Article

Foundational principles should guide care decisions for COVID-19 patients, ethicists say

April – May, 2020

By LISA EISENHAUER
April 6, 2020

If the COVID-19 pandemic reaches the point where decisions have to be made about who gets limited resources, CHRISTUS Health care providers will strive to give patients who don't get scarce resources, such as ventilators, whatever treatment and comfort care is available.

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Gremmels

"From a human dignity standpoint, those who are not going to be receiving those scarce (lifesaving) resources still have a right to ordinary care and comfort care, as appropriate, and potentially curative treatments that are not scarce," said Becket Gremmels, the system's director of ethics.

In practical terms, that could mean that if pain medicines run short, those who are receiving life-saving treatments might not get painkillers so that those who are dying can have them, Gremmels said. In response to a follow-up question, Gremmels offered another example, that of a patient who comes in with an infection and is bordering on sepsis. The patient might be refused access to the ICU and ventilator due to end-stage COPD, but could potentially receive IV antibiotics in the hopes it would cure the infection. "This assumes, of course, the IV antibiotics aren't scarce. Many patients in that condition would still die, but there's a chance some of them might not, depending on the source of the infection," he said.

Gremmels was one of four ethicists who took part in a CHA webinar called "Making Ethical Choices with Limited Resources: Lessons from Catholic Health Care" on April 1. He shared insights about how Irving, Texas-based CHRISTUS is developing policies and procedures to care for victims of the pandemic.

Relying on guiding principles
Moderator Brian Kane, CHA's senior director of ethics, pointed out that human dignity is one of the guiding principles of Catholic social teaching, along with the pursuit of the common good and social justice. "We have always gone to our social principles of Catholic teaching to inform us about how we approach health care and how we best serve the needs of everybody," Kane said.

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Kane

Putting those principles into practice, Kane said, means caring not only for patients but also being mindful of the dignity and needs of clinicians and others working at health care facilities. "The work they are doing is valuable to everybody," Kane said. "We must respect their rights and support them."

Gremmels said CHRISTUS is basing its policies and procedures for the triage of COVID-19 patients on those foundational guiding principles as well as "second order" ones that include equity, transparency and consistency. He said the crisis protocols the system is crafting are only for worst-case situations in which facilities are inundated and overwhelmed and resources are insufficient to meet needs -- situations the system, which operates in Texas, Arkansas, Louisiana, Georgia, and New Mexico, is anticipating but not yet experiencing.

Objective triage criteria
Gremmels said the system will use evidence-based objective clinical criteria such as Sequential Organ Failure Assessment, or SOFA, scores in assessing who gets the most extreme care, like intubation. He also said that, to ensure that all patients get equal consideration for access to what could be limited critical care, triage teams will be established to do the assessments based on the objective criteria.

Gremmels said CHRISTUS will work to make patients and families aware of the decision-making process for those critical care decisions. "I think that the more people can be transparent about the process, the more likely there is to be acceptance about the outcome," he said.

Common practices
Kevin Murphy, senior vice president, mission innovation, ethics and theology at CommonSpirit Health, said he has surveyed many policies internal and external to Catholic health care systems nationwide and found that many have common ground in that they are using some of the same source documents as a basis for their pandemic care protocols. For crisis guidelines, for example, one of five main sources they are turning to is an article called "Development of a Triage Protocol for Critical Care During an Influenza Pandemic" that was published in CMAJ, the journal of the Canadian Medical Association in 2006.

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Murphy

They are also using common patient assessment tools such as SOFA scores and other critical care clinical tools to aid in a focus on using clinical criteria for allocation decisions.

In addition, Murphy said that as they prepare for the worst of the pandemic, Catholic health systems are following common ethical standards. In practice, that includes striving for regional collaboration among hospitals and care providers, especially with regard to treatment protocols and patient transfers, and issuing statements that make clear that patients will be treated with dignity and respect regardless of race, ethnicity, national origin, age, sexual orientation, gender identity, and other demographic factors.

Decision teams counter bias
Also, he said systems are setting up decision teams so that allocation decisions do not rest on the shoulders of an individual clinician. This aids in addressing moral distress and offering less bias within decision making. Also, in order to address conflicts of interest, "We're separating those teams that are attending to the needs of patients and those teams that are responsible for the allocation decisions and that separation demonstrates a level of objectivity with respect to those decisions," said Murphy, who is based in Englewood, Colorado, and whose system operates in 21 states.

Meanwhile, Catholic health systems are also seeing common ethical concerns raised, Murphy said. Among them are whether to take a "blanket" or universal approach when it comes to do-not-resuscitate orders for dying patients or an individualized approach in which each case and DNR is evaluated separately. So far, he said, systems seem to be opting for the latter approach.

Should challenges to care or resource allocation decisions need to be made, Murphy said there is a shared belief among Catholic health care ethicists that there should be review and appeal processes. Those reviews can happen in several ways, he said, such as reevaluations of whether the criteria being used in the decision-making process is fair, and reevaluations of patients' conditions every 48 hours to see if treatments should be changed.

Setting policies for rural/suburban/urban division
Leslie Kuhnel, division vice president, theology and ethics for CHI Health-Midwest and CHI-Fargo, said her division is still at the discussion stage on its triage protocols for the pandemic, which at the time of the webinar had not yet spread across middle America as it had in other parts of the country.

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Kuhnel

Because her Omaha, Nebraska, and Fargo, North Dakota-based divisions have rural, suburban and urban facilities, it is being mindful that different protocols might be needed among them. In urban areas, for example, collaboration among hospitals is a major goal but in rural areas some facilities might stand alone. A big issue for those rural care centers and critical access hospitals, she said, will be how to relieve doctors and nurses on the front lines when there are few backup clinicians to step in and how to address the changes in service response.

"Under pandemic surge circumstances, there will be patients who will remain in the rural communities for palliative and comfort care, rather than be transferred to higher levels of care as they would under non-pandemic circumstances," she said. A key will be to support staff in developing the skills and emotional stamina they may need to provide care for patients who are their friends and family members and who may not survive as a result of resource scarcity.

Kuhnel said one piece she expects to see in the strategy her divisions are formulating is to communicate to the staff and public as early as possible that the system will confront difficult treatment choices, how those choices will be made and how they will affect patients' care and the emotional well-being of health care providers.

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