Tele-advocacy and Bioethics During the Pandemic: A Telehealth Approach in Perinatal-neonatal Care for Mitigating Ethical and Moral Tensions at a Safety-net Hospital

Our neonatal intensive care unit (NICU) serves an underprivileged population in a resource-restricted environment. The recent COVID-19 pandemic and rapidly changing institutional protocols accentuated the challenges of caring for critically ill newborns. Concurrently, evolving paradigms in neonatal ethics required urgent and high-quality palliative care in a background of racial and socio-economic inequities. Balancing ethical and moral tensions was necessary for compassionate and shared decision-making with families of newborns in high-risk scenarios. Our approach aimed to ensure sustainable online interactions with parents and care providers, virtual education, and, when needed, timely referrals for life-sustaining therapies and palliative care. The key steps consisted of virtual and in-person family meetings, telehealth for prenatal consultations, traditional in-person teaching, remote educational webinars, and integrating bioethics in providing perinatal and neonatal palliative care. Case examples representing the gray zones of resuscitation, which were incredibly challenging for family-centered decision-making during the pandemic, are highlighted. NICU providers often experience ethical and moral tensions due to conflicting data on long-term outcomes in many cases, evolving research with contrasting curative care models, and bioethical ambiguity in justifying referrals for regional perinatal centers of care. Ethical stress was addressed by explicating prognostic uncertainty, pathophysiologic heterogeneity, and core concepts in neonatal bioethics. The multilevel allocation of scarce resources, a consistent transdisciplinary approach, and transparent communication with families helped in reducing moral tension. Tele-advocacy, tele-palliative care, and bioethics education were vital resources for alleviating ethical and moral tensions at our safety-net hospital.