampling - inclusion and exclusion criteria were established, databases were screened and studies were selected; 3) data extraction - two tables were filled in with information about the works that formed the corpus of this work; 4) critical evaluation of works included - classification of evidence level (EL); 5) analysis and synthesis of results - collection of information focused on the research question; and 6) presentation of the integrative revision(¹⁷17 Paula CC, Padoin SSM, Galvão CM. Revisão integrativa como ferramenta para tomada de decisão na prática clínica. In: Lacerda MM, Costenaro RGS. Metodologias da pesquisa para a enfermagem e saúde: da teoria à prática. Porto Alegre: Moriá; 2016. p. 51-76.).

Data collection and organization

In this study, the PICo strategy was used to elaborate the guiding question(¹⁸18 Lockwood C, Munn Z, Porritt K. Qualitative research synthesis: methodological guidance for systematic reviewers utilizing meta-aggregation. Int J Evid Based Healthc. 2015;13(3):179-87. https://doi.org/10.1097/XEB.0000000000000062
https://doi.org/10.1097/XEB.000000000000... ): (P) Population - health workers; (I) Phenomenon of Interest - decision making; and (Co) Context - a moment during the COVID-19 pandemic. As a result, the following research question was formed: How do health professionals make decisions during the COVID-19 pandemic?

To answer it, studies on the theme were surveyed. The terms selected for the search were validated in the Medical Subject Headings (Mesh/PubMed), with their respective synonyms found in the Health Sciences Descriptors (DeCS), considering those that fit the theme of the research better. The following electronic databases were consulted: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medical Literature Analysis and Retrieval System Online (MEDLINE), Scopus, ScienceDirect, Web of Science (WoS), and in the Virtual Health Library (Biblioteca Virtual em Saúde - BVS) portal. Associations between the descriptors, using the boolean operators AND and OR were carried out in the databases and in the BVS portal, and the search strategies presented in Chart 1 were structured.

The criteria of inclusion were: original articles available in full, in any language, related to the object investigated. The criteria of exclusion were: revisions, experience reports, case studies, editorials, book chapters, abstracts from annals, articles found duplicate in the bases, studies whose design or objective were not made explicit and about the DM of professionals in management, research, or teaching. As a temporal framework, studies considered since the beginning of the COVID-19 were published until July 2020, the period in which the search took place in the bases and in the portal.

After the survey, the publications found were read in the following order: titles, abstracts, and text in full. In each stage, the works that were not in accordance with the inclusion criteria and/or did not answer the research question were excluded. Data selection, from its initial survey until the formation of the sample, was carried out by two of the six authors of the study, separately, following, thus, a double independent selection. Disagreements in the results were solved via consensus, and a third reviewer was unnecessary.

A table was formed including the following variables: title, authors, language, year of publication, journal, and database where the work is indexed. This contributed to compile and summarize the external information of each production selected. Later, a second table was formed with all internal information: title, method, main results and level of evidence (LE)(¹⁹19 Melnyk BM, Fineout-Overholt E. Evidence based practice in nursing and healthcare: a guide to best practice. Philadelphia: Lippincot Williams & Wilkins; 2005. Making the case for evidence based practice; p. 3-24.). The tables were organized by all authors in a process of continuous revision.

The articles included in the study were selected in accordance with the recommendations from the flowchart Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA), which is considered to be useful in many different types of revision(²⁰20 Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med. 2009;(6):e1000097. doi: https://doi.org/10.1371/journal.pmed1000097
https://doi.org/10.1371/journal.pmed1000... ). Through its use, it became easy to show the process of selection of articles (Figure 1).

RESULTS

The sample was formed by 18 articles. Reflection articles were the most common design (94.44%)(²2 Iserson K. Healthcare ethics during a pandemic. West J Emerg Med. 2020;21(3):477-83. https://doi.org/10.5811/westjem.2020.4.47549
https://doi.org/10.5811/westjem.2020.4.4... ,⁴4 Shah A, Aacharya RP. Combating COVID-19 pandemic in Nepal: ethical challenges in an outbreak. JNMA J Nepal Med Assoc. 2020;58(224):276-9. https://doi.org/10.31729/jnma.4959
https://doi.org/10.31729/jnma.4959...

5 Jeffrey DI. Relational ethical approaches to the COVID-19 pandemic. J Med Ethics. 2020;46:495-8. https://doi.org/10.1136/medethics-2020-106264
https://doi.org/10.1136/medethics-2020-1... -⁶6 Solnica A, Barski L, Jotkowitz A. Allocation of scarce resources during the COVID-19 pandemic: a jewish ethical perspective. J Med Ethics. 2020;46:444-6. https://doi.org/10.1136/medethics-2020-106242
https://doi.org/10.1136/medethics-2020-1... ,⁸8 Chan PS, Berg RA, Nadkarni VM. Code blue during the COVID-19 pandemic. Circ Cardiovasc Qual Outcomes. 2020;13(5):e006779. https://doi.org/10.1161/circoutcomes.120.006779
https://doi.org/10.1161/circoutcomes.120...

9 Morley G, Grady C, Mccarthy J, Ulrich CM. Covid-19: ethical challenges for nurses. Hastings Cent Rep. 2020;50(3):35-9. https://doi.org/10.1002/hast.1110
https://doi.org/10.1002/hast.1110...

10 Nicoli F, Gasparetto A. Italy in a time of emergency and scarce resources: the need for embedding ethical reflection in social and clinical settings. J Clin Ethics. [Internet]. 2020[cited 2020 July 27];31(1):92-4. Available from: https://pubmed.ncbi.nlm.nih.gov/32213700/
https://pubmed.ncbi.nlm.nih.gov/32213700... -¹¹11 Vincent J-L, Creteur J. Ethical aspects of the COVID-19 crisis: how to deal with an overwhelming shortage of acute beds. Eur Heart J Acute Cardiovasc Care. 2020;9(3):248-52. https://doi.org/10.1177/2048872620922788
https://doi.org/10.1177/2048872620922788... ,¹³13 Virani A, Singh G, Bewick D, Chow C-M, Clarke B, Cowan S, et al. Guiding cardiac care during the COVID-19 pandemic: How ethics shapes our health system response. Can J Cardiol. 2020;36(8):1313-6. https://doi.org/10.1016/j.cjca.2020.06.002
https://doi.org/10.1016/j.cjca.2020.06.0...

14 Romanò M. Fra cure intensive e cure palliative ai tempi di CoViD-19. Recenti Prog Med. 2020;111(4):223-30. doi: http://doi.org/10.1701/3347.33185
http://doi.org/10.1701/3347.33185...

15 Kramer JB, Brown DE, Kopar PK. Ethics in the time of coronavirus: recommendations in the COVID-19 Pandemic. J Am Coll Surg. 2020;230(6):1114-8. https://doi.org/10.1016/j.jamcollsurg.2020.04.004
https://doi.org/10.1016/j.jamcollsurg.20... -¹⁶16 Rawlings A, Brandt L, Ferreres A, Asbun H, Shadduck P. Ethical considerations for allocation of scarce resources and alterations in surgical care during a pandemic. Surg Endosc. 2021;35(5)2217-22. https://doi.org/10.1007/s00464-020-07629-x
https://doi.org/10.1007/s00464-020-07629... ,²¹21 Flaatten H. The good, the bad and the ugly: pandemic priority decisions and triage. J Med Ethics. 2020;0:1-3. https://doi.org/10.1136/medethics-2020-106489
https://doi.org/10.1136/medethics-2020-1...

22 Rubio O, Estella A, Cabre L, Saralegui-Reta I, Martin MC, Zapata L, et al. Recomendaciones éticas para la toma de decisiones difíciles en las unidades de cuidados intensivos ante la situación excepcional de crisis por la pandemia por COVID-19: revisión rápida y consenso de expertos. Med Intensiva. 2020. https://doi.org/10.1016/j.medin.2020.04.006
https://doi.org/10.1016/j.medin.2020.04....

23 DeBruin D, Leider JP. COVID-19: The shift from clinical to public health ethics. J Public Health Manag Pract. 2020;26(4):306-9. https://doi.org/10.1097/PHH.0000000000001204
https://doi.org/10.1097/PHH.000000000000...

24 Parsons JA, Johal HK. Best interests versus resource allocation: could COVID-19 cloud decision-making for the cognitively impaired? J Med Ethics. 2020;46:447-50. https://doi.org/10.1136/medethics-2020-106323
https://doi.org/10.1136/medethics-2020-1... -²⁵25 Kirkpatrick JN, Hull SC, Fedson S, Mullen B, Goodlin SJ. Scarce-Resource allocation and patient triage during the COVID-19 pandemic: JACC review topic of the week. J Am Coll Cardiol. 2020;76(1). https://doi.org/10.1016/j.jacc.2020.05.006
https://doi.org/10.1016/j.jacc.2020.05.0... ), followed by descriptive qualitative studies (5.56%)(²⁶26 Herreros B, Gella P, Asua DR. Triage during the COVID-19 epidemic in Spain: better and worse ethical arguments. J Med Ethics. 2020;46:455-58. https://doi.org/10.1136/medethics-2020-106352
https://doi.org/10.1136/medethics-2020-1... ). Most articles were published in English (94.74%)(²2 Iserson K. Healthcare ethics during a pandemic. West J Emerg Med. 2020;21(3):477-83. https://doi.org/10.5811/westjem.2020.4.47549
https://doi.org/10.5811/westjem.2020.4.4... ,⁴4 Shah A, Aacharya RP. Combating COVID-19 pandemic in Nepal: ethical challenges in an outbreak. JNMA J Nepal Med Assoc. 2020;58(224):276-9. https://doi.org/10.31729/jnma.4959
https://doi.org/10.31729/jnma.4959...

5 Jeffrey DI. Relational ethical approaches to the COVID-19 pandemic. J Med Ethics. 2020;46:495-8. https://doi.org/10.1136/medethics-2020-106264
https://doi.org/10.1136/medethics-2020-1... -⁶6 Solnica A, Barski L, Jotkowitz A. Allocation of scarce resources during the COVID-19 pandemic: a jewish ethical perspective. J Med Ethics. 2020;46:444-6. https://doi.org/10.1136/medethics-2020-106242
https://doi.org/10.1136/medethics-2020-1... ,⁹9 Morley G, Grady C, Mccarthy J, Ulrich CM. Covid-19: ethical challenges for nurses. Hastings Cent Rep. 2020;50(3):35-9. https://doi.org/10.1002/hast.1110
https://doi.org/10.1002/hast.1110...

10 Nicoli F, Gasparetto A. Italy in a time of emergency and scarce resources: the need for embedding ethical reflection in social and clinical settings. J Clin Ethics. [Internet]. 2020[cited 2020 July 27];31(1):92-4. Available from: https://pubmed.ncbi.nlm.nih.gov/32213700/
https://pubmed.ncbi.nlm.nih.gov/32213700... -¹¹11 Vincent J-L, Creteur J. Ethical aspects of the COVID-19 crisis: how to deal with an overwhelming shortage of acute beds. Eur Heart J Acute Cardiovasc Care. 2020;9(3):248-52. https://doi.org/10.1177/2048872620922788
https://doi.org/10.1177/2048872620922788... ,¹³13 Virani A, Singh G, Bewick D, Chow C-M, Clarke B, Cowan S, et al. Guiding cardiac care during the COVID-19 pandemic: How ethics shapes our health system response. Can J Cardiol. 2020;36(8):1313-6. https://doi.org/10.1016/j.cjca.2020.06.002
https://doi.org/10.1016/j.cjca.2020.06.0...

14 Romanò M. Fra cure intensive e cure palliative ai tempi di CoViD-19. Recenti Prog Med. 2020;111(4):223-30. doi: http://doi.org/10.1701/3347.33185
http://doi.org/10.1701/3347.33185... -¹⁵15 Kramer JB, Brown DE, Kopar PK. Ethics in the time of coronavirus: recommendations in the COVID-19 Pandemic. J Am Coll Surg. 2020;230(6):1114-8. https://doi.org/10.1016/j.jamcollsurg.2020.04.004
https://doi.org/10.1016/j.jamcollsurg.20... ,²⁴24 Parsons JA, Johal HK. Best interests versus resource allocation: could COVID-19 cloud decision-making for the cognitively impaired? J Med Ethics. 2020;46:447-50. https://doi.org/10.1136/medethics-2020-106323
https://doi.org/10.1136/medethics-2020-1...

25 Kirkpatrick JN, Hull SC, Fedson S, Mullen B, Goodlin SJ. Scarce-Resource allocation and patient triage during the COVID-19 pandemic: JACC review topic of the week. J Am Coll Cardiol. 2020;76(1). https://doi.org/10.1016/j.jacc.2020.05.006
https://doi.org/10.1016/j.jacc.2020.05.0... -²⁶26 Herreros B, Gella P, Asua DR. Triage during the COVID-19 epidemic in Spain: better and worse ethical arguments. J Med Ethics. 2020;46:455-58. https://doi.org/10.1136/medethics-2020-106352
https://doi.org/10.1136/medethics-2020-1... ), in journals from the medical (55.60%)(²2 Iserson K. Healthcare ethics during a pandemic. West J Emerg Med. 2020;21(3):477-83. https://doi.org/10.5811/westjem.2020.4.47549
https://doi.org/10.5811/westjem.2020.4.4... ,⁴4 Shah A, Aacharya RP. Combating COVID-19 pandemic in Nepal: ethical challenges in an outbreak. JNMA J Nepal Med Assoc. 2020;58(224):276-9. https://doi.org/10.31729/jnma.4959
https://doi.org/10.31729/jnma.4959... ,⁸8 Chan PS, Berg RA, Nadkarni VM. Code blue during the COVID-19 pandemic. Circ Cardiovasc Qual Outcomes. 2020;13(5):e006779. https://doi.org/10.1161/circoutcomes.120.006779
https://doi.org/10.1161/circoutcomes.120... ,¹¹11 Vincent J-L, Creteur J. Ethical aspects of the COVID-19 crisis: how to deal with an overwhelming shortage of acute beds. Eur Heart J Acute Cardiovasc Care. 2020;9(3):248-52. https://doi.org/10.1177/2048872620922788
https://doi.org/10.1177/2048872620922788... ,¹³13 Virani A, Singh G, Bewick D, Chow C-M, Clarke B, Cowan S, et al. Guiding cardiac care during the COVID-19 pandemic: How ethics shapes our health system response. Can J Cardiol. 2020;36(8):1313-6. https://doi.org/10.1016/j.cjca.2020.06.002
https://doi.org/10.1016/j.cjca.2020.06.0...

14 Romanò M. Fra cure intensive e cure palliative ai tempi di CoViD-19. Recenti Prog Med. 2020;111(4):223-30. doi: http://doi.org/10.1701/3347.33185
http://doi.org/10.1701/3347.33185...

15 Kramer JB, Brown DE, Kopar PK. Ethics in the time of coronavirus: recommendations in the COVID-19 Pandemic. J Am Coll Surg. 2020;230(6):1114-8. https://doi.org/10.1016/j.jamcollsurg.2020.04.004
https://doi.org/10.1016/j.jamcollsurg.20... -¹⁶16 Rawlings A, Brandt L, Ferreres A, Asbun H, Shadduck P. Ethical considerations for allocation of scarce resources and alterations in surgical care during a pandemic. Surg Endosc. 2021;35(5)2217-22. https://doi.org/10.1007/s00464-020-07629-x
https://doi.org/10.1007/s00464-020-07629... ,²²22 Rubio O, Estella A, Cabre L, Saralegui-Reta I, Martin MC, Zapata L, et al. Recomendaciones éticas para la toma de decisiones difíciles en las unidades de cuidados intensivos ante la situación excepcional de crisis por la pandemia por COVID-19: revisión rápida y consenso de expertos. Med Intensiva. 2020. https://doi.org/10.1016/j.medin.2020.04.006
https://doi.org/10.1016/j.medin.2020.04.... ,²⁵25 Kirkpatrick JN, Hull SC, Fedson S, Mullen B, Goodlin SJ. Scarce-Resource allocation and patient triage during the COVID-19 pandemic: JACC review topic of the week. J Am Coll Cardiol. 2020;76(1). https://doi.org/10.1016/j.jacc.2020.05.006
https://doi.org/10.1016/j.jacc.2020.05.0... ), ethical (33.30%)(⁵5 Jeffrey DI. Relational ethical approaches to the COVID-19 pandemic. J Med Ethics. 2020;46:495-8. https://doi.org/10.1136/medethics-2020-106264
https://doi.org/10.1136/medethics-2020-1... -⁶6 Solnica A, Barski L, Jotkowitz A. Allocation of scarce resources during the COVID-19 pandemic: a jewish ethical perspective. J Med Ethics. 2020;46:444-6. https://doi.org/10.1136/medethics-2020-106242
https://doi.org/10.1136/medethics-2020-1... ,¹⁰10 Nicoli F, Gasparetto A. Italy in a time of emergency and scarce resources: the need for embedding ethical reflection in social and clinical settings. J Clin Ethics. [Internet]. 2020[cited 2020 July 27];31(1):92-4. Available from: https://pubmed.ncbi.nlm.nih.gov/32213700/
https://pubmed.ncbi.nlm.nih.gov/32213700... ,²¹21 Flaatten H. The good, the bad and the ugly: pandemic priority decisions and triage. J Med Ethics. 2020;0:1-3. https://doi.org/10.1136/medethics-2020-106489
https://doi.org/10.1136/medethics-2020-1... ,²⁴24 Parsons JA, Johal HK. Best interests versus resource allocation: could COVID-19 cloud decision-making for the cognitively impaired? J Med Ethics. 2020;46:447-50. https://doi.org/10.1136/medethics-2020-106323
https://doi.org/10.1136/medethics-2020-1... ,²⁶26 Herreros B, Gella P, Asua DR. Triage during the COVID-19 epidemic in Spain: better and worse ethical arguments. J Med Ethics. 2020;46:455-58. https://doi.org/10.1136/medethics-2020-106352
https://doi.org/10.1136/medethics-2020-1... ), and public health fields (11.10%)(⁹9 Morley G, Grady C, Mccarthy J, Ulrich CM. Covid-19: ethical challenges for nurses. Hastings Cent Rep. 2020;50(3):35-9. https://doi.org/10.1002/hast.1110
https://doi.org/10.1002/hast.1110... ,²³23 DeBruin D, Leider JP. COVID-19: The shift from clinical to public health ethics. J Public Health Manag Pract. 2020;26(4):306-9. https://doi.org/10.1097/PHH.0000000000001204
https://doi.org/10.1097/PHH.000000000000... ). The BVS was the portal with the highest number of articles (73.68%)(²2 Iserson K. Healthcare ethics during a pandemic. West J Emerg Med. 2020;21(3):477-83. https://doi.org/10.5811/westjem.2020.4.47549
https://doi.org/10.5811/westjem.2020.4.4... ,⁴4 Shah A, Aacharya RP. Combating COVID-19 pandemic in Nepal: ethical challenges in an outbreak. JNMA J Nepal Med Assoc. 2020;58(224):276-9. https://doi.org/10.31729/jnma.4959
https://doi.org/10.31729/jnma.4959... -⁵5 Jeffrey DI. Relational ethical approaches to the COVID-19 pandemic. J Med Ethics. 2020;46:495-8. https://doi.org/10.1136/medethics-2020-106264
https://doi.org/10.1136/medethics-2020-1... ,⁸8 Chan PS, Berg RA, Nadkarni VM. Code blue during the COVID-19 pandemic. Circ Cardiovasc Qual Outcomes. 2020;13(5):e006779. https://doi.org/10.1161/circoutcomes.120.006779
https://doi.org/10.1161/circoutcomes.120... ,¹⁰10 Nicoli F, Gasparetto A. Italy in a time of emergency and scarce resources: the need for embedding ethical reflection in social and clinical settings. J Clin Ethics. [Internet]. 2020[cited 2020 July 27];31(1):92-4. Available from: https://pubmed.ncbi.nlm.nih.gov/32213700/
https://pubmed.ncbi.nlm.nih.gov/32213700... ,¹³13 Virani A, Singh G, Bewick D, Chow C-M, Clarke B, Cowan S, et al. Guiding cardiac care during the COVID-19 pandemic: How ethics shapes our health system response. Can J Cardiol. 2020;36(8):1313-6. https://doi.org/10.1016/j.cjca.2020.06.002
https://doi.org/10.1016/j.cjca.2020.06.0... -¹⁴14 Romanò M. Fra cure intensive e cure palliative ai tempi di CoViD-19. Recenti Prog Med. 2020;111(4):223-30. doi: http://doi.org/10.1701/3347.33185
http://doi.org/10.1701/3347.33185... ,¹⁶16 Rawlings A, Brandt L, Ferreres A, Asbun H, Shadduck P. Ethical considerations for allocation of scarce resources and alterations in surgical care during a pandemic. Surg Endosc. 2021;35(5)2217-22. https://doi.org/10.1007/s00464-020-07629-x
https://doi.org/10.1007/s00464-020-07629... ,²¹21 Flaatten H. The good, the bad and the ugly: pandemic priority decisions and triage. J Med Ethics. 2020;0:1-3. https://doi.org/10.1136/medethics-2020-106489
https://doi.org/10.1136/medethics-2020-1... ,²⁶26 Herreros B, Gella P, Asua DR. Triage during the COVID-19 epidemic in Spain: better and worse ethical arguments. J Med Ethics. 2020;46:455-58. https://doi.org/10.1136/medethics-2020-106352
https://doi.org/10.1136/medethics-2020-1... ), followed by ScienceDirect (15.79%)(⁹9 Morley G, Grady C, Mccarthy J, Ulrich CM. Covid-19: ethical challenges for nurses. Hastings Cent Rep. 2020;50(3):35-9. https://doi.org/10.1002/hast.1110
https://doi.org/10.1002/hast.1110... ,¹⁵15 Kramer JB, Brown DE, Kopar PK. Ethics in the time of coronavirus: recommendations in the COVID-19 Pandemic. J Am Coll Surg. 2020;230(6):1114-8. https://doi.org/10.1016/j.jamcollsurg.2020.04.004
https://doi.org/10.1016/j.jamcollsurg.20... ,²⁵25 Kirkpatrick JN, Hull SC, Fedson S, Mullen B, Goodlin SJ. Scarce-Resource allocation and patient triage during the COVID-19 pandemic: JACC review topic of the week. J Am Coll Cardiol. 2020;76(1). https://doi.org/10.1016/j.jacc.2020.05.006
https://doi.org/10.1016/j.jacc.2020.05.0... ), and MEDLINE (10.53%)(⁶6 Solnica A, Barski L, Jotkowitz A. Allocation of scarce resources during the COVID-19 pandemic: a jewish ethical perspective. J Med Ethics. 2020;46:444-6. https://doi.org/10.1136/medethics-2020-106242
https://doi.org/10.1136/medethics-2020-1... ,¹¹11 Vincent J-L, Creteur J. Ethical aspects of the COVID-19 crisis: how to deal with an overwhelming shortage of acute beds. Eur Heart J Acute Cardiovasc Care. 2020;9(3):248-52. https://doi.org/10.1177/2048872620922788
https://doi.org/10.1177/2048872620922788... ).

Eight studies were carried out in North America (seven in the United States of America and one in Canada)(²2 Iserson K. Healthcare ethics during a pandemic. West J Emerg Med. 2020;21(3):477-83. https://doi.org/10.5811/westjem.2020.4.47549
https://doi.org/10.5811/westjem.2020.4.4... ,⁸8 Chan PS, Berg RA, Nadkarni VM. Code blue during the COVID-19 pandemic. Circ Cardiovasc Qual Outcomes. 2020;13(5):e006779. https://doi.org/10.1161/circoutcomes.120.006779
https://doi.org/10.1161/circoutcomes.120... -⁹9 Morley G, Grady C, Mccarthy J, Ulrich CM. Covid-19: ethical challenges for nurses. Hastings Cent Rep. 2020;50(3):35-9. https://doi.org/10.1002/hast.1110
https://doi.org/10.1002/hast.1110... ,¹³13 Virani A, Singh G, Bewick D, Chow C-M, Clarke B, Cowan S, et al. Guiding cardiac care during the COVID-19 pandemic: How ethics shapes our health system response. Can J Cardiol. 2020;36(8):1313-6. https://doi.org/10.1016/j.cjca.2020.06.002
https://doi.org/10.1016/j.cjca.2020.06.0... ,¹⁵15 Kramer JB, Brown DE, Kopar PK. Ethics in the time of coronavirus: recommendations in the COVID-19 Pandemic. J Am Coll Surg. 2020;230(6):1114-8. https://doi.org/10.1016/j.jamcollsurg.2020.04.004
https://doi.org/10.1016/j.jamcollsurg.20... -¹⁶16 Rawlings A, Brandt L, Ferreres A, Asbun H, Shadduck P. Ethical considerations for allocation of scarce resources and alterations in surgical care during a pandemic. Surg Endosc. 2021;35(5)2217-22. https://doi.org/10.1007/s00464-020-07629-x
https://doi.org/10.1007/s00464-020-07629... ,²³23 DeBruin D, Leider JP. COVID-19: The shift from clinical to public health ethics. J Public Health Manag Pract. 2020;26(4):306-9. https://doi.org/10.1097/PHH.0000000000001204
https://doi.org/10.1097/PHH.000000000000... ,²⁵25 Kirkpatrick JN, Hull SC, Fedson S, Mullen B, Goodlin SJ. Scarce-Resource allocation and patient triage during the COVID-19 pandemic: JACC review topic of the week. J Am Coll Cardiol. 2020;76(1). https://doi.org/10.1016/j.jacc.2020.05.006
https://doi.org/10.1016/j.jacc.2020.05.0... ), seven in Europe (two in Spain, two in Italy, two in the United Kingdom, and one in Belgium)(⁵5 Jeffrey DI. Relational ethical approaches to the COVID-19 pandemic. J Med Ethics. 2020;46:495-8. https://doi.org/10.1136/medethics-2020-106264
https://doi.org/10.1136/medethics-2020-1... ,¹⁰10 Nicoli F, Gasparetto A. Italy in a time of emergency and scarce resources: the need for embedding ethical reflection in social and clinical settings. J Clin Ethics. [Internet]. 2020[cited 2020 July 27];31(1):92-4. Available from: https://pubmed.ncbi.nlm.nih.gov/32213700/
https://pubmed.ncbi.nlm.nih.gov/32213700... -¹¹11 Vincent J-L, Creteur J. Ethical aspects of the COVID-19 crisis: how to deal with an overwhelming shortage of acute beds. Eur Heart J Acute Cardiovasc Care. 2020;9(3):248-52. https://doi.org/10.1177/2048872620922788
https://doi.org/10.1177/2048872620922788... ,¹⁴14 Romanò M. Fra cure intensive e cure palliative ai tempi di CoViD-19. Recenti Prog Med. 2020;111(4):223-30. doi: http://doi.org/10.1701/3347.33185
http://doi.org/10.1701/3347.33185... ,²²22 Rubio O, Estella A, Cabre L, Saralegui-Reta I, Martin MC, Zapata L, et al. Recomendaciones éticas para la toma de decisiones difíciles en las unidades de cuidados intensivos ante la situación excepcional de crisis por la pandemia por COVID-19: revisión rápida y consenso de expertos. Med Intensiva. 2020. https://doi.org/10.1016/j.medin.2020.04.006
https://doi.org/10.1016/j.medin.2020.04.... ,²⁴24 Parsons JA, Johal HK. Best interests versus resource allocation: could COVID-19 cloud decision-making for the cognitively impaired? J Med Ethics. 2020;46:447-50. https://doi.org/10.1136/medethics-2020-106323
https://doi.org/10.1136/medethics-2020-1... ,²⁶26 Herreros B, Gella P, Asua DR. Triage during the COVID-19 epidemic in Spain: better and worse ethical arguments. J Med Ethics. 2020;46:455-58. https://doi.org/10.1136/medethics-2020-106352
https://doi.org/10.1136/medethics-2020-1... ), two in Asia (one in Israel and one in Nepal)(⁴4 Shah A, Aacharya RP. Combating COVID-19 pandemic in Nepal: ethical challenges in an outbreak. JNMA J Nepal Med Assoc. 2020;58(224):276-9. https://doi.org/10.31729/jnma.4959
https://doi.org/10.31729/jnma.4959... ,⁶6 Solnica A, Barski L, Jotkowitz A. Allocation of scarce resources during the COVID-19 pandemic: a jewish ethical perspective. J Med Ethics. 2020;46:444-6. https://doi.org/10.1136/medethics-2020-106242
https://doi.org/10.1136/medethics-2020-1... ), and one involved researchers from both Europe and Asia(²¹21 Flaatten H. The good, the bad and the ugly: pandemic priority decisions and triage. J Med Ethics. 2020;0:1-3. https://doi.org/10.1136/medethics-2020-106489
https://doi.org/10.1136/medethics-2020-1... ). There were no studies in South America.

Regarding the professionals analyzed, 11 articles referred to health workers in general(²2 Iserson K. Healthcare ethics during a pandemic. West J Emerg Med. 2020;21(3):477-83. https://doi.org/10.5811/westjem.2020.4.47549
https://doi.org/10.5811/westjem.2020.4.4... ,⁴4 Shah A, Aacharya RP. Combating COVID-19 pandemic in Nepal: ethical challenges in an outbreak. JNMA J Nepal Med Assoc. 2020;58(224):276-9. https://doi.org/10.31729/jnma.4959
https://doi.org/10.31729/jnma.4959... -⁵5 Jeffrey DI. Relational ethical approaches to the COVID-19 pandemic. J Med Ethics. 2020;46:495-8. https://doi.org/10.1136/medethics-2020-106264
https://doi.org/10.1136/medethics-2020-1... ,¹¹11 Vincent J-L, Creteur J. Ethical aspects of the COVID-19 crisis: how to deal with an overwhelming shortage of acute beds. Eur Heart J Acute Cardiovasc Care. 2020;9(3):248-52. https://doi.org/10.1177/2048872620922788
https://doi.org/10.1177/2048872620922788... ,¹⁴14 Romanò M. Fra cure intensive e cure palliative ai tempi di CoViD-19. Recenti Prog Med. 2020;111(4):223-30. doi: http://doi.org/10.1701/3347.33185
http://doi.org/10.1701/3347.33185...

15 Kramer JB, Brown DE, Kopar PK. Ethics in the time of coronavirus: recommendations in the COVID-19 Pandemic. J Am Coll Surg. 2020;230(6):1114-8. https://doi.org/10.1016/j.jamcollsurg.2020.04.004
https://doi.org/10.1016/j.jamcollsurg.20... -¹⁶16 Rawlings A, Brandt L, Ferreres A, Asbun H, Shadduck P. Ethical considerations for allocation of scarce resources and alterations in surgical care during a pandemic. Surg Endosc. 2021;35(5)2217-22. https://doi.org/10.1007/s00464-020-07629-x
https://doi.org/10.1007/s00464-020-07629... ,²¹21 Flaatten H. The good, the bad and the ugly: pandemic priority decisions and triage. J Med Ethics. 2020;0:1-3. https://doi.org/10.1136/medethics-2020-106489
https://doi.org/10.1136/medethics-2020-1...

22 Rubio O, Estella A, Cabre L, Saralegui-Reta I, Martin MC, Zapata L, et al. Recomendaciones éticas para la toma de decisiones difíciles en las unidades de cuidados intensivos ante la situación excepcional de crisis por la pandemia por COVID-19: revisión rápida y consenso de expertos. Med Intensiva. 2020. https://doi.org/10.1016/j.medin.2020.04.006
https://doi.org/10.1016/j.medin.2020.04.... -²³23 DeBruin D, Leider JP. COVID-19: The shift from clinical to public health ethics. J Public Health Manag Pract. 2020;26(4):306-9. https://doi.org/10.1097/PHH.0000000000001204
https://doi.org/10.1097/PHH.000000000000... ,²⁶26 Herreros B, Gella P, Asua DR. Triage during the COVID-19 epidemic in Spain: better and worse ethical arguments. J Med Ethics. 2020;46:455-58. https://doi.org/10.1136/medethics-2020-106352
https://doi.org/10.1136/medethics-2020-1... ); five, to physicians(⁶6 Solnica A, Barski L, Jotkowitz A. Allocation of scarce resources during the COVID-19 pandemic: a jewish ethical perspective. J Med Ethics. 2020;46:444-6. https://doi.org/10.1136/medethics-2020-106242
https://doi.org/10.1136/medethics-2020-1... ,⁸8 Chan PS, Berg RA, Nadkarni VM. Code blue during the COVID-19 pandemic. Circ Cardiovasc Qual Outcomes. 2020;13(5):e006779. https://doi.org/10.1161/circoutcomes.120.006779
https://doi.org/10.1161/circoutcomes.120... ,¹³13 Virani A, Singh G, Bewick D, Chow C-M, Clarke B, Cowan S, et al. Guiding cardiac care during the COVID-19 pandemic: How ethics shapes our health system response. Can J Cardiol. 2020;36(8):1313-6. https://doi.org/10.1016/j.cjca.2020.06.002
https://doi.org/10.1016/j.cjca.2020.06.0... ,²⁴24 Parsons JA, Johal HK. Best interests versus resource allocation: could COVID-19 cloud decision-making for the cognitively impaired? J Med Ethics. 2020;46:447-50. https://doi.org/10.1136/medethics-2020-106323
https://doi.org/10.1136/medethics-2020-1... -²⁵25 Kirkpatrick JN, Hull SC, Fedson S, Mullen B, Goodlin SJ. Scarce-Resource allocation and patient triage during the COVID-19 pandemic: JACC review topic of the week. J Am Coll Cardiol. 2020;76(1). https://doi.org/10.1016/j.jacc.2020.05.006
https://doi.org/10.1016/j.jacc.2020.05.0... ); one to a bioethicist(¹⁰10 Nicoli F, Gasparetto A. Italy in a time of emergency and scarce resources: the need for embedding ethical reflection in social and clinical settings. J Clin Ethics. [Internet]. 2020[cited 2020 July 27];31(1):92-4. Available from: https://pubmed.ncbi.nlm.nih.gov/32213700/
https://pubmed.ncbi.nlm.nih.gov/32213700... ); and one, to nurses(⁹9 Morley G, Grady C, Mccarthy J, Ulrich CM. Covid-19: ethical challenges for nurses. Hastings Cent Rep. 2020;50(3):35-9. https://doi.org/10.1002/hast.1110
https://doi.org/10.1002/hast.1110... ). Most authors were physicians working on research or teaching (84.22%), followed by researchers connected to departments or institutions of nursing (5.26%), bioethics (5.26%), and philosophy (5.26%). Regarding ethics, some authors were associated with research ethics committees or ethical communities (31.58%). Regarding the context, they addressed DM in intensive care (44.45%)(⁴4 Shah A, Aacharya RP. Combating COVID-19 pandemic in Nepal: ethical challenges in an outbreak. JNMA J Nepal Med Assoc. 2020;58(224):276-9. https://doi.org/10.31729/jnma.4959
https://doi.org/10.31729/jnma.4959... ,⁶6 Solnica A, Barski L, Jotkowitz A. Allocation of scarce resources during the COVID-19 pandemic: a jewish ethical perspective. J Med Ethics. 2020;46:444-6. https://doi.org/10.1136/medethics-2020-106242
https://doi.org/10.1136/medethics-2020-1... ,⁸8 Chan PS, Berg RA, Nadkarni VM. Code blue during the COVID-19 pandemic. Circ Cardiovasc Qual Outcomes. 2020;13(5):e006779. https://doi.org/10.1161/circoutcomes.120.006779
https://doi.org/10.1161/circoutcomes.120... -⁹9 Morley G, Grady C, Mccarthy J, Ulrich CM. Covid-19: ethical challenges for nurses. Hastings Cent Rep. 2020;50(3):35-9. https://doi.org/10.1002/hast.1110
https://doi.org/10.1002/hast.1110... ,¹⁴14 Romanò M. Fra cure intensive e cure palliative ai tempi di CoViD-19. Recenti Prog Med. 2020;111(4):223-30. doi: http://doi.org/10.1701/3347.33185
http://doi.org/10.1701/3347.33185... ,²¹21 Flaatten H. The good, the bad and the ugly: pandemic priority decisions and triage. J Med Ethics. 2020;0:1-3. https://doi.org/10.1136/medethics-2020-106489
https://doi.org/10.1136/medethics-2020-1... -²²22 Rubio O, Estella A, Cabre L, Saralegui-Reta I, Martin MC, Zapata L, et al. Recomendaciones éticas para la toma de decisiones difíciles en las unidades de cuidados intensivos ante la situación excepcional de crisis por la pandemia por COVID-19: revisión rápida y consenso de expertos. Med Intensiva. 2020. https://doi.org/10.1016/j.medin.2020.04.006
https://doi.org/10.1016/j.medin.2020.04.... ,²⁴24 Parsons JA, Johal HK. Best interests versus resource allocation: could COVID-19 cloud decision-making for the cognitively impaired? J Med Ethics. 2020;46:447-50. https://doi.org/10.1136/medethics-2020-106323
https://doi.org/10.1136/medethics-2020-1... ), as well as in outpatient (33.34%)(²2 Iserson K. Healthcare ethics during a pandemic. West J Emerg Med. 2020;21(3):477-83. https://doi.org/10.5811/westjem.2020.4.47549
https://doi.org/10.5811/westjem.2020.4.4... ,⁵5 Jeffrey DI. Relational ethical approaches to the COVID-19 pandemic. J Med Ethics. 2020;46:495-8. https://doi.org/10.1136/medethics-2020-106264
https://doi.org/10.1136/medethics-2020-1... ,¹⁵15 Kramer JB, Brown DE, Kopar PK. Ethics in the time of coronavirus: recommendations in the COVID-19 Pandemic. J Am Coll Surg. 2020;230(6):1114-8. https://doi.org/10.1016/j.jamcollsurg.2020.04.004
https://doi.org/10.1016/j.jamcollsurg.20... ,²³23 DeBruin D, Leider JP. COVID-19: The shift from clinical to public health ethics. J Public Health Manag Pract. 2020;26(4):306-9. https://doi.org/10.1097/PHH.0000000000001204
https://doi.org/10.1097/PHH.000000000000... ,²⁵25 Kirkpatrick JN, Hull SC, Fedson S, Mullen B, Goodlin SJ. Scarce-Resource allocation and patient triage during the COVID-19 pandemic: JACC review topic of the week. J Am Coll Cardiol. 2020;76(1). https://doi.org/10.1016/j.jacc.2020.05.006
https://doi.org/10.1016/j.jacc.2020.05.0... -²⁶26 Herreros B, Gella P, Asua DR. Triage during the COVID-19 epidemic in Spain: better and worse ethical arguments. J Med Ethics. 2020;46:455-58. https://doi.org/10.1136/medethics-2020-106352
https://doi.org/10.1136/medethics-2020-1... ), surgical (11.11%)(¹¹11 Vincent J-L, Creteur J. Ethical aspects of the COVID-19 crisis: how to deal with an overwhelming shortage of acute beds. Eur Heart J Acute Cardiovasc Care. 2020;9(3):248-52. https://doi.org/10.1177/2048872620922788
https://doi.org/10.1177/2048872620922788... ,¹⁶16 Rawlings A, Brandt L, Ferreres A, Asbun H, Shadduck P. Ethical considerations for allocation of scarce resources and alterations in surgical care during a pandemic. Surg Endosc. 2021;35(5)2217-22. https://doi.org/10.1007/s00464-020-07629-x
https://doi.org/10.1007/s00464-020-07629... ), cardiological (5.55%)(¹³13 Virani A, Singh G, Bewick D, Chow C-M, Clarke B, Cowan S, et al. Guiding cardiac care during the COVID-19 pandemic: How ethics shapes our health system response. Can J Cardiol. 2020;36(8):1313-6. https://doi.org/10.1016/j.cjca.2020.06.002
https://doi.org/10.1016/j.cjca.2020.06.0... ), and emergency care (5.55%)(¹⁰10 Nicoli F, Gasparetto A. Italy in a time of emergency and scarce resources: the need for embedding ethical reflection in social and clinical settings. J Clin Ethics. [Internet]. 2020[cited 2020 July 27];31(1):92-4. Available from: https://pubmed.ncbi.nlm.nih.gov/32213700/
https://pubmed.ncbi.nlm.nih.gov/32213700... ).

Regarding the EL(¹⁹19 Melnyk BM, Fineout-Overholt E. Evidence based practice in nursing and healthcare: a guide to best practice. Philadelphia: Lippincot Williams & Wilkins; 2005. Making the case for evidence based practice; p. 3-24.), 55.6%(²2 Iserson K. Healthcare ethics during a pandemic. West J Emerg Med. 2020;21(3):477-83. https://doi.org/10.5811/westjem.2020.4.47549
https://doi.org/10.5811/westjem.2020.4.4... ,⁴4 Shah A, Aacharya RP. Combating COVID-19 pandemic in Nepal: ethical challenges in an outbreak. JNMA J Nepal Med Assoc. 2020;58(224):276-9. https://doi.org/10.31729/jnma.4959
https://doi.org/10.31729/jnma.4959...

5 Jeffrey DI. Relational ethical approaches to the COVID-19 pandemic. J Med Ethics. 2020;46:495-8. https://doi.org/10.1136/medethics-2020-106264
https://doi.org/10.1136/medethics-2020-1... -⁶6 Solnica A, Barski L, Jotkowitz A. Allocation of scarce resources during the COVID-19 pandemic: a jewish ethical perspective. J Med Ethics. 2020;46:444-6. https://doi.org/10.1136/medethics-2020-106242
https://doi.org/10.1136/medethics-2020-1... ,⁸8 Chan PS, Berg RA, Nadkarni VM. Code blue during the COVID-19 pandemic. Circ Cardiovasc Qual Outcomes. 2020;13(5):e006779. https://doi.org/10.1161/circoutcomes.120.006779
https://doi.org/10.1161/circoutcomes.120... -⁹9 Morley G, Grady C, Mccarthy J, Ulrich CM. Covid-19: ethical challenges for nurses. Hastings Cent Rep. 2020;50(3):35-9. https://doi.org/10.1002/hast.1110
https://doi.org/10.1002/hast.1110... ,¹¹11 Vincent J-L, Creteur J. Ethical aspects of the COVID-19 crisis: how to deal with an overwhelming shortage of acute beds. Eur Heart J Acute Cardiovasc Care. 2020;9(3):248-52. https://doi.org/10.1177/2048872620922788
https://doi.org/10.1177/2048872620922788... ,¹⁶16 Rawlings A, Brandt L, Ferreres A, Asbun H, Shadduck P. Ethical considerations for allocation of scarce resources and alterations in surgical care during a pandemic. Surg Endosc. 2021;35(5)2217-22. https://doi.org/10.1007/s00464-020-07629-x
https://doi.org/10.1007/s00464-020-07629... ,²³23 DeBruin D, Leider JP. COVID-19: The shift from clinical to public health ethics. J Public Health Manag Pract. 2020;26(4):306-9. https://doi.org/10.1097/PHH.0000000000001204
https://doi.org/10.1097/PHH.000000000000... ,²⁶26 Herreros B, Gella P, Asua DR. Triage during the COVID-19 epidemic in Spain: better and worse ethical arguments. J Med Ethics. 2020;46:455-58. https://doi.org/10.1136/medethics-2020-106352
https://doi.org/10.1136/medethics-2020-1... ) of studies were classified as level VI (evidences from descriptive or qualitative studies), while 44.4%(¹⁰10 Nicoli F, Gasparetto A. Italy in a time of emergency and scarce resources: the need for embedding ethical reflection in social and clinical settings. J Clin Ethics. [Internet]. 2020[cited 2020 July 27];31(1):92-4. Available from: https://pubmed.ncbi.nlm.nih.gov/32213700/
https://pubmed.ncbi.nlm.nih.gov/32213700... ,¹³13 Virani A, Singh G, Bewick D, Chow C-M, Clarke B, Cowan S, et al. Guiding cardiac care during the COVID-19 pandemic: How ethics shapes our health system response. Can J Cardiol. 2020;36(8):1313-6. https://doi.org/10.1016/j.cjca.2020.06.002
https://doi.org/10.1016/j.cjca.2020.06.0...

14 Romanò M. Fra cure intensive e cure palliative ai tempi di CoViD-19. Recenti Prog Med. 2020;111(4):223-30. doi: http://doi.org/10.1701/3347.33185
http://doi.org/10.1701/3347.33185... -¹⁵15 Kramer JB, Brown DE, Kopar PK. Ethics in the time of coronavirus: recommendations in the COVID-19 Pandemic. J Am Coll Surg. 2020;230(6):1114-8. https://doi.org/10.1016/j.jamcollsurg.2020.04.004
https://doi.org/10.1016/j.jamcollsurg.20... ,²¹21 Flaatten H. The good, the bad and the ugly: pandemic priority decisions and triage. J Med Ethics. 2020;0:1-3. https://doi.org/10.1136/medethics-2020-106489
https://doi.org/10.1136/medethics-2020-1... -²²22 Rubio O, Estella A, Cabre L, Saralegui-Reta I, Martin MC, Zapata L, et al. Recomendaciones éticas para la toma de decisiones difíciles en las unidades de cuidados intensivos ante la situación excepcional de crisis por la pandemia por COVID-19: revisión rápida y consenso de expertos. Med Intensiva. 2020. https://doi.org/10.1016/j.medin.2020.04.006
https://doi.org/10.1016/j.medin.2020.04.... ,²⁴24 Parsons JA, Johal HK. Best interests versus resource allocation: could COVID-19 cloud decision-making for the cognitively impaired? J Med Ethics. 2020;46:447-50. https://doi.org/10.1136/medethics-2020-106323
https://doi.org/10.1136/medethics-2020-1... -²⁵25 Kirkpatrick JN, Hull SC, Fedson S, Mullen B, Goodlin SJ. Scarce-Resource allocation and patient triage during the COVID-19 pandemic: JACC review topic of the week. J Am Coll Cardiol. 2020;76(1). https://doi.org/10.1016/j.jacc.2020.05.006
https://doi.org/10.1016/j.jacc.2020.05.0... ) as level VII (evidences from the opinion of authorities and/or reports from specialist committees). The articles that form the sample are characterized in Chart 2.

DISCUSSION

From the articles analyzed, 12(²2 Iserson K. Healthcare ethics during a pandemic. West J Emerg Med. 2020;21(3):477-83. https://doi.org/10.5811/westjem.2020.4.47549
https://doi.org/10.5811/westjem.2020.4.4... ,⁴4 Shah A, Aacharya RP. Combating COVID-19 pandemic in Nepal: ethical challenges in an outbreak. JNMA J Nepal Med Assoc. 2020;58(224):276-9. https://doi.org/10.31729/jnma.4959
https://doi.org/10.31729/jnma.4959...

5 Jeffrey DI. Relational ethical approaches to the COVID-19 pandemic. J Med Ethics. 2020;46:495-8. https://doi.org/10.1136/medethics-2020-106264
https://doi.org/10.1136/medethics-2020-1... -⁶6 Solnica A, Barski L, Jotkowitz A. Allocation of scarce resources during the COVID-19 pandemic: a jewish ethical perspective. J Med Ethics. 2020;46:444-6. https://doi.org/10.1136/medethics-2020-106242
https://doi.org/10.1136/medethics-2020-1... ,⁹9 Morley G, Grady C, Mccarthy J, Ulrich CM. Covid-19: ethical challenges for nurses. Hastings Cent Rep. 2020;50(3):35-9. https://doi.org/10.1002/hast.1110
https://doi.org/10.1002/hast.1110... ,¹¹11 Vincent J-L, Creteur J. Ethical aspects of the COVID-19 crisis: how to deal with an overwhelming shortage of acute beds. Eur Heart J Acute Cardiovasc Care. 2020;9(3):248-52. https://doi.org/10.1177/2048872620922788
https://doi.org/10.1177/2048872620922788... ,¹³13 Virani A, Singh G, Bewick D, Chow C-M, Clarke B, Cowan S, et al. Guiding cardiac care during the COVID-19 pandemic: How ethics shapes our health system response. Can J Cardiol. 2020;36(8):1313-6. https://doi.org/10.1016/j.cjca.2020.06.002
https://doi.org/10.1016/j.cjca.2020.06.0... -¹⁴14 Romanò M. Fra cure intensive e cure palliative ai tempi di CoViD-19. Recenti Prog Med. 2020;111(4):223-30. doi: http://doi.org/10.1701/3347.33185
http://doi.org/10.1701/3347.33185... ,¹⁶16 Rawlings A, Brandt L, Ferreres A, Asbun H, Shadduck P. Ethical considerations for allocation of scarce resources and alterations in surgical care during a pandemic. Surg Endosc. 2021;35(5)2217-22. https://doi.org/10.1007/s00464-020-07629-x
https://doi.org/10.1007/s00464-020-07629... ,²³23 DeBruin D, Leider JP. COVID-19: The shift from clinical to public health ethics. J Public Health Manag Pract. 2020;26(4):306-9. https://doi.org/10.1097/PHH.0000000000001204
https://doi.org/10.1097/PHH.000000000000...

24 Parsons JA, Johal HK. Best interests versus resource allocation: could COVID-19 cloud decision-making for the cognitively impaired? J Med Ethics. 2020;46:447-50. https://doi.org/10.1136/medethics-2020-106323
https://doi.org/10.1136/medethics-2020-1... -²⁵25 Kirkpatrick JN, Hull SC, Fedson S, Mullen B, Goodlin SJ. Scarce-Resource allocation and patient triage during the COVID-19 pandemic: JACC review topic of the week. J Am Coll Cardiol. 2020;76(1). https://doi.org/10.1016/j.jacc.2020.05.006
https://doi.org/10.1016/j.jacc.2020.05.0... ) discussed ethical principles and values for the DM of professionals during this pandemic. “Principles”, here, are understood as the starting point and the foundation of any process of being, of having a responsibility, and/or of knowing. Valuesmean any contribution for a life which is made according to reason, in accordance with nature, or which is deserving to be chosen(²⁷27 Nocola A. Dicionário de Filosofia. 5. ed. rev. ampl. São Paulo (SP): Martins Fontes; 2007. 1026 p.).

The essential bioethics principles (autonomy, beneficence, non-maleficence, and justice) were the most mentioned(⁴4 Shah A, Aacharya RP. Combating COVID-19 pandemic in Nepal: ethical challenges in an outbreak. JNMA J Nepal Med Assoc. 2020;58(224):276-9. https://doi.org/10.31729/jnma.4959
https://doi.org/10.31729/jnma.4959... ,¹³13 Virani A, Singh G, Bewick D, Chow C-M, Clarke B, Cowan S, et al. Guiding cardiac care during the COVID-19 pandemic: How ethics shapes our health system response. Can J Cardiol. 2020;36(8):1313-6. https://doi.org/10.1016/j.cjca.2020.06.002
https://doi.org/10.1016/j.cjca.2020.06.0... -¹⁴14 Romanò M. Fra cure intensive e cure palliative ai tempi di CoViD-19. Recenti Prog Med. 2020;111(4):223-30. doi: http://doi.org/10.1701/3347.33185
http://doi.org/10.1701/3347.33185... ,¹⁶16 Rawlings A, Brandt L, Ferreres A, Asbun H, Shadduck P. Ethical considerations for allocation of scarce resources and alterations in surgical care during a pandemic. Surg Endosc. 2021;35(5)2217-22. https://doi.org/10.1007/s00464-020-07629-x
https://doi.org/10.1007/s00464-020-07629... ,²³23 DeBruin D, Leider JP. COVID-19: The shift from clinical to public health ethics. J Public Health Manag Pract. 2020;26(4):306-9. https://doi.org/10.1097/PHH.0000000000001204
https://doi.org/10.1097/PHH.000000000000...

24 Parsons JA, Johal HK. Best interests versus resource allocation: could COVID-19 cloud decision-making for the cognitively impaired? J Med Ethics. 2020;46:447-50. https://doi.org/10.1136/medethics-2020-106323
https://doi.org/10.1136/medethics-2020-1... -²⁵25 Kirkpatrick JN, Hull SC, Fedson S, Mullen B, Goodlin SJ. Scarce-Resource allocation and patient triage during the COVID-19 pandemic: JACC review topic of the week. J Am Coll Cardiol. 2020;76(1). https://doi.org/10.1016/j.jacc.2020.05.006
https://doi.org/10.1016/j.jacc.2020.05.0... ). Individual autonomy is related to self-determination or self-governance, to the power of deciding about oneself; beneficence means acting in the best interest of others; non-maleficence is the obligation of not prejudicing others and acting to avoid damage; and justice relates to the coherent and adequate distribution of social duties and benefits(²⁸28 Koerich, MS, Machado RR, Costa E. Ética e bioética: para dar início à reflexão. Texto Contexto Enferm. 2005;14(1):106-10. https://doi.org/10.1590/S0104-07072005000100014
https://doi.org/10.1590/S0104-0707200500... ), it means treating others fairly, impartially, and equally(¹⁶16 Rawlings A, Brandt L, Ferreres A, Asbun H, Shadduck P. Ethical considerations for allocation of scarce resources and alterations in surgical care during a pandemic. Surg Endosc. 2021;35(5)2217-22. https://doi.org/10.1007/s00464-020-07629-x
https://doi.org/10.1007/s00464-020-07629... ,²⁸28 Koerich, MS, Machado RR, Costa E. Ética e bioética: para dar início à reflexão. Texto Contexto Enferm. 2005;14(1):106-10. https://doi.org/10.1590/S0104-07072005000100014
https://doi.org/10.1590/S0104-0707200500... ).

During the attention to the person with COVID-19, the making of decisions related to the treatments adopted must go through the patient, who must agree, as the principle of autonomy advocates(²⁸28 Koerich, MS, Machado RR, Costa E. Ética e bioética: para dar início à reflexão. Texto Contexto Enferm. 2005;14(1):106-10. https://doi.org/10.1590/S0104-07072005000100014
https://doi.org/10.1590/S0104-0707200500... ); this must be done in respect to the fact that all persons are capable of self-determination, as moral agents of infinite value. Therefore, physicians and other health professionals cannot retain or remove, unilaterally, a treatment that is clinically approved or indicated without the consent of the patient or of someone who can speak for the patient. Considering this reasoning, they have the duty of caring for the patient to improve their health and wellbeing and avoid doing harm, according with the precept of non-maleficence as described in a NorthAmerican study(²⁵25 Kirkpatrick JN, Hull SC, Fedson S, Mullen B, Goodlin SJ. Scarce-Resource allocation and patient triage during the COVID-19 pandemic: JACC review topic of the week. J Am Coll Cardiol. 2020;76(1). https://doi.org/10.1016/j.jacc.2020.05.006
https://doi.org/10.1016/j.jacc.2020.05.0... ).

In the setting of a crisis, the principle of autonomy is no longer focused on the individual and changes its focus towards what is beneficial to society (which is also known as “ethics of solidarity”). As a result, the decisions made by all professionals must consider social wellbeing, as show studies from Canada(¹³13 Virani A, Singh G, Bewick D, Chow C-M, Clarke B, Cowan S, et al. Guiding cardiac care during the COVID-19 pandemic: How ethics shapes our health system response. Can J Cardiol. 2020;36(8):1313-6. https://doi.org/10.1016/j.cjca.2020.06.002
https://doi.org/10.1016/j.cjca.2020.06.0... ) and the United States(⁹9 Morley G, Grady C, Mccarthy J, Ulrich CM. Covid-19: ethical challenges for nurses. Hastings Cent Rep. 2020;50(3):35-9. https://doi.org/10.1002/hast.1110
https://doi.org/10.1002/hast.1110... ,¹⁶16 Rawlings A, Brandt L, Ferreres A, Asbun H, Shadduck P. Ethical considerations for allocation of scarce resources and alterations in surgical care during a pandemic. Surg Endosc. 2021;35(5)2217-22. https://doi.org/10.1007/s00464-020-07629-x
https://doi.org/10.1007/s00464-020-07629... ). One of the ways to prioritize the collective is to isolate suspected cases for the good of the population, that is, showing commitment to beneficence(⁴4 Shah A, Aacharya RP. Combating COVID-19 pandemic in Nepal: ethical challenges in an outbreak. JNMA J Nepal Med Assoc. 2020;58(224):276-9. https://doi.org/10.31729/jnma.4959
https://doi.org/10.31729/jnma.4959... ). Furthermore, measures to encourage hand hygiene, respiratory etiquette, and the use of home-made facial masks, in addition to continuous social-distancing measures, were implemented in many countries, to a greater or lesser extent. Their results, probably, depend on socioeconomic and cultural aspects, on the characteristics of political and health systems, and on the operational procedures for their implementation(³3 Aquino EML, Silveira IH, Pescarini JM, Souza-Filho JA, Rocha AS, Ferreira A, et al. Social distancing measures to control the COVID-19 pandemic: potential impacts and challenges in Brazil. Cienc Saude Colet. 2020;25(suppl 1):2423-46. https://doi.org/10.1590/1413-81232020256.1.10502020
https://doi.org/10.1590/1413-81232020256... ).

The preservation and effectiveness of these measures depend on the establishment of policies of social protection and for the support of vulnerable people(³3 Aquino EML, Silveira IH, Pescarini JM, Souza-Filho JA, Rocha AS, Ferreira A, et al. Social distancing measures to control the COVID-19 pandemic: potential impacts and challenges in Brazil. Cienc Saude Colet. 2020;25(suppl 1):2423-46. https://doi.org/10.1590/1413-81232020256.1.10502020
https://doi.org/10.1590/1413-81232020256... ). This idea finds support on a study from Nepal which, in accordance with the principle of non-maleficence, states that the poor and marginalized, as well as people being treated for comorbidities, need social mechanisms that can aid them, since they are the ones who suffer the most with restrictive measures. Also, the professionals must pay close attention to these groups during DM(⁴4 Shah A, Aacharya RP. Combating COVID-19 pandemic in Nepal: ethical challenges in an outbreak. JNMA J Nepal Med Assoc. 2020;58(224):276-9. https://doi.org/10.31729/jnma.4959
https://doi.org/10.31729/jnma.4959... ). Elders are one of the vulnerable groups, which makes the decision to admit them into ICUs an ethical dilemma(²¹21 Flaatten H. The good, the bad and the ugly: pandemic priority decisions and triage. J Med Ethics. 2020;0:1-3. https://doi.org/10.1136/medethics-2020-106489
https://doi.org/10.1136/medethics-2020-1... ), since they are the population affected the most by COVID-19 and who is the most likely to die after hospitalization(²⁹29 Fhon JRS, Silva LM, Leitón-Espinoza ZE, Matiello FB, Araújo JS, Rodrigues RAP. Atendimento hospitalar ao idoso com COVID-19. Rev Latino-Am Enfermagem. 2020;28(e3396):1-10. https://doi.org/10.1590/1518-8345.4649.3396
https://doi.org/10.1590/1518-8345.4649.3... ).

Reflecting on this issue in regard to the elderly population, some problems that involve the DM by the health professionals should be highlighted. One of the most commonly mentioned ethical issues related to health involves deciding between offering resources (mechanical ventilation, beds in the ICU) to elderly people (80 years old or older) in a setting in which these resources are scarce, or to use them to attend to the needs of those infected by COVID-19. In this regard, an ethical specialist recommends prioritizing the younger, who are more likely to survive and live longer after the disease, while providing adequate palliative care to those who renounced the use of any specific resource, to provide them with a dignified death, assistance, and guarantee the least possible suffering(³⁰30 Miller FG. Why I Support Age-Related Rationing of Ventilators for Covid-19 Patients [Internet]. 2020 [cited 2020 Dec 29]. Available from: https://www.thehastingscenter.org/why-i-support-age-related-rationing-ofventilators-for-covid-19-patients/
https://www.thehastingscenter.org/why-i-... ).

Although the authors of the North-American(²⁵25 Kirkpatrick JN, Hull SC, Fedson S, Mullen B, Goodlin SJ. Scarce-Resource allocation and patient triage during the COVID-19 pandemic: JACC review topic of the week. J Am Coll Cardiol. 2020;76(1). https://doi.org/10.1016/j.jacc.2020.05.006
https://doi.org/10.1016/j.jacc.2020.05.0... ) study corroborate the perception of this specialist, others believe this view to be controversial and discriminatory. They disagree, claiming the criteria of age alone is insufficient to make this decision, since not all elders are diseased and not all young people are healthy(¹¹11 Vincent J-L, Creteur J. Ethical aspects of the COVID-19 crisis: how to deal with an overwhelming shortage of acute beds. Eur Heart J Acute Cardiovasc Care. 2020;9(3):248-52. https://doi.org/10.1177/2048872620922788
https://doi.org/10.1177/2048872620922788... ). Therefore, this criteria cannot be considered alone, and many others should be taken into account, such as: years of life to be lived, presence and extent of comorbidities(⁸8 Chan PS, Berg RA, Nadkarni VM. Code blue during the COVID-19 pandemic. Circ Cardiovasc Qual Outcomes. 2020;13(5):e006779. https://doi.org/10.1161/circoutcomes.120.006779
https://doi.org/10.1161/circoutcomes.120... ,¹⁴14 Romanò M. Fra cure intensive e cure palliative ai tempi di CoViD-19. Recenti Prog Med. 2020;111(4):223-30. doi: http://doi.org/10.1701/3347.33185
http://doi.org/10.1701/3347.33185... ), degree of fragility(¹⁴14 Romanò M. Fra cure intensive e cure palliative ai tempi di CoViD-19. Recenti Prog Med. 2020;111(4):223-30. doi: http://doi.org/10.1701/3347.33185
http://doi.org/10.1701/3347.33185... ), expectancy of recovery with good quality of life(¹¹11 Vincent J-L, Creteur J. Ethical aspects of the COVID-19 crisis: how to deal with an overwhelming shortage of acute beds. Eur Heart J Acute Cardiovasc Care. 2020;9(3):248-52. https://doi.org/10.1177/2048872620922788
https://doi.org/10.1177/2048872620922788... ), characteristics and state of health(²²22 Rubio O, Estella A, Cabre L, Saralegui-Reta I, Martin MC, Zapata L, et al. Recomendaciones éticas para la toma de decisiones difíciles en las unidades de cuidados intensivos ante la situación excepcional de crisis por la pandemia por COVID-19: revisión rápida y consenso de expertos. Med Intensiva. 2020. https://doi.org/10.1016/j.medin.2020.04.006
https://doi.org/10.1016/j.medin.2020.04.... ), calculation of the base functional and cognitive levels, measurement of the severity of the disease, possibility of recuperation, and potential to recover after treatment(²⁶26 Herreros B, Gella P, Asua DR. Triage during the COVID-19 epidemic in Spain: better and worse ethical arguments. J Med Ethics. 2020;46:455-58. https://doi.org/10.1136/medethics-2020-106352
https://doi.org/10.1136/medethics-2020-1... ).

Regarding who receives priority in care, that is, the triage, whether it takes place in the admission, allocation, or relocation of resources, the results highlighted the predominance of the principle of utilitarianism in DM. According to this principle, a moral decision is only adequate when it brings the best results for the highest number of people. The DM must be based on helping those who have a higher life expectancy, and resources should be allocated to patients who are more likely to survive, to be cured, and have the perspective to have a reasonable quality of life(²2 Iserson K. Healthcare ethics during a pandemic. West J Emerg Med. 2020;21(3):477-83. https://doi.org/10.5811/westjem.2020.4.47549
https://doi.org/10.5811/westjem.2020.4.4... ,⁴4 Shah A, Aacharya RP. Combating COVID-19 pandemic in Nepal: ethical challenges in an outbreak. JNMA J Nepal Med Assoc. 2020;58(224):276-9. https://doi.org/10.31729/jnma.4959
https://doi.org/10.31729/jnma.4959... ,⁶6 Solnica A, Barski L, Jotkowitz A. Allocation of scarce resources during the COVID-19 pandemic: a jewish ethical perspective. J Med Ethics. 2020;46:444-6. https://doi.org/10.1136/medethics-2020-106242
https://doi.org/10.1136/medethics-2020-1... ,¹¹11 Vincent J-L, Creteur J. Ethical aspects of the COVID-19 crisis: how to deal with an overwhelming shortage of acute beds. Eur Heart J Acute Cardiovasc Care. 2020;9(3):248-52. https://doi.org/10.1177/2048872620922788
https://doi.org/10.1177/2048872620922788... ,²⁵25 Kirkpatrick JN, Hull SC, Fedson S, Mullen B, Goodlin SJ. Scarce-Resource allocation and patient triage during the COVID-19 pandemic: JACC review topic of the week. J Am Coll Cardiol. 2020;76(1). https://doi.org/10.1016/j.jacc.2020.05.006
https://doi.org/10.1016/j.jacc.2020.05.0... ).

A British study stated that the utilitarian principle was the base for the creation of the Mental Capacity Act, an instrument formed by variables that indicate how and when professionals can make decisions for the good of their patients with cognitive disabilities(²⁴24 Parsons JA, Johal HK. Best interests versus resource allocation: could COVID-19 cloud decision-making for the cognitively impaired? J Med Ethics. 2020;46:447-50. https://doi.org/10.1136/medethics-2020-106323
https://doi.org/10.1136/medethics-2020-1... ). This helps making the best decision possible, focusing on providing holistic and integral health care. An American study follows a similar path with regard to attending the patient with coronavirus, stating that the best possible care should be provided to them, including palliative care, mental health care, and spiritual assistance(²³23 DeBruin D, Leider JP. COVID-19: The shift from clinical to public health ethics. J Public Health Manag Pract. 2020;26(4):306-9. https://doi.org/10.1097/PHH.0000000000001204
https://doi.org/10.1097/PHH.000000000000... ).

An example of the adoption of the utilitarian principle is expressed when two patients with distinct prognosis need the same resource, but it can only be provided to one of them. In this case, the resource is offered to the person who has a better prognosis, even if this means that the resource should be relocated(²2 Iserson K. Healthcare ethics during a pandemic. West J Emerg Med. 2020;21(3):477-83. https://doi.org/10.5811/westjem.2020.4.47549
https://doi.org/10.5811/westjem.2020.4.4... ,⁶6 Solnica A, Barski L, Jotkowitz A. Allocation of scarce resources during the COVID-19 pandemic: a jewish ethical perspective. J Med Ethics. 2020;46:444-6. https://doi.org/10.1136/medethics-2020-106242
https://doi.org/10.1136/medethics-2020-1... ,⁹9 Morley G, Grady C, Mccarthy J, Ulrich CM. Covid-19: ethical challenges for nurses. Hastings Cent Rep. 2020;50(3):35-9. https://doi.org/10.1002/hast.1110
https://doi.org/10.1002/hast.1110... ). During this process, the DM should also consider the distributive justice principle, that is, resources must be allocated or relocated to those who are likely to reap more benefits and to survive(¹¹11 Vincent J-L, Creteur J. Ethical aspects of the COVID-19 crisis: how to deal with an overwhelming shortage of acute beds. Eur Heart J Acute Cardiovasc Care. 2020;9(3):248-52. https://doi.org/10.1177/2048872620922788
https://doi.org/10.1177/2048872620922788... ,²²22 Rubio O, Estella A, Cabre L, Saralegui-Reta I, Martin MC, Zapata L, et al. Recomendaciones éticas para la toma de decisiones difíciles en las unidades de cuidados intensivos ante la situación excepcional de crisis por la pandemia por COVID-19: revisión rápida y consenso de expertos. Med Intensiva. 2020. https://doi.org/10.1016/j.medin.2020.04.006
https://doi.org/10.1016/j.medin.2020.04.... ). Health professionals, in turn, must remain neutral and impartial(²2 Iserson K. Healthcare ethics during a pandemic. West J Emerg Med. 2020;21(3):477-83. https://doi.org/10.5811/westjem.2020.4.47549
https://doi.org/10.5811/westjem.2020.4.4... ).

Even when they are aware of this reality, professionals in the front lines need to deal with painful and traumatic choices, and as a result, feel impotent, guilty, anguished, and suffer morally(⁶6 Solnica A, Barski L, Jotkowitz A. Allocation of scarce resources during the COVID-19 pandemic: a jewish ethical perspective. J Med Ethics. 2020;46:444-6. https://doi.org/10.1136/medethics-2020-106242
https://doi.org/10.1136/medethics-2020-1... ,⁹9 Morley G, Grady C, Mccarthy J, Ulrich CM. Covid-19: ethical challenges for nurses. Hastings Cent Rep. 2020;50(3):35-9. https://doi.org/10.1002/hast.1110
https://doi.org/10.1002/hast.1110... ). This setting may also get worse when there are insufficient human and material resources and inadequate working conditions(³¹31 Teixeira CFS, Soares CM, Souza EA, Lisboa ES. A saúde dos profissionais de saúde no enfrentamento da pandemia de Covid-19. Ciênc Saúde Coletiva. 2020;25(9):3465-74. https://doi.org/10.1590/1413-81232020259.19562020
https://doi.org/10.1590/1413-81232020259... ). Some authors believe that it is necessary to emphasize to professionals that, in situations of crisis in health care, such as experiences during the COVID-19 pandemic, the circumstances are not under their personal control; even if they offer all the life-support treatments there are, some patients will not survive(⁹9 Morley G, Grady C, Mccarthy J, Ulrich CM. Covid-19: ethical challenges for nurses. Hastings Cent Rep. 2020;50(3):35-9. https://doi.org/10.1002/hast.1110
https://doi.org/10.1002/hast.1110... ,²⁵25 Kirkpatrick JN, Hull SC, Fedson S, Mullen B, Goodlin SJ. Scarce-Resource allocation and patient triage during the COVID-19 pandemic: JACC review topic of the week. J Am Coll Cardiol. 2020;76(1). https://doi.org/10.1016/j.jacc.2020.05.006
https://doi.org/10.1016/j.jacc.2020.05.0... ).

From this perspective, this pandemic came like an avalanche. It was an unprecedented situation in modern history, and it generated, in these professionals, suffering, fear, dilemmas, anxiety, and uncertainties in daily work. These workers have to deal with the challenge of making ethically safe and reasonable decisions when confronted with the scarcity of resources and the lack of knowledge about the exact way in which the virus propagates, not to mention the lack of effective treatment.

In the beginning of the pandemic, mistakes regarding triage, admission, and the allocation of resources were made(⁸8 Chan PS, Berg RA, Nadkarni VM. Code blue during the COVID-19 pandemic. Circ Cardiovasc Qual Outcomes. 2020;13(5):e006779. https://doi.org/10.1161/circoutcomes.120.006779
https://doi.org/10.1161/circoutcomes.120... ,²⁶26 Herreros B, Gella P, Asua DR. Triage during the COVID-19 epidemic in Spain: better and worse ethical arguments. J Med Ethics. 2020;46:455-58. https://doi.org/10.1136/medethics-2020-106352
https://doi.org/10.1136/medethics-2020-1... ). In a setting where sanitary resources are overloaded, as is the case during COVID-19, professionals must deal with situations that require complex decisions, and, on occasion, they must decide who will not receive the ideal treatment. As a result, they feel anguish and suffering, especially in urgent situations, which require fast actions with no reflection on the circumstances(¹²12 Sanches MA, Cunha TR, Siqueira SS, Siqueira JE. Perspectivas bioéticas sobre tomada de decisão em tempos de pandemia. Rev Bioet. 2020;28(3):410-7. https://doi.org/10.1590/1983-80422020283401
https://doi.org/10.1590/1983-80422020283... ).

North-American studies have reported this issue as they described that some American institutions, when there was no PPE, advocated orders not to reanimate or to delay the start of thoracic compressions, due to worries about the release of aerosols(⁸8 Chan PS, Berg RA, Nadkarni VM. Code blue during the COVID-19 pandemic. Circ Cardiovasc Qual Outcomes. 2020;13(5):e006779. https://doi.org/10.1161/circoutcomes.120.006779
https://doi.org/10.1161/circoutcomes.120... ,¹⁵15 Kramer JB, Brown DE, Kopar PK. Ethics in the time of coronavirus: recommendations in the COVID-19 Pandemic. J Am Coll Surg. 2020;230(6):1114-8. https://doi.org/10.1016/j.jamcollsurg.2020.04.004
https://doi.org/10.1016/j.jamcollsurg.20... ). SARS-CoV-2 patients must be attended with caution to guarantee the safety of the professionals(⁸8 Chan PS, Berg RA, Nadkarni VM. Code blue during the COVID-19 pandemic. Circ Cardiovasc Qual Outcomes. 2020;13(5):e006779. https://doi.org/10.1161/circoutcomes.120.006779
https://doi.org/10.1161/circoutcomes.120... ), who, generally, become emotionally exhausted(¹⁶16 Rawlings A, Brandt L, Ferreres A, Asbun H, Shadduck P. Ethical considerations for allocation of scarce resources and alterations in surgical care during a pandemic. Surg Endosc. 2021;35(5)2217-22. https://doi.org/10.1007/s00464-020-07629-x
https://doi.org/10.1007/s00464-020-07629... ). Providing safety to these workers is the role of the health institutions, who must provide both the adequate PPEs in a sufficient amount and training on their correct and rational use. The professionals have the social responsibility to use PPEs in situations where they risk exposure.

In an attempt to minimize the possibility of health professionals getting mentally ill, studies recommend, as alternatives, the creation of Triage and Health Ethics Committees, as well as the formation of teams by professionals who have experience in dealing with COVID-19 and ethical issues(⁸8 Chan PS, Berg RA, Nadkarni VM. Code blue during the COVID-19 pandemic. Circ Cardiovasc Qual Outcomes. 2020;13(5):e006779. https://doi.org/10.1161/circoutcomes.120.006779
https://doi.org/10.1161/circoutcomes.120... ,¹⁶16 Rawlings A, Brandt L, Ferreres A, Asbun H, Shadduck P. Ethical considerations for allocation of scarce resources and alterations in surgical care during a pandemic. Surg Endosc. 2021;35(5)2217-22. https://doi.org/10.1007/s00464-020-07629-x
https://doi.org/10.1007/s00464-020-07629... ,²⁶26 Herreros B, Gella P, Asua DR. Triage during the COVID-19 epidemic in Spain: better and worse ethical arguments. J Med Ethics. 2020;46:455-58. https://doi.org/10.1136/medethics-2020-106352
https://doi.org/10.1136/medethics-2020-1... ). These can elaborate criteria for the admission and allocation of resources, guiding the professionals in the front line in the making of hard decisions. The criteria established must be structured in protocols or algorithms, and must include clear and transparent information for professionals, patients, and patient relatives(⁸8 Chan PS, Berg RA, Nadkarni VM. Code blue during the COVID-19 pandemic. Circ Cardiovasc Qual Outcomes. 2020;13(5):e006779. https://doi.org/10.1161/circoutcomes.120.006779
https://doi.org/10.1161/circoutcomes.120... ,¹⁴14 Romanò M. Fra cure intensive e cure palliative ai tempi di CoViD-19. Recenti Prog Med. 2020;111(4):223-30. doi: http://doi.org/10.1701/3347.33185
http://doi.org/10.1701/3347.33185... ,¹⁶16 Rawlings A, Brandt L, Ferreres A, Asbun H, Shadduck P. Ethical considerations for allocation of scarce resources and alterations in surgical care during a pandemic. Surg Endosc. 2021;35(5)2217-22. https://doi.org/10.1007/s00464-020-07629-x
https://doi.org/10.1007/s00464-020-07629... ). It is worth highlighting that, even with carefully developed protocols there will always be uncertainties(⁹9 Morley G, Grady C, Mccarthy J, Ulrich CM. Covid-19: ethical challenges for nurses. Hastings Cent Rep. 2020;50(3):35-9. https://doi.org/10.1002/hast.1110
https://doi.org/10.1002/hast.1110... ,¹¹11 Vincent J-L, Creteur J. Ethical aspects of the COVID-19 crisis: how to deal with an overwhelming shortage of acute beds. Eur Heart J Acute Cardiovasc Care. 2020;9(3):248-52. https://doi.org/10.1177/2048872620922788
https://doi.org/10.1177/2048872620922788... ), and one must learn to deal with them.

The need to allocate supplies, equipment, beds, medication and human resources in a pandemic can generate ethical and moral conflicts for decision makers, leading to physical and mental disease(³²32 Silva KR, Ribeiro RM, Roquete FF, Rodrigues CM, Lopes PT, Fernandes ML, et al. Narratives of health professionals relating to scarce resources in an urgency service. Int J Adv Engin Res Sci. 2019;6(6):66-73. https://doi.org/10.22161/ijaers.6.6.7
https://doi.org/10.22161/ijaers.6.6.7... ). As a result, there must be a shared structure for ethical DM based on a dialogue between health professionals and society. Still, the decisions made must be robust (well thought-out), reasonable (based on evidence and relevant factors), transparent (the decision-making process must be clear and open) and fair (the resources must be distributed equally)(¹³13 Virani A, Singh G, Bewick D, Chow C-M, Clarke B, Cowan S, et al. Guiding cardiac care during the COVID-19 pandemic: How ethics shapes our health system response. Can J Cardiol. 2020;36(8):1313-6. https://doi.org/10.1016/j.cjca.2020.06.002
https://doi.org/10.1016/j.cjca.2020.06.0... ).

There are shortcomings in the DM about the best allocation of equipment, which shows that professionals are not prepared for it. However, this decision should not be based on pandemic control measures, but on preestablished criteria to better direct the resources available in order to attend to a specific populational reality(³³33 Koonin LM, Pillai S, Kahn EB, Moulia D, Patel A. Strategies to inform allocation of stockpiled ventilators to healthcare facilities during a pandemic. Health Security. 2020;18(2):1-6. https://doi.org/10.1089/hs.2020.0028
https://doi.org/10.1089/hs.2020.0028... ). In an attempt to deal with this shortcoming, protocols, manuals and instruments are adopted to guide the DM when it comes to resource allocation; however, these are often unable to prevent conflict and, often, lead to interventions that are not pertinent or, in some cases, even unfair(¹²12 Sanches MA, Cunha TR, Siqueira SS, Siqueira JE. Perspectivas bioéticas sobre tomada de decisão em tempos de pandemia. Rev Bioet. 2020;28(3):410-7. https://doi.org/10.1590/1983-80422020283401
https://doi.org/10.1590/1983-80422020283... ).

The studies analyzed, in order to guide the health practices adopted in this new reality, suggested protocols and orientations elaborated by ethical committees, such as the a document which included the position and recommendations from the SEMICYUC, in Spain, based on solid criteria, fundamental ethical principles and the equal and fair provision of service(²²22 Rubio O, Estella A, Cabre L, Saralegui-Reta I, Martin MC, Zapata L, et al. Recomendaciones éticas para la toma de decisiones difíciles en las unidades de cuidados intensivos ante la situación excepcional de crisis por la pandemia por COVID-19: revisión rápida y consenso de expertos. Med Intensiva. 2020. https://doi.org/10.1016/j.medin.2020.04.006
https://doi.org/10.1016/j.medin.2020.04.... ); the Blue Code, from the United States(⁸8 Chan PS, Berg RA, Nadkarni VM. Code blue during the COVID-19 pandemic. Circ Cardiovasc Qual Outcomes. 2020;13(5):e006779. https://doi.org/10.1161/circoutcomes.120.006779
https://doi.org/10.1161/circoutcomes.120... ); the recommendations from the SIAARTI(¹⁰10 Nicoli F, Gasparetto A. Italy in a time of emergency and scarce resources: the need for embedding ethical reflection in social and clinical settings. J Clin Ethics. [Internet]. 2020[cited 2020 July 27];31(1):92-4. Available from: https://pubmed.ncbi.nlm.nih.gov/32213700/
https://pubmed.ncbi.nlm.nih.gov/32213700... ,¹⁴14 Romanò M. Fra cure intensive e cure palliative ai tempi di CoViD-19. Recenti Prog Med. 2020;111(4):223-30. doi: http://doi.org/10.1701/3347.33185
http://doi.org/10.1701/3347.33185... ); the clinical directives for DM in the response of COVID-19, elaborated by the National Institute of Health from the United Kingdom(⁶6 Solnica A, Barski L, Jotkowitz A. Allocation of scarce resources during the COVID-19 pandemic: a jewish ethical perspective. J Med Ethics. 2020;46:444-6. https://doi.org/10.1136/medethics-2020-106242
https://doi.org/10.1136/medethics-2020-1... ); and the demands from the Mental Capacity Act, to guide DM when the patient, due to cognitive disability, cannot participate in the decision making process(²⁴24 Parsons JA, Johal HK. Best interests versus resource allocation: could COVID-19 cloud decision-making for the cognitively impaired? J Med Ethics. 2020;46:447-50. https://doi.org/10.1136/medethics-2020-106323
https://doi.org/10.1136/medethics-2020-1... ).

It should also be mentioned that the protocols, algorithms, and guidance are not always enough to subsidize DM. However, fundamental bioethical principles should guide any decision in health(¹²12 Sanches MA, Cunha TR, Siqueira SS, Siqueira JE. Perspectivas bioéticas sobre tomada de decisão em tempos de pandemia. Rev Bioet. 2020;28(3):410-7. https://doi.org/10.1590/1983-80422020283401
https://doi.org/10.1590/1983-80422020283... ). Professionals also should resort to their religious beliefs, motivations and values, both as people and professionals(²2 Iserson K. Healthcare ethics during a pandemic. West J Emerg Med. 2020;21(3):477-83. https://doi.org/10.5811/westjem.2020.4.47549
https://doi.org/10.5811/westjem.2020.4.4... ), and must guide themselves according to the decisions of the local authority that regulates their profession, also considering their Professional Code of Ethics (PCE).

Solidarity, equity, utilitarianism, relational autonomy, reliability, and reciprocity, adopted by the health professionals during COVID-19, are the marks that guide a humane, dignified, and integral action when difficult decisions must be made. This includes deciding who will receive potentially curative treatment, knowing that those who do not may not survive(¹²12 Sanches MA, Cunha TR, Siqueira SS, Siqueira JE. Perspectivas bioéticas sobre tomada de decisão em tempos de pandemia. Rev Bioet. 2020;28(3):410-7. https://doi.org/10.1590/1983-80422020283401
https://doi.org/10.1590/1983-80422020283... ), and asking if the professionals can choose whether to provide care to COVID-19 patients, especially if the procedure to be performed puts their own safety at risk(⁹9 Morley G, Grady C, Mccarthy J, Ulrich CM. Covid-19: ethical challenges for nurses. Hastings Cent Rep. 2020;50(3):35-9. https://doi.org/10.1002/hast.1110
https://doi.org/10.1002/hast.1110... ,¹³13 Virani A, Singh G, Bewick D, Chow C-M, Clarke B, Cowan S, et al. Guiding cardiac care during the COVID-19 pandemic: How ethics shapes our health system response. Can J Cardiol. 2020;36(8):1313-6. https://doi.org/10.1016/j.cjca.2020.06.002
https://doi.org/10.1016/j.cjca.2020.06.0... ). In summation, the process of DM is widely experienced by health professionals in their work routine as they struggle against the coronavirus; knowing how to make decisions makes a difference in this moment of uncertainty, since the choices made will guide attention, leading to the continuity or interruption of lives.

Study limitations

Although there have been other pandemics throughout history, this study, intentionally, only discussed the most recent one, caused by SARS-CoV-2. Furthermore, during the elaboration of this study, new works may have been published due to the fact that society and the scientific community need knowledge about COVID-19. However, instead of exhausting the topic, this work aims to raise questions for other investigations to be made, due to the relevance of the subject.

Contributions for the field of nursing and health

The results of this revision are relevant, but an article is too small to group the abundant knowledge on the issue of DM by health professionals who struggle against the coronavirus around the world. Although the nursing category is the largest health workforce in the world and DM is a competency of nurses, the studies analyzed showed that DM by nurses is seldom addressed. As a result, this work encourages the development of investigations that articulate this topic and nursing, to fill in this gap in knowledge, which still persists.

FINAL CONSIDERATIONS

This review found that DM has never been so as necessary as now, when demand is higher than supply. Resources are scarce, and professionals have accumulated stress and emotional burdens that prevent them from attending with efficiency, quality, ethics, and humanity a large number of people who were infected by COVID-19 and other diseases.

This article does not attempt to be a recipe for professionals, due to the fact that DM involves multiple factors. However, it provides many bases, presented in its results and discussion, that can aid them in this difficult and complex process, so they can make ethical and safe decisions.

To this end, to aid the DM during the pandemic, many alternatives can be adopted, including ethical principles such as utilitarianism; a fair and targeted allocation of resources; in addition to the creation of triage and health ethics committees, and of teams of professionals with experience confronting COVID-19 and dealing with ethical issues. The use of protocols or algorithms with clear and transparent information also contributes for this process, not to mention that professionals should resort to their own beliefs, motivations, and values, and follow the guidelines of the authorities that regulate their professions.

The COVID-19 pandemic asks health professionals to make hard decisions, which leads to moral suffering. They are advised to dialogue with other members in the health team about how to better deal with the ethical dilemmas and conflicts that appear in their daily work. Furthermore, health institutions should guarantee that workers have better working conditions. This includes the provision of adequate PPEs, training, psychological support, and the implantation of a committee of specialists, preferably ethics specialists, that can be consulted when there are difficult decisions to be made. Giving support to professionals is to recognize their instrumental value without letting their efforts go unnoticed, as they risk their own lives to save others.

The results of this revision are expected to encourage reflection about the DM of nursing professionals in dealing with COVID-19, aiding in their recognition of the ethical challenges they experience in their daily work and aiding in the resolution of these challenges through shared processes of decision making, based on evidence whenever possible.

REFERENCES

Publication Dates

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