BY LISA EISENHAUER
April 23, 2020
As clinicians risk their lives to save people stricken by COVID-19, one fact that shouldn't get lost in the discussion is that even for patients who aren't battling the deadly and highly contagious virus, the chance that resuscitation efforts will succeed is fairly low, Catholic ethicists said during a recent webinar.
"I have told our students that if they were ever to experience cardiopulmonary arrest, the safest place for them to do it would be on TV," said Dr. G. Kevin Donovan, a professor of pediatrics at Georgetown University and director of its Pellegrino Center for Clinical Bioethics, noting that television shows and movies offer unrealistic depictions of how effective resuscitation efforts actually are. In reality, he said, "Even in the hospital in the best of circumstances, it's an 80% failure rate to resuscitate people and get them out of the hospital alive."
Donovan was one of the featured speakers in the webinar on April 16 that is the first of a series titled "Catholic Ethics and the challenge of COVID-19." The series is being presented on consecutive Thursdays through May by CHA and Georgetown University with the help of the Pellegrino Center.
Donovan was joined in a discussion of the ethical and practical considerations surrounding do-not-resuscitate orders and invasive lifesaving procedures such as intubation amid the COVID-18 pandemic by Dr. Myles N. Sheehan, a Jesuit priest and lecturer at the Pellegrino Center whose expertise includes ethics and geriatric and palliative care.
Avoiding futile care
As he and Donovan reviewed potential scenarios that clinicians might face, Sheehan said he thinks most people share his belief that resuscitation efforts should not be undertaken for every patient who is dying. The pandemic, however, has raised new issues about when resuscitation and other extraordinary efforts should be undertaken, he noted.
One big concern is the contagion risk to caregivers during the intubation of critically ill patients infected with COVID-19. Another is that undertaking some lifesaving efforts when there is little chance of saving a life could further deplete scarce supplies such as ventilators and personal protection equipment for clinicians.
Sheehan advised that hospitals and health systems have policies in place to ensure that lifesaving efforts are undertaken without regard to discriminatory factors such as race and age but also on an individual basis with the overall condition and prognosis of the patient in mind. "I guess there are two take-home points," Sheehan said. "One is no blanket refusal of COVID resuscitations. Second is think about the cases carefully."
Additionally, those policies need to keep staff safety in mind, he said. For example, hospital policies should mandate that clinicians take the time to properly don whatever protective gear is necessary and that as few people as possible be part of the teams involved in risky procedures. "I think the prudent approach is to try to make sure we have adequately protected the smallest number of people as possible to do the resuscitation," he said. "And then we focus those resuscitative efforts on those people who are most likely to be resuscitated."
Following patient preferences
Sheehan and Donovan agreed that care providers should do their best to learn the preferences of patients when it comes to resuscitation or procedures such as intubation. They urged asking questions about preferences as early as possible in the course of care, even as soon as the admission process.
"Particularly when we're trying to minimize exposure of health care workers while maximizing appropriate care, we really need to have these discussions," Sheehan said.
For clinicians who aren't comfortable holding such sensitive conversations with patients at risk of death or with their relatives, Sheehan suggested asking for help from others on the hospital staff, such as members of the palliative care team. Those specialists can also help provide comfort care to patients who don't want to undergo invasive procedures such as intubation, he said.
Sheehan and Donovan discussed how giving all patients quality and appropriate care is inherent in Catholic teachings. "Over and over I've said, we don't do these things ad hoc," Sheehan said. "Catholics are people who believe in human dignity, but they also believe in community and the common good. So, we consult and work collaboratively to ensure good care, fairness, and learning from what we do."
The second half of the webinar focused on the ethics of a theoretical nonconsensual reallocation of ventilators in use by sick patients to make them available to other patients who have a better prognosis for recovery during the pandemic. Dr. Allen Roberts, professor of clinical medicine and associate medical director and chair of the ethics committee at MedStar Georgetown University Hospital in Washington, said there are many innovative steps that should be considered before a process is put in place to decide who gets access if the supply of ventilators can't meet the demand. Among those he mentioned are limiting elective surgeries and redeploying anesthesia machines as ventilators.
If a situation arises where there are too few ventilators for the number of patients, Donovan said a concern Catholic health providers might face is having the reallocation of the machines dictated by government policies. In such a situation, he said, the criteria for the reallocation needs to be narrowly drawn, the triage process for patients fair and transparent, and an appeals process set up for those who don't get or lose access to ventilators.
Even so, because there as so many factors at play in health care, such as disparities of access, Donovan said, any reallocation process is suspect. "It's not really clear that any of the various reallocation criteria would not unfairly disadvantage somebody," Donovan said.
The bottom line for Catholic ethics in a pandemic: Consider best outcome for each individual
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