DIGNITY: Nurse, Laure Madé

Laure Madé (FRANCE) , is a practicing Covid-19 Nurse at Hospital Bichat, Paris and Epidemiologist. Trained as a nurse in France, she completed a MSc in Epidemiology at the London School of Hygiene and Tropical Medicine. She has been working on emerging infectious diseases at Institut Pasteur, the University of Liverpool.
I worked as a nurse in a Covid-19 ward in a French hospital in Paris during the Covid-19 outbreak. The Bichat hospital is a referral hospital for the treatment of emerging infectious diseases and a leading player for the management of epidemic and biological hazards. During this unprecedented sanitary crisis, I witnessed numerous situations where health professionals faced ethical dilemmas in human lives. After fighting tirelessly against Covid-19 in France and oversea, I am still wondering whether we can effectively control this outbreak while treating both patients and the deceased with sensitivity, dignity, and respect.
In early April 2020, we were overwhelmed with Covid-19‘s media coverage. Many patients in an artificial coma were exposed to French TV news as an attempt to raise awareness of the threat of the unseen virus. In France, patients have to give consent to appear on TV, but this is not mandatory if they are unconscious as long as their face is covered. According to French law, the consent of the people filmed is not required when the image is illustrating a topical subject. I did not experience this specific situation as I wasn’t working in the Intensive Care Unit, but I know some colleagues who felt uncomfortable dealing with this specific situation and found it particularly inappropriate.
We experienced other dilemmas during the outbreak that went beyond the media issue. What called my attention was how the patients were extremely terrified by being infected with Covid-19. It was indeed a new disease, very contagious with no proven treatment available. Every single health worker was entirely covered up with protective personal equipment: mask, gloves, gown, cap, glasses, and so on. All doctors looked similar and patients couldn’t differentiate the many different nurses. This was a very stressful environment for them. On top of that, we could not enter the Covid-19 rooms as often as we wanted because we had to restrict our visits to limit the risk of contamination. Relatives and close friends were denied access for the same reason. In many rooms, Covid-19 related news was displayed repeatedly on TV screens leaving these patients with feelings of loneliness, isolation, and fear. They were fortunately allowed to keep their phones with them and could, therefore, maintain a much-needed virtual contact with their loved ones. Despite these challenges, we tried our best to reassure them, and we made sure to provide emotional support every time we interacted with them.
The fact that our country was unevenly affected meant that a lot of human and material resources were allocated to the most affected areas. We did not experience a lack of staff, as hundreds of health workers came to help from different cities, including medical and nursing students. We were lucky to have at least one nurse for every four patients in the Non-Intensive Care Unit. However, we had severe issues accessing personal protective equipment, especially appropriate masks (34). This was a major challenge because we really wanted to give the best care possible to our patients, but we also needed to feel safe and protected ourselves. We had an incredibly high number of sick colleagues, and we even had to resuscitate one of them who was hospitalized in our ward. The feeling of fear was shared by everyone, patients, and health workers alike.
Finally, Covid-19 protocols in place at the time also impacted the way we handled the deceased bodies. Whenever we had a death in our ward, which was unfortunately frequent during the outbreak, we had to put the body entirely naked in the mortuary bag (35). This situation was distressful as we felt that we could not honor the deceased properly. We were not allowed to dress them up and the family was not allowed to view them. The rationale behind this recommendation was to limit the risk of contamination after death even though no evidence of transmission of SARS-CoV-2 through the handling of the body of a deceased person has been documented. The French High Council for Public Health amended its recommendations end of March (36) when the risk of infectious transmission from bodies was proven to be lower than for living patients. They allowed the viewing of the body for mourners immediately and the presentation of the body to the family. However, these less stringent guidelines did not reach our hospital.
During this pandemic, health professionals faced ethical dilemma situations more frequently due to various factors such as time required for the healthcare system to adjust to the crisis (hiring extra staff, set up of space/beds for patients, procurement of appropriate protective equipment, etc.), intensive workload among others, and potentially impacting the standard of care. But despite this stressful period, our intent was always to keep humanity in the care provided. Finding the right balance between the need to control the infection and the respect of the patients and families’ rights is a difficult exercise, but the dignity of the patients and the deceased should be respected and must remain a priority, even in such chaotic time.