Ethical road map through the covid-19 pandemic. Zoe Fritz, Richard Huxtable, Jonathan Ives, Alexis Paton, Anne Marie Slowther, Dominic Wilkinson. En BMJ Editorial
https://www.bmj.com/content/369/bmj.m2033
“The covid-19 pandemic has created profound ethical challenges in health and social care, not only for current decisions about individuals but also for longer term and population level policy decisions. Already covid-19 has generated ethical questions about the prioritisation of treatment, protective equipment, and testing; the impact of covid-19 strategies on patients with other health conditions; the approaches taken to advance care planning and resuscitation decisions; and the crisis in care homes.”
Ethical considerations for epidemic vaccine trials. Joshua Teperowski Monrad. En JME.
https://jme.bmj.com/content/early/2020/05/15/medethics-2020-106235
“Vaccines are a powerful measure to protect the health of individuals and to combat outbreaks such as the COVID-19 pandemic. An ethical dilemma arises when one effective vaccine has been successfully developed against an epidemic disease and researchers seek to test the efficacy of another vaccine for the same pathogen in clinical trials involving human subjects.”
Sustaining Clinical Empathy During the Pandemic. Jodi Halpern and Douglas J. Opel. The Hasting Center Report.
https://www.thehastingscenter.org/sustaining-clinical-empathy-during-the-pandemic/
“As Covid-19 continues to spread throughout the United States, doctors, nurses, and other clinicians are facing unmistakable tragedies. But something less perceptible is afoot. Empathy in medicine is under siege.
Across the country, clinicians are showing evidence of psychological exhaustion, demoralization, and the sine qua non of burnout — empathy depletion. The effects are not insignificant. Clinical empathy is crucial for providing effective care for patients and families during a crisis. It promotes trust and disclosure, and can be directly therapeutic. Empathy is beneficial for clinicians too: it is central to finding clinical practice meaningful.”
Post-Covid Bioethics. Vardit Ravitsky. The Hasting Center Report.
https://www.thehastingscenter.org/post-covid-bioethics/
“Covid-19 is making bioethics more relevant than ever. The ethical dilemmas raised by the pandemic are urgent and heart-wrenching. Who should get a ventilator if we do not have enough? How can we protect the most vulnerable (for example, disabled or elderly people) from discrimination in the face of difficult triage decisions? How should we balance our need for surveillance with considerations of privacy? How do we weigh individual liberty against the public interest of keeping people confined?
First, justice – and, in particular, distributive justice. Second, bioethics should also pay more attention to the broader context in which health care is embedded. It should promote the understanding that ethical challenges related to health do not begin when we are sick and in need of medical attention. Third, bioethics should focus on exploring the global aspects of the bioethical dilemmas we face. It should recognize our connectedness not just as members of our local societies, but as members of a global community.”
Grappling with the Ethics of Reopening: A Framework for Evaluating Reopening Policies. Justin Bernstein, Brian Hutler, Travis N. Rieder, Ruth Faden, Hahrie Han, and Anne Barnhill. Johns Hopkins Berman Institute of Bioethics.
“This document guides users through an ethical assessment of COVID-19 reopening policies. When and how to reopen our society is not merely a matter of epidemiology and economics. It also raises questions about many shared values in our society, values like promoting well-being, liberty, and justice. These values are the subject of ethics. The framework developed here can be used to ethically assess both maintaining and relaxing social distancing policies such as when to reopen shops or schools. It can also be used to assess the ethics of public health measures to boost the public health response and contain the virus by, for example, increased testing. The framework is especially designed to aid government decision-makers at the state and local levels. The framework may also be used by private institutions such as retailers, workplaces, and universities to ethically assess their own reopening policies.”
The Ethics of COVID-19 Immunity-Based Licenses (“Immunity Passports”). Govind Persad, Ezekiel J. Emanuel. En The Lancet..
https://jamanetwork.com/journals/jama/fullarticle/2765836
“Certifications of immunity are sometimes called “immunity passports” but are better conceptualized as immunity-based licenses. Such policies raise important questions about fairness, stigma, and counterproductive incentives but could also further individual freedom and improve public health.
Immunity licenses should not be evaluated against a baseline of normalcy, ie, uninfected free movement. Rather, they should be compared to the alternatives of enforcing strict public health restrictions for many months or permitting activities that could spread infection, both of which exacerbate inequalities and impose serious burdens. This Viewpoint presents a framework for analyzing the ethics of immunity licenses.”
Show Me Your Passport: Ethical Concerns About Covid-19 Antibody Testing as Key to Reopening Public Life. Olivia S. Kates. En The Hasting Center Report.
“Some might hear all of this and say we do not know enough, yet, to implement immunity passports. But I think that we ought to know enough not to. Antibody testing will still be needed to answer other important personal health and population health questions, and investigations into coronavirus antibodies must and will continue. But the path to reopening public life should be set by expert health officials, with close attention to justice and equity, and at no point on that path should anyone be stopped and asked, “Show me your passport.””
Love in the time of coronavirus. Iona Heath. En BMJ.
https://www.bmj.com/content/369/bmj.m1801
“We had somehow allowed ourselves to forget that everyone must die and that those who are lucky enough to die in old age will almost certainly die with one or more non-communicable diseases. We had begun to believe that we had a right to a long and healthy life and that any deviation from this must represent some sort of neglect. Yet everyone will die, and as Philip Larkin wrote, “What will survive of us is love.””
Ethics of instantaneous contact tracing using mobile phone apps in the control of the COVID-19 pandemic. Michael J Parker, Christophe Fraser, Lucie Abeler-Dörner, David Bonsall. En Journal of Medical Ethics.
https://jme.bmj.com/content/early/2020/05/05/medethics-2020-106314
“Contact tracing is a well-established feature of public health practice during infectious disease outbreaks and epidemics. However, the high proportion of pre-symptomatic transmission in COVID-19 means that standard contact tracing methods are too slow to stop the progression of infection through the population. To address this problem, many countries around the world have deployed or are developing mobile phone apps capable of supporting instantaneous contact tracing. Informed by the on-going mapping of ‘proximity events’ these apps are intended both to inform public health policy and to provide alerts to individuals who have been in contact with a person with the infection. The proposed use of mobile phone data for ‘intelligent physical distancing’ in such contexts raises a number of important ethical questions.”
Physician Burnout, Interrupted. Pamela Hartzband, M.D., and Jerome Groopman, M.D. NEJM Perspective.
https://www.nejm.org/doi/full/10.1056/NEJMp2003149?query=featured_coronavirus
“Before the onset of the Covid-19 pandemic, each day seemed to bring another headline about the crisis of physician burnout. The issue had been simmering for years and was brought to a boil by mounting changes in the health care system, most prominently the widespread implementation of the electronic health record (EHR) and performance metrics. Initially, the prevailing attitude was that burnout is a physician problem and that those who can’t adapt to the new environment need to get with the program or leave. Some dismissed the problem as a generation of “dinosaur” doctors whining and pining for an inefficient, low-tech past. But recently, it has become clear that millennials, residents, and even medical students are showing signs of burnout. The unintended consequences of radical alterations in the health care system that were supposed to make physicians more efficient and productive, and thus more satisfied, have made them profoundly alienated and disillusioned.”
COVID-19: where is the national ethical guidance? Richard Huxtable BMC Medical Ethics Editorial.
https://bmcmedethics.biomedcentral.com/articles/10.1186/s12910-020-00478-2
“The COVID-19 pandemic poses numerous – and substantial – ethical challenges to health and healthcare. Debate continues about whether there is adequate protective equipment, testing and monitoring, and about when a vaccine might become available and social restrictions might be lifted. The thorny dilemmas posed by triage and resource allocation also attract considerable attention, particularly access to intensive care resources, should demand outstrip supply.”
Against pandemic research exceptionalism. Alex John London, Jonathan Kimmelman. En Science.
https://science.sciencemag.org/content/early/2020/04/22/science.abc1731
“Crises are no excuse for lowering scientific standards… A palpable sense of urgency and a lingering concern that “in critical situations, large randomized controlled trials are not always feasible or ethical”, perpetuate the perception that, when it comes to the rigors of science, crisis situations demand exceptions to high standards for quality. Numerous trials investigating similar hypotheses risk duplication of effort, and droves of research papers have been rushed to preprint servers, essentially outsourcing peer review to practicing physicians and journalists. Although crises present major logistical and practical challenges, the moral mission of research remains the same: to reduce uncertainty and enable caregivers, health systems, and policy-makers to better address individual and public health”.
Ventilator Triage Policies During the COVID-19 Pandemic at U.S. Hospitals Associated With Members of the Association of Bioethics Program Directors Free. Armand H. Matheny Antommaria, et al, and for a Task Force of the Association of Bioethics Program Director. En Annals of Internal Medicine.
Survey on prioritization criteria in different hospitals. The conclusión is that over one half of respondents did not have ventilator triage policies. Policies have substantial heterogeneity, and many omit guidance on fair implementation.
Covid-19 — A Reminder to Reason. Ivry Zagury-Orly, and Richard M. Schwartzstein. En NEJM Perspective.
https://www.nejm.org/doi/full/10.1056/NEJMp2009405?query=RP#.XqlYOdQx7Nc.twitter
“Even as we acknowledge that the world now feels strange and that doctors are susceptible to human anxieties, we should remember to accept uncertainty rationally and beware of potential undesirable consequences of our instinctive desire to see patterns in what may be random happenstance. Our mission as healers, in a situation such as the Covid-19 pandemic, makes us feel compelled to do something. As doctors trained in the scientific method, however, we are committed to practicing evidence-based medicine, which is premised on the ability to interpret scientific reports on supposed diagnostic and therapeutic advances. We need to retain a healthy skepticism and remember the principle of clinical equipoise, particularly when considering interventions that could cause harm. Otherwise, in our effort to “do good” for our patients, we may fall prey to cognitive biases and therapeutic errors.”
Denying Ventilators to Covid-19 Patients with Prior DNR Orders is Unethical. Valerie Gutmann Koch and Susie A. Han. En The Hasting Centre.
“When deciding which patients with Covid-19 should get scarce ventilators, should hospitals consider a person’s DNR status – the previously stated wish not to receive cardiopulmonary resuscitation (CPR) to restart the heart and breathing after cardiac arrest? This would seem irrelevant to ventilator allocation, and yet some existing and proposed guidelines for triage during a public health emergency put DNR status in the list of criteria for excluding patients from getting ventilators or other life-saving health care. This approach is in direct opposition to the generally agreed-upon goal of maximizing the number of survivors, and could result in confusion and public mistrust of the health care system. “
Not a Perfect Storm — Covid-19 and the Importance of Language. Allan M. Brandt, Alyssa Botelho. En NEJM Perspectives
https://www.nejm.org/doi/full/10.1056/NEJMp2005032?query=recirc_inIssue_bottom_article
“Many commentators have described this emerging pandemic as a “perfect storm”… And some of the reasons for Covid-19’s high rate of transmission and mortality are in fact beyond human control — for example, the particular biologic characteristics that lend Covid-19 its virulence. But myriad biologic, environmental, social, and political forces are shaping the spread of Covid-19 around the world, and the way we conceptualize the interplay of these forces matters. Are epidemics the result of a combination of unusual and unpredictable forces, as the notion of perfect storms would suggest? Or are they substantially shaped by long-standing and well-understood human actions (and inaction)?”
Cardiopulmonary resuscitation after hospital admission with covid-19. Zoë Fritz, Gavin D Perkins. En BMJ
https://www.bmj.com/content/369/bmj.m1387
“The balance of benefits and risks has changed, and practice must change with it. Guidelines on attempting cardiopulmonary resuscitation (CPR) in the acute hospital setting for patients with covid-19 have produced conflict and moral discomfort because of differences of opinion about the balance of benefits and risks to both patients and staff.
This pandemic has changed the risk-benefit balance for CPR: from “there is no harm in trying” to “there is little benefit to the patient, and potentially significant harm to staff.” The argument for not attempting CPR on hospital patients with covid-19 without enhanced personal protection is therefore justifiable, even though it feels uncomfortable.”
Cultivating Deliberate Resilience During the Coronavirus Disease 2019 Pandemic. Rosenberg. En JAMA
https://jamanetwork.com/journals/jamapediatrics/fullarticle/2764729#.Xpg62Cmq0uM.twitter
“As a pediatric oncologist who studies resilience in the context of illness, I started thinking about what this pandemic means for our professional resilience a few weeks ago, when the first US patient with fatal COVID-19 died in my home city of Seattle, Washington.
Promoting resilience among health care workers and organizations starts with understanding what resilience is (and what it is not). Categories of resilience resources are individual (eg, personal characteristics and skills), community (eg, social supports and sense of connection), and existential (eg, sense of meaning and purpose
The process of resilience requires these deliberate actions. It is complicated and contextual. It is promotable.”
Disease Control, Civil Liberties, and Mass Testing — Calibrating Restrictions during the Covid-19 Pandemic. David M. Studdert, Mark A. Hall, J.D.. En NEJM Perspectives.
https://www.nejm.org/doi/full/10.1056/NEJMp2007637?query=recirc_top_ribbon_article_3
“Law and public policy have a long history of deference to intrusive action by public health authorities, especially during deadly infectious disease outbreaks. There are limits, however.1 To respect civil liberties, courts have insisted that coercive restrictions must be necessary; must be crafted as narrowly as possible — in their intrusiveness, duration, and scope — to achieve the protective goal; and must not be used to target ostracized groups.2 Although these broad principles are useful touchstones, historical experience with quarantine provides little practical guidance because of several distinctive features of Covid-19 and the public health response it provokes.”
Covid-19: Can France’s ethical support units help doctors make challenging decisions? Sophie Arie. En BMJ Global Health.
“Patients must be assessed on a combination of factors to decide which patients have the greatest chance of survival and the most life years to gain from surviving. These factors include:
The patient’s wishes
The patient’s baseline condition: age, frailty score (using the French clinical frailty score or GIR frailty score, the Katz index, and the World Health Organization’s performance index score if already known), nutritional status, and cognitive status
The severity of the virus: respiratory failure and organ failure, measured using a SOFA (sequential organ failure assessment) score
The potential life years to be gained, and
The availability of beds and ventilators.”
Ethics and Evidence in the Search for a Vaccine and Treatments for Covid-19. Karen J. Maschke, Michael K. Gusmano. En The Hasting Center
“During public heath emergencies like the Covid-19 pandemic, when no known preventive or effective treatment exists, researchers understandably want to start conducting studies with humans as soon as possible to find a vaccine and therapeutic treatments that are safe and effective.”
“Yet in the rush to find a Covid-19 vaccine and one or more drugs to treat the deadly disease, concerns are being raised that ethical standards for conducting human clinical trials, and the evidentiary standards for determining whether interventions are safe and effective, might be loosened.”
Medicine: before COVID-19, and after. Margaret McCartney. En The Lancet Perspectives.
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30756-X/fulltext
“It was a simmering that has caught fire. When, earlier this year, it became obvious that coronavirus disease 2019 (COVID-19) was a virus capable of pandemic damage and global reach, I wondered whether we were looking into the abyss. But my work in general practice was busy with so many seemingly more important things, and I looked away.
General practitioners deal in uncertainty: it is our stock in trade. We rate possibilities and reckon with potentials; we consider chances and debate differentials. We are Bayesians, constantly swinging between one action versus another. Little things—the tone of a patient's voice or the raising of eyebrows—pitch us one way or another.”
Please Don’t (Need to) Use My Work. Susan Dorr Goold. En The hasting Centre Report.
https://www.thehastingscenter.org/please-dont-need-to-use-my-work/
“I am a professor in a medical school and a school of public health who studies resource allocation, with attention to ethics, justice, and health policy. I am also an internist whose experience caring for patients powerfully informs my scholarly work. I hope my contributions have an impact and don’t just sit on a shelf or in archived digital folders. I especially hope to see my work used since it emphasizes the perspectives of minority and underserved communities, who tend to have less voice in health policy. I have partnered with these communities to learn their informed, deliberative priorities for scarce health resources, and, together, we have tried to get decision makers to listen to and incorporate their points of view.”
But instead of hoping for attention, now I find myself dreading the use of my work. Over a decade ago, I helped develop guidelines for the ethical allocation of scarce resources during a public health emergency, such as a pandemic.
Age, Complexity, and Crisis — A Prescription for Progress in Pandemic. Louise Aronson. En NEJM Perpective.
https://www.nejm.org/doi/full/10.1056/NEJMp2006115#.Xo5GSvA2MWg.twitter
“During a pandemic in which 80% of U.S. deaths are in people over 65, especially affecting those who are around 80 with underlying conditions,2 health leaders and clinicians might reasonably conclude that they’re too busy saving lives to also consider preventing the hazards of hospitalization for elders or their postdischarge lives. In a crisis, they might argue, different rules apply. This unprecedented crisis is exactly why we need to think now about how best to manage the care of sick elders….we can harness the expertise and person-power of the many clinicians and clinician-researchers who can’t currently do their usual work to develop crisis-related protocols for ambulatory, institutionalized, homebound, and hospitalized patients, with special attention to elders and other populations with predictably high health care needs. And we can acknowledge the particular presentations, needs, and risks of elders in our protocols and planning.”
Understanding and Addressing Sources of Anxiety Among Health Care Professionals During the COVID-19 Pandemic. Tait Shanafelt, Jonathan Ripp, Mickey Trockel. En JAMA
https://jamanetwork.com/journals/jama/fullarticle/2764380
“Health care professionals of all types are caring for patients with this disease. Maintaining an adequate health care workforce in this crisis requires not only an adequate number of physicians, nurses, advanced practice clinicians, pharmacists, respiratory therapists, and other clinicians, but also maximizing the ability of each clinician to care for a high volume of patients.
These discussions consistently centered on 8 sources of anxiety: (1) access to appropriate personal protective equipment, (2) being exposed to COVID-19 at work and taking the infection home to their family, (3) not having rapid access to testing if they develop COVID-19 symptoms and concomitant fear of propagating infection at work, (4) uncertainty that their organization will support/take care of their personal and family needs if they develop infection, (5) access to childcare during increased work hours and school closures, (6) support for other personal and family needs as work hours and demands increase (food, hydration, lodging, transportation), (7) being able to provide competent medical care if deployed to a new area (eg, non-ICU nurses having to function as ICU nurses), and (8) lack of access to up-to-date information and communication.
The 8 concerns can be organized into 5 requests from health care professionals to their organization: hear me, protect me, prepare me, support me, and care for me.”
Prediction models for diagnosis and prognosis of covid-19 infection: systematic review and critical appraisal
https://www.bmj.com/content/369/bmj.m1328
“Prediction models for covid-19 are quickly entering the academic literature to support medical decision making at a time when they are urgently needed. This review indicates that proposed models are poorly reported, at high risk of bias, and their reported performance is probably optimistic.”
Disaster Planning and Public Health. Bruce Jennings. En The Hasting Center Report. FROM BIOETHICS BRIEFINGS.
https://www.thehastingscenter.org/briefingbook/disaster-planning-and-public-health/
“Public health emergencies may require priority setting, rationing, and triage—which may involve coercive measures that override individual liberty and property rights.
Special arrangements must be made to protect and accommodate persons with special needs and vulnerabilities in the planning, response, and aftermath of emergencies.
Key questions to ask about emergency preparedness planning and emergency response measures are their goals, including their ethical goals and their effectiveness.”
Public Health Ethics and Law.. Lawrence O. Gostin and Lindsay F. Wiley. En The Hasting Center Report. FROM BIOETHICS BRIEFINGS.
https://www.thehastingscenter.org/briefingbook/public-health/
“Public health encompasses what society does to assure the conditions that are necessary for its members to be healthy, including economic, social, and environmental factors.
The public health tradition adopts a prevention orientation and views health from the population, rather than individual, perspective.”
Importance of Addressing Advance Care Planning and Decisions About Do-Not-Resuscitate Orders During Novel Coronavirus 2019 (COVID-19). J. Randall Curtis, Erin K. Kross, Renee D. Stapleton. En JAMA
“Clinicians should ensure patients receive the care they want, aligning the care that is delivered with patients’ values and goals. The importance of goal-concordant care is not new or even substantially different in the context of this pandemic, but the importance of providing goal-concordant care is now heightened in several ways. Patients most likely to develop severe illness will be older and have greater burden of chronic illness—exactly those who may wish to forgo prolonged life support and who may find their quality of life unacceptable after prolonged life support.”
This article reviews key aspects such as the Advance Care Planning or orders of do-not-resuscitation, and reviews how to improve communication in this situation.
One of the references includes an interesting communication improvement tool: COVID-Ready Communication Skills, A playbook of VitalTalk Tips https://www.vitaltalk.org/guides/covid-19-communication-skills/
Managing mental health challenges faced by healthcare workers during covid-19 pandemic. Neil Greenberg, professor of defence mental health1, Mary Docherty, consultant liaison psychiatrist2, Sam Gnanapragasam, NIHR academic clinical fellow in psychiatry2, Simon Wessely, regius professor of psychiatry1. En The BMJ.
“The covid-19 pandemic is likely to put healthcare professionals across the world in an unprecedented situation, having to make impossible decisions and work under extreme pressures. These decisions may include how to allocate scant resources to equally needy patients, how to balance their own physical and mental healthcare needs with those of patients, how to align their desire and duty to patients with those to family and friends, and how to provide care for all severely unwell patients with constrained or inadequate resources”.
Key message:
- Healthcare managers need to proactively take steps to protect the mental wellbeing of staff
- Managers must be frank about the situations staff are likely to face
- Staff can be supported by reinforcing teams and providing regular contact to discuss decisions and check on wellbeing
- Once the crisis begins to recede, staff must be actively monitored, supported, and, where necessary, provided with evidence based treatments
Responding to COVID-19: How to Navigate a Public Health Emergency Legally and Ethically. Lawrence O. Gostin, Eric A. Friedman, and Sarah A. Wetter. En The Hasting Center Report.
This article tries to answer some of the great ethical questions, such as:
How can we avoid the scarcity dilemma?
How can we ethically balance physicians’ duties to patients and to the wider community?
How can we ethically allocate scarce resources?
At the Epicenter of the Covid-19 Pandemic and Humanitarian Crises in Italy: Changing Perspectives on Preparation and Mitigation. By Mirco Nacoti, MD, Andrea Ciocca, MEng, Angelo Giupponi, MD, Pietro Brambillasca, MD, Federico Lussana, MD, Michele Pisano, MD, Giuseppe Goisis, PhD, Daniele Bonacina, MD, Francesco Fazzi, MD, Richard Naspro, MD, et al. En NEJM
An article from the epicenter of the pandemic, in a Hospital in Bergamo: “Western health care systems have been built around the concept of patient-centered care, but an epidemic requires a change of perspective toward a concept of community-centered care. Pandemic solutions are required for the entire population, not only for hospitals.”
Novel Coronavirus and Old Lessons — Preparing the Health System for the Pandemic. John L. Hick, Paul D. Biddinger. In The New England Journal of Medicine
https://www.nejm.org/doi/full/10.1056/NEJMp2005118?query=featured_home
The article analyzes the changes in medicine since the last flu pandemic in 1968. It discusses what improvements are needed, such as working with public health colleagues to ensure that population-based interventions, including actions of social detachment, quarantine and isolation, are taken promptly and wisely to smooth the epidemic curve; secondly, the preparation and extension of the possibilities of care; furthermore, understanding the wishes of people at the end of their life, which is of vital importance in a situation of potential shortage of resources in the face of a disease that may require prolonged aggressive intervention; and, finally, protecting the healthcare workers.
COVID-19: Supporting Ethical Care and Responding to Moral Distress in a Public Health Emergency. Guidance, tools, and resources for Hospital Ethics Committees (HECs), Clinical Ethics Consultation (CEC). In The Hastings Center
https://www.thehastingscenter.org/guidancetoolsresourcescovid19/
Indispensable guideline to be able to respond to the moral distress of healthcare professionals in the face of the pandemic challenges.
Virtually Perfect? Telemedicine for Covid-19. Judd E. Hollander, Brendan. In The New England Journal of Medicine
https://www.nejm.org/doi/full/10.1056/NEJMp2003539?query=NC
Interesting article about the use of telemedicine, mainly for the triage and following of COVID-19 patients.
Fair Allocation of Scarce Medical Resources in the Time of Covid-19. Ezekiel J. Emanuel, Govind Persad, Ross Upshur, Beatriz Thome, Michael Parker, Aaron Glickman, Cathy Zhang, Connor Boyle, Maxwell Smith, and James P. Phillips. In The New England Jounal of Medicine
https://www.nejm.org/doi/full/10.1056/NEJMsb2005114?query=featured_home
How can a fair allocation of medical resources be done in a country like the United States? This is a reflection led by renowned bioethicist Ezekiel Emanuel. The rapidly growing imbalance between the supply and demand of medical resources in many countries presents an inherently normative question: How can medicine be done? Will resources be strongly used during the COVID-19 pandemic?
Consensus Ethical Values and Guiding Principles to streamline healthcare in a pandemic: maximize benefits, treat people equally, promote and reward instrumental value, and give priority to the worst off (includes table)
From these ethical values some specific recommendations for the allocation of medical resources at the COVID-19 pandemic emerge: maximizing benefits; prioritize healthcare workers; do not use "first come, first served" in the allocation processes; follow changes in scientific evidence; recognize participation in research; and apply the same principles in allocating scarce resources between patients with COVID-19 and those with other medical conditions.
Ethics Committee Reviews of Applications for Research Studies at 1 Hospital in China During the 2019 Novel Coronavirus Epidemic. Hui Zhang, Fengmin Shao, Jianqin Gu et al. In JAMA
Te experience of a Chinese Research Ethics Committee for the avaluation of clinical trials during COVID-19 pandemics.
COVID-19: protecting health-care workers. Editorial. In The Lancet
One of the great paradoxes of the current pandemic is that while the general recommendation is to "stay home" and avoid social contact, healthcare workers are doing the opposite: they are closer to the virus.
One of the main ethical challenges is the protection of healthcare professionals, but the PPE (Personal Protective Equipment) is in short supply. Medical staff reports describe physical and mental exhaustion, the torment of difficult triage choices and the pain of losing patients and colleagues, plus the risk of infection.
Health care professionals are subjected to physical and emotional overload, with high emotional impact and very difficult decisions and risk of contagion, themselves and their families.
It is crucial that the proper response to healthcare professionals arrives. A first step is the proper provision of PPE, then measures of support, rest and family support; and valuing psychological support. Today, health workers are the most valuable resource in every country.
At the Epicenter of the Covid-19 Pandemic and Humanitarian Crises in Italy: Changing Perspectives on Preparation and Mitigation. Mirco Nacoti et al. In The New England Jounal of Medicine
https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0080#.Xnd7TZxjZds.twitter
This article talks about adaptation of hospitals in Italy. It is said that " Western health care systems have been built around the concept of patient-centered care, but an epidemic requires a change of perspective toward a concept of community-centered care (...). This outbreak is more than an intensive care phenomenon, rather it is a public health and humanitarian crisis. It requires social scientists, epidemiologists, experts in logistics, psychologists, and social workers. We urgently need humanitarian agencies who recognize the importance of local engagement".
Facing Covid-19 in Italy — Ethics, Logistics, and Therapeutics on the Epidemic’s Front Line. Lisa Rosenbaum. In The New England Jounal of Medicine
https://www.nejm.org/doi/full/10.1056/NEJMp2005492?query=featured_home
This article provides an wide view of the development of the pandemic in Italy, its impact on hospitals, healthcare professionals and prioritization strategies.
Novel coronavirus infection during the 2019–2020 epidemic: preparing intensive care units—the experience in Sichuan Province, China. Xuelian Liao, Bo Wang & Yan Kang. In Intensive Care Medicine
https://link.springer.com/article/10.1007/s00134-020-05954-2
This article describes the preparation of ICU, including an interesting table for clinical triage.
The resilience of the Spanish health system against the COVID-19 pandemic. Helena Legido-Quigley, José Tomás Mateos-García, Vanesa Regulez Campos, Montserrat Gea-Sánchez, Carles Muntaner, Martin McKee. In The Lancet
One of the first analysis of COVID-19 in the Spanish Health System. Authors say that "A crisis such as this places pressure on all building blocks of a health system", and one has to assess how these components respond:
- Governance. Coordination is crucial in any country, but especially in one like Spain in which responsibility for health is devolved to 17 very diverse regions.
- Financing. New funds provided to face this crisis need to be seen against the background of almost a decade of austerity from which the health system has yet to recover.
- Clinical protocols and advices and health facilities. The national Ministry of Health has developed a set of clinical protocols. Additional advice is published by certain regions. Health facilities in the worst affected regions are struggling, with inadequate intensive care capacity and an insufficient number of ventilators in particular. The new decree allows the regions to take over management of private health services while military installations will be used for public health purposes.
- Medicines and equipment. Supplies of personal protective equipment in health facilities have been a concern in all regions leading to re-use, despite the known risks.
- Health workers. Factors as exhaustion or quarantining of health workers, associated to staff shortages, must be taken into account.
- Information. Is widely considered to have been properly provided not only by authorities, but also by Spanish media. There have been changing attitudes among the Spanish population. Initially, the disease attracted little attention, but this calm soon gave way to panic and hoarding of key supplies once cases began to increase.
The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Samantha K Brooks et al. In The Lancet
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30460-8/fulltext
This article reviews the mental health effects of quarantine. The literature shows that emotional impact is broad, substantial, and can be lasting. It can be mitigated: with information (telling people what is happening and why, telling how long it will continue), prompting meaningful activities to perform while they are quarantined, guaranteeing basic supplies (such as food, water and medical
Facing Covid-19 in Italy — Ethics, Logistics, and Therapeutics on the Epidemic’s Front Line. List of authors. Lisa Rosenbaum. In The New England Journal of Medicine
https://www.nejm.org/doi/full/10.1056/NEJMp2005492
Interesting reflection on how the pandemic has evolved in Italy, on how ethical decisions and priorities were made. There were many criticisms of SIAARTI's recommendations, but “as excruciating as it was to admit, about a week into the epidemic’s peak, it became clear that ventilating patients who were extremely unlikely to survive meant denying ventilatory support to many who could. Nevertheless, even under the direst circumstances, rationing is often better tolerated when done silently. Indeed, the ethical guidance was widely criticized. Committee members were accused of ageism, and critics suggested that the gravity of the situation had been exaggerated and that Covid-19 was no worse than influenza". Although ethical dilemmas, by definition, do not have a correct answer, when other health systems face similar rationing decisions, is social reaction inevitable?
COVID Chronicles: What Does Triage Mean, How Does it Work, and When Will We Need It. In Bioethics.net
The Italians ran out of beds and ventilators. They had to decide who could live and who could die.
Klugman, following a 2012 paper, defines three levels of resources: conventional functioning, contingency status and crisis status. He proposes to carry out a whole process of preparation in the situation of contingency and defines the shortage of resources and some solutions to the state of crisis. Next, he defines situations of ethical conflict and offers the link to the Minnesota Department of Health document "Patient care strategies for scarce resource situations".
He considers the basic ethical recommendations for triage decision-making to be:
- Never make decisions alone. No one person should make these life-and-death choices. Collegiate decisions help spread the responsibility for the choice, increase the chances of creative thinking and making sure different perspectives are represented.
- All lives are equal. It should not matter any of the conditions that accompany the patient. All patients should be treated in the same way.
- Once a prioritization formula is instituted, it should be followed. There is no an only, ideal scale, but the one used should be the same for everyone.
- We owe each other reciprocity. Professionals providing essential services (such as health care providers, EMTs, truck drivers or electrical workers) may deserve to jump the line ahead of others so that they can be fairly quickly returned ,to their task of helping others.
- Be clear and transparent in communicating. This is hard but in the long run is the better choice.
- Resources rationing should be done by regions and not by hospitals. And this has to be done before the state of crisis.
We need to learn from how previous experiences have been handled. In the field of COVID these experiences are mainly those of China and Italy.
Ethical Framework for Health Care Institutions and Guidelines for Institutional Ethics Services Responding to the Novel Coronavirus Pandemic. Nancy Berlinger, PhD; Matthew Wynia, MD, MPH; Tia Powell, MD; D. Micah Hester, PhD; Aimee Milliken, RN, PhD, HEC-C; Rachel Fabi, PhD; Felicia Cohn, PhD, HEC-C; Laura K. Guidry-Grimes, PhD; Jamie Carlin Watson, PhD; Lori Bruce, MA, MBE; Elizabeth J. Chuang, MD, MPH; Grace Oei, MD, HEC-C; Jean Abbott, MD, HEC-C; Nancy Piper Jenks, MS, CFNP, FAANP. In Hastings Center
https://www.thehastingscenter.org/ethicalframeworkcovid19/
This document is designed for use within a health care institution’s preparedness work, supplementing public health and clinical practice guidance on COVID-19. It aims to help structure ongoing discussion of significant, foreseeable ethical concerns arising under contingency levels of care and potentially crisis standards of care. Its method is to
- pose practical questions that administrators and clinicians may not yet have considered and support real-time reflection and review of policy and processes;
- explain three duties of health care leaders during a public health emergency: to plan, to safeguard, and to guide; and
- offer detailed guidelines to help hospital ethics committees and clinical ethics consultation (CEC) services quickly prepare to support clinicians who are caring for patients under contingency levels of care and, potentially, crisis standards of care.
Una mirada ética a las epidemias. Juan Pablo beca. In Revista Academia - UDD
https://medicina.udd.cl/centro-bioetica/files/2010/08/Una-mirada-%C3%A9tica-a-las-epidemias.pdf
This article gives some insights into ethical criteria and values in decision making in the context of a developing epidemic. They are reflections on the crisis of the 'Human Influenza' epidemic due to the H1N1 virus (2009-2010), but they can be extrapolated to the current situation caused by COVID-19.
El impacto social de la comunicación en las epidemias: perspectivas bioéticas y de salud pública. A. Duro. In Revista Iberoamericana de Bioética.
https://revistas.comillas.edu/index.php/bioetica-revista-iberoamericana/article/view/8374/8346
This article reflects on the ethical issues involved in information management by the media in case of epidemics.
Pandemic influenza preparedness: an ethical framework to guide decision-making. Alison K Thompson, Karen Faith, Jennifer L Gibson & Ross EG Upshur. In BMC Medical Ethics
https://bmcmedethics.biomedcentral.com/articles/10.1186/1472-6939-7-12
Reference article about how to establish an ethical framework for decision-making and the associated values. The main identified problems are: prioritization of populations for treatment; intensive care unit and hospital bed assignment; duty to care; human resources allocation and staffing; visiting restrictions; and communications and how reviews of decisions will be handled. The values to make decisions would be: accountability, inclusiveness, openness and transparency, reasonableness and responsiveness.
Indispensable
Critical Care Utilization for the COVID-19 Outbreak in Lombardy, ItalyEarly Experience and Forecast During an Emergency Response. Giacomo Grasselli, Antonio Pesenti, Maurizio Cecconi. In JAMA
https://jamanetwork.com/journals/jama/fullarticle/2763188
Interesting article about ICU management in Italy. Key points are: create cohort ICU for COVID-19 patients (separated from the rest of the ICU beds to minimize the risk of hospital transmission); organize a triage area where patients could receive mechanical ventilation if necessary in every hospital to support critically ill patients with suspected COVID-19 infection, pending the final result of diagnostic tests; establish local protocols for triage of patients with respiratory symptoms, to test them rapidly, and, depending on the diagnosis, to allocate them to the appropriate cohort; ensure that adequate personal protective equipment (PPE) for health personnel is available, with the organization of adequate supply and distribution along with adequate training of all personnel at risk of contagion; report every positive or suspected critically ill COVID-19 patient to the regional coordinating center.
Recommendations for intensive care unit and hospital preparations for an influenza epidemic or mass disaster: summary report of the European Society of Intensive Care Medicine’s Task Force for intensive care unit triage during an influenza epidemic or mass disaster. Charles L. Sprung, Janice L. Zimmerman, Michael D. Christian, Gavin M. Joynt, John L. Hick, Bruce Taylor, Guy A. Richards, Christian Sandrock, Robert Cohen & Bruria Adini. In Intensive Care Medicine
https://link.springer.com/article/10.1007/s00134-010-1759-y
Article summarizing recommendations for adapting ICUs and hospitals to pandemics: "Hospitals should increase their ICU beds to the maximal extent by expanding ICU capacity and expanding ICUs into other areas. Hospitals should have appropriate beds and monitors for these expansion areas. Establish a management system with control groups at facility, local, regional and/or national levels to exercise authority over resources. Establish a system of communication, coordination and collaboration between the ICU and key interface departments. A plan to access, coordinate and increase labor resources is required with a central inventory of all clinical and non-clinical staff. Delegate duties not within the usual scope of workers’ practice. Ensure that adequate essential medical equipment, pharmaceuticals and supplies are available. Protect patients and staff with infection control practices and supporting occupational health policies. Maintain staff confidence with reassurance plans for legal protection and assistance. Have objective, ethical, transparent triage criteria that are applied equitably and publically disclosed. ICU triage of patients should be based on the likelihood for patients to benefit most or a ‘first come, first served’ basis. Develop protocols for safe performance of high-risk procedures. Train and educate staff."
Indispensable
Altered Standards of Care During an Influenza Pandemic: Identifying Ethical, Legal, and Practical Principles to Guide Decision Making. Donna Levin, Rebecca Orfaly Cadigan, Paul D. Biddinger, Suzanne Condon, Howard K. Koh & Joint Massachusetts Department of Public Health-Harvard Altered Standards of Care Working Group. In Disaster Medicine.
This article describes the planning process undertaken by public health officials in the Commonwealth of Massachusetts, along with community and academic partners, to explore the issues surrounding altered standards of care in the event of pandemic influenza. Throughout 2006, the Massachusetts Department of Public Health and the Harvard School of Public Health Center for Public Health Preparedness jointly convened a working group comprising ethicists, lawyers, clinicians, and local and state public health officials to consider issues such as allocation of antiviral medications, prioritization of critical care, and state seizure of private assets.
How will country-based mitigation measures influence the course of the COVID-19 epidemic? Roy M Anderson, Hans Heesterbeek, Don Klinkenberg & T Déirdre Hollingsworth. In The Lancet.
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30567-5/fulltext
Interesting reflection about mitigation measures. It is said: "Governments will not be able to minimise both deaths from coronavirus disease 2019 (COVID-19) and the economic impact of viral spread. Keeping mortality as low as possible will be the highest priority for individuals; hence governments must put in place measures to ameliorate the inevitable economic downturn".
History in a Crisis — Lessons for Covid-19. David S. Jones. In The New England Journal of Medicine
https://www.nejm.org/doi/full/10.1056/NEJMp2004361?query=featured_home
Interesting historical reflection about the history of epidemics: " Epidemics unfold as social dramas in three acts, according to Rosenberg. The earliest signs are subtle. Whether influenced by a desire for self-reassurance or a need to protect economic interests, citizens ignore clues that something is awry until the acceleration of illness and deaths forces reluctant acknowledgment. Recognition launches the second act, in which people demand and offer explanations, both mechanistic and moral. Explanations, in turn, generate public responses. These can make the third act as dramatic and disruptive as the disease itself. Epidemics eventually resolve, whether succumbing to societal action or having exhausted the supply of susceptible victims."
COVID-19: towards controlling of a pandemic. Juliet Bedford, Delia Enria, Johan Giesecke, *David L Heymann, Chikwe Ihekweazu, Gary Kobinger, H Clifford Lane,Ziad Memish, Myoung-don Oh, Amadou Alpha Sall, Anne Schuchat, Kumnuan Ungchusak, Lothar H Wieler, for the WHO Strategic and Technical Advisory Group for Infectious Hazards. In The Lancet
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30673-5/fulltext
The WHO Strategic and Technical Advisory Group for Infectious Hazards published its recommendations for controlling the pandemic on Monday, March 16. This group periodically reviews and updates the situation with COVID-19 to make recommendations to the WHO health emergencies programme.
The report, based on the experience of more than 72,000 cases in China and the rapid evolution of the disease in other countries (up to 143 by March 16), makes the following recommendations:
- Countries need to rapidly and robustly increase their preparedness, readiness, and response actions based on their national risk assessment and the four WHO transmission scenarios for countries with no cases, first cases, first clusters, and community transmission and spread (4Cs).
- All countries should consider a combination of response measures: case and contact finding; containment or other measures that aim to delay the onset of patient surges where feasible; and measures such as public awareness, promotion of personal protective hygiene, preparation of health systems for a surge of severely ill patients, stronger infection prevention and control in health facilities, nursing homes, and long-term care facilities, and postponement or cancellation of large-scale public gatherings.
- Countries with no or a few first cases of COVID-19 should consider active surveillance for timely case finding; isolate, test, and trace every contact in containment; practise social distancing; and ready their health-care systems and populations for spread of infection.
- Lower-income and middle-income countries that request support from WHO should be fully supported technically and financially.
- Research gaps about COVID-19 should be addressed and divulgated.
Finally, the group emphasizes the importance of early sharing of public health data, as it contributes to a better understanding of the problem.
Ethical Considerations Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement. Lee Daugherty Biddison , Kenneth A. Berkowitz , Brooke Courtney , COL Marla J. De Jong , Asha V. Devereaux , Niranjan Kissoon , Beth E. Roxland , Charles L. Sprung , Jeff rey R. Dichter , Michael D. Christian , Tia Powell , on behalf of the Task Force for Mass Critical Care. En CHEST Journal.
https://journal.chestnet.org/article/S0012-3692(15)51996-X/fulltext
Ethical issues imbue almost every aspect of the response to disasters and pandemics. Five essential domains are addressed: triage and allocation; responding to ethical concerns of patients and families; ethical responsibilities with providers; conducting research; and international disaster response. Triage and allocating scarce critical care resources remain as persistent controversial issues in public health emergencies. Research and international concerns have received minimal attention in previous guidance papers.