II. Ethical / Legal Issues

1. 1. COVID-19 Patients
      September 16, 2020
      • Time-critical goals of care in the Emergency Department during COVID-19: A three-stage protocol. 6/17/20. Nakagawa S. Journal of the American Geriatric Society.
        This is an important and ethically relevant research letter discussing applicability of initiating palliative care discussions in the Emergency Department (ED) and defining a “clear goal of care” in this COVID-19 pandemic. The author proposes a simple 3-stage communication approach (1. sharing knowledge, 2. clarifying goal of care, and 3. negotiating treatment options) with the patient’s family and ED physicians that allows clinicians to quickly share the clinical picture, effectively assess the patient’s values, and make a goal recommendation for care during our rapidly progressing crisis. The 3-stage tool is very practical and saves resources while preserving the patient’s autonomy and wishes.

      July 24, 2020

      • The Structural and Social Determinants of the Racial/Ethnic Disparities in the U.S. COVID-19 Pandemic: What’s Our Role? 7/17/20. Thakur N. Am J Respir Crit Care Med.
        A call to arms for critical care and pulmonary specialists: black, Latinx, and Native Americans test positive for and die from coronavirus at higher proportion than other racial and ethnic groups. Their mortality rates far exceed the proportion of the population that these groups represent. Historically disadvantaged communities have reduced capacity to adopt preventive measures. Minority communities with low socioeconomic status (SES) and/or limited English proficiency receive less public communication during crisis and pandemics; access to testing and care is greatly limited in low-SES and minority communities. This article advocates for under-represented minority patients, who are becoming critically ill and dying at disproportionate rates.

      July 20, 2020

      • CPR in the COVID-19 Era – An Ethical Framework. 7/9/20. Kramer DB. N Engl J Med.
        Review by the SAB
        By David Clement, on behalf of the SAB
        This opinion paper provides important reading on the ethics of how the surge of patients with COVID-19 complicate standard CPR practices. An ethical framework of three crisis standards is proposed: acknowledge resource limitations, forgo CPR in certain circumstances, and impose selective constraints on CPR to ensure the safety of healthcare personnel. Hospitals need to develop such explicit crisis standards for CPR to help clinicians and the public understand when strict adherence to established resuscitation protocols may no longer be appropriate.

      May 27, 2020

      • Saving Lives Versus Saving Dollars: The Acceptable Loss for Coronavirus Disease 2019. May 18. Ashkenazi. Crit Care Med.
        This is in response to the previous article “Adult ICU Triage During the Coronavirus Disease 2019 Pandemic. Who Will Live and Who Will Die?” Recommendations to Improve Survival in CCM.
        A thought provoking reply: Care for patient vs. population and simultaneously incorporating a principal of “life for ‘Fittest for a survival’” while accepting the strategic “retrieve” in this pandemic.
        The author questions the article’s recommendation of a triage algorithm based on various criteria—except for the age.
        The formula in question is based on 1. Performance score; 2. ASA score; 3. Number of organ failures; and 4. Predicted survival. Performance score and predicted survival has indirectly incorporated the age of the patient in consideration for “greater good to great number of people / year.”
        The author makes a cerebral argument for a need for strategic pre-planning of the national capacities (based on ICU beds) and capabilities (surge of 100 + Supply + Space) of a pandemic. Here the policy maker should consider as an “acceptable loss,” which represents the ultimate balance between saving lives and keeping life routines. This includes defining the “price” that we are willing to “pay” in order to be able to save the most lives and life-years and to lower the morbidity rate while, at the same time safeguarding the economy and individuals at workplaces and the fabric of social existence. Social distancing, quarantine, tracking and monitoring are medical aspects of a pandemics but does cause a collateral damage in the area with 1. Loss of lives due to suicides; 2. Psychiatry diseases; 3.Delayed chronic treatment; 4. Domestic violence; and 5. Economic losses. An evaluation of the “acceptable loss” is a professional, financial, ethical, legal, social, cultural, and historical dilemma. The COVID-19 pandemic has shown a dichotomy of the society: “the objective element” of the lethal virus and “controlled element” of the overprotective reaction for those who are not at risk, while vulnerable populations are left unprotected.
        ICU Triage needs to be 1. Differential diagnosis with comorbidities – risks stratification of population; 2. International surge – share and care of equipment and valuable resources; 3. Awareness to differential age; and 4. Meta leadership at stages (country, state, city level). The author appeals a medical triage, acceptable loss is based on two basic principles: beneficence and distributive justice.
        In a big country that is fractured at several levels, these suggested principals will need “a well-orchestrated political will” in this pandemic. On the other side, success for a smaller, monolithic, resources poor, undemocratic country from the author’s perspective in this pandemic.

      May 14, 2020

      • Critical Care During the Coronavirus Crisis: Challenges and Considerations for the Cardiothoracic and Vascular Anesthesia Community. May 12. Augoustides. J Cardiothorac Vasc Anesth.
        Editorial commentary on planning and preparation for ICU utilization during pandemic (COVID-19) with specific reference to surge planning. Notes importance of graded response using a framework leading from conventional through contingency to crisis emphasizing the importance of understanding varying response levels, all of which have been seen during the current crisis; conservation, substitution, adaptation, reuse and reallocation. Discusses importance of developing early and well accepted institutional triage plan. Document geared for hospital and ICU administrative purposes for preparation and planning.

      May 13, 2020

      • Adult ICU Triage During the Coronavirus Disease 2019 Pandemic: Who Will Live and Who Will Die? Recommendations to Improve Survival
        May 6. Sprung. Critical Care Medicine.
        Opinion from SAB Member: Dr. Jagdip Shah
        The authors review 3 methods of triage (Andorran Model, Medical Benefit, and Manchester Triage System), in 3 countries (Spain, Ecuador, and the Netherlands). They then compared results with current COVID-19 pandemic ICU care profiles. The Netherlands ICU was able to increase capacity 4-fold and was able to decrease mortality while other ICUs in Ecuador and Spain more than doubled ICU bed capacity and experienced an increased mortality of almost 2- to 3-fold. Triage is to be used only in crisis mode, not in contingency mode (e.g. when demand for ICU bed is increased >100%). Here the authors make an appeal for a flexible, simple and powerful tool implemented by a triage committee that may include doctors with relevant experience (palliative care, critical care, administration), nurses, social workers, and ethicists for ICU admission and discharge. The authors recommend a triage algorithm based on clinical estimations of the incremental survival benefit (saving the most life-years) with “first come, first served” being applied for patients with otherwise equal priorities/benefits. Prognosis is an important factor to consider with emphasis on biologic age being needed for COVID-19, specifically. Fairness by age, gender, race ethnicity, sex preference, financial status, social worth is also recommended. The triage model proposed here is based on the priority (1 to 4) label of all ICU seeking patients. The triage committee will make color coding of each patient seeking ICU based on: 1. performance score (The premorbid baseline condition using the Eastern Cooperative Oncology Group Performance Score + the Clinical Frailty Score + the Karnofsky Performance Scale), 2. ASA class, 3. SOFA score, 4. predicted survival. The triage committee reviews all ICU admitted patients Q24 hrs and also Q14 days for discharge from the ICU. The authors make a plea for health workers to get priority for treatment with a blessing from the government/communities that they serve. Administrators in the committee are likely to guide space, staff and supplies. An excellent graphic clearly written for the current pandemic is included.

      April 21, 2020

      • Airway management in COVID-19: in the den of the beast. Apr 18. Sorbello. Anesthesia & Analgesia.
        In this letter to the editor, the authors encourage healthcare providers should be protected and should undergo training in using personal protective equipment.

      April 13, 2020

      • Lessons learned from first COVID-19 cases in the United States. Mar 31. Landau. Anesthesia & Analgesia.
        Assessment of data surrounding best anesthesia management of pregnant women who have tested positive for SARS-CoV-2 (COVID-19).

      April 11, 2020

      • Between Scylla and Charybdis — Oncologic Decision Making in the Time of Covid-19. Apr 7. Lewis. NEJM.
        Poses the question: Does treatment of malignancy outweigh the increased risk of death from covid-19?
      • Structure of Mpro from COVID-19 virus and discovery of its inhibitors. Apr 9. Zhenming. Nature.
        A deep dive computer and bench-cell research study describing a model to develop a drug that inhibits intracellular COVID-19 replication. A drug in ongoing studies by the FDA, Ebselen, best fits the model.

      April 8, 2020

      • Patients who are improving could have treatment withdrawn if others could benefit more. Apr 2. Mahase. BMJ.
        Doctors could be forced to withdraw lifesaving treatment from stable or improving patients.
      • Potential Legal Liability for Withdrawing or Withholding Ventilators During COVID-19: Assessing the Risks and Identifying Needed Reforms Apr 1. Cohen. JAMA.
        COVID-19 SAB Opinion from: Dr. Philip Lumb
        Sobering discussion on potential legal liability for physicians and organizations following triage protocols that refuse, withdraw, and reassign or withdraw lifesaving equipment (ventilators) from non-consenting patients. The discussion is well founded and provides a call for state legislatures to enact similar statutes to a ‘”Maryland statute in place since 2004, indicating that “A health care provider is immune from civil or criminal liability if the health care provider acts in good faith and under a catastrophic health emergency proclamation” with health care provider defined to include most health care facilities.”‘ The discussion notes the possibility of criminal and/or civil charges in certain situations and urges rapid action at state level to create 120-day, self-expiring legislation to hold harmless institutions and physicians who make triage decisions following defined protocols. (Reference A Framework for Rationing Ventilators and Critical Care Beds During the COVID-19 Pandemic JAMA. Mar 27, 2020. Douglas B. White MD MAS; Bernard Lo MD)

      April 3, 2020

      • Covid-19: Patients who are improving could have treatment withdrawn if others could benefit more. Apr 2. Mahase. BMJ.
        Doctors could be forced to withdraw lifesaving treatment from stable or improving patients.

      March 31, 2020

      • COVID-19: Hospitals Should Consider CoP Carefully Before Deciding on DNR Policy. Mar 26. Plunkett. PSQH.
        Clinicians and others in facilities, many in areas becoming overwhelmed by the number of patients with COVID-19 experiencing extreme problems breathing, have discussed whether to implement blanket “Do Not Resuscitate” (DNR) orders for COVID patients.
      • Hospitals consider universal do-not-resuscitate orders for coronavirus patients. Mar 25. Eunjung Cha. The Washington Post.
        Concerns that “all hands” responses may expose doctors and nurses to infection prompts debate about prioritizing the survival of the many over the one.
      • How Should We Ethically Allocate Scarce Critical Care Resources During COVID-19 Pandemic? Mar 27. Suresh. UPMC.
        Researchers at the University of Pittsburgh School of Medicine have developed a new framework that helps hospitals ethically allocate scarce critical care resources during this pandemic.
      • The Curve Is Not Flat Enough. Mar 28. Hamblin. The Atlantic.
        Hospitals are poised to face the kind of life-and-death decisions that industrialized countries typically encounter only in times of war and natural disaster.
      • The Importance of Addressing Advance Care Planning and Decisions About Do-Not-Resuscitate Orders During Novel Coronavirus 2019 (COVID-19). Mar 27. Curtis. JAMA.
        Even if capacity to provide care is sufficient with the COVID-19 pandemic, one priority should be addressing goals of care in the setting of acute life-threatening illness, especially for patients with chronic, life-limiting disease.

      March 29, 2020

      • Covid-19: Doctors are told not to perform CPR on patients in cardiac arrest. BMJ.

      March 23, 2020

      • Life, or death? Experts guide pandemic medical equipment decisions. CIDRAP. March 23, 2020.
      • Perspective: The Toughest Triage — Allocating Ventilators in a Pandemic. Robert D. Truog, MD, Christine Mitchell, RN, & George Q. Daley, MD, PhD. March 23, 2020.

      March 18, 2020

      • Facing COVID-19 in Italy — Ethics, Logistics, and Therapeutics on the Epidemic’s Front Line. Lisa Rosenbaum, MD. NEJM. March 18, 2020.

1. 2. Healthcare Workers
      May 15, 2020
      • Medically Vulnerable Clinicians and Unnecessary Risk During the COVID-19 Pandemic
        May 13. Janvier. The American Journal of Bioethics.
        Opinion from SAB Member: Dr. Philip Lumb
        This is an intellectually provocative discussion on appropriate tasks for retired physician volunteers in COVID-19 areas. The article entertains appropriate conflict between “wishing to be in the front line” versus more appropriate and potentially intellectually valuable activities that entertain less risk for volunteers and the health system.

1. 3. Society
      April 30, 2020
      • Reduced Rate of Hospital Admissions for ACS during Covid-19 Outbreak in Northern Italy. Apr 29. De Filippo. N Engl J Med.
        Higher death rate not accounted for by Covid-19 disease may indicate patients dying at home from untreated ACS.

      April 25, 2020

      • What the Great Pandemic Novels Teach Us
        Apr 23. Pamuk. The New York Times.
        Opinion from SAB Member: Dr. J. Lance Lichtor, Dr. David M. Clement
        JLC: Though not really a science paper, this piece shows, based on literary history, how eerily similar the current pandemic is compared to what has happened over the last 400 years in terms of initial response (denial); the carelessness, incompetence and selfishness of those in power that infuriates the masses; how institutions are unsure how to deal with many of the issues; how rumor and the spread of false information has been a universal and unprompted response, including how the disease is foreign, and is brought in with malicious intent; the intensity of suffering; and finally the terror all of us feel which shows how fragile our lives are and how we all share the same humanity. Fear may cause us to withdraw, but it also teaches us to be humble and practice solidarity.
        DC: One may question the historical accuracy of novels. During the current pandemic some countries (New Zealand, Australia and Taiwan for example) have largely avoided baseless rumors and false information. But the human tendency for such dysfunctional approaches to pandemics are wonderfully illustrated in this article.

      April 21, 2020

      • The Untold Toll – The Pandemic’s Effects on Patients without Covid-19. Apr 18. Rosenbaum. NEJM.
        An articulate, appropriately emotional and well written article on the peripheral and usually undocumented costs of COVID-19’s effects on other (frequently emergency) patient care priorities. Details experiences with delayed coronary angiography, rushed decisions to perform bilateral mastectomy, and inadequate post procedural follow-up. Timely, thoughtful and obvious future implications when “routine” access to medical care resumes.