Article

Sulmasy says it should be 'ethics as usual,' even in extraordinary times

April – May, 2020

By JULIE MINDA
April 14, 2020

Physicians are delivering care in extraordinary circumstances, and many are facing — or anticipate they will face — extremely difficult ethical decisions with regard to patient care amid scarce resources.

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Sulmasy

But clinicians are not starting from scratch in navigating these decisions because longstanding ethical principles of Catholic health care provide a reliable framework for such decisions, Dr. Daniel P. Sulmasy said during an April 9 webinar titled "Bioethics in the Time of Coronavirus."

"The circumstances we're facing do not dictate our ethical principles. When circumstances are extraordinary, we need our ethical principles even more than we did before," said Sulmasy.

He was the presenter at the third of five webinars being jointly sponsored by the Supportive Care Coalition and CHA to provide palliative care specialists and other health care practitioners with information during the COVID-19 pandemic. The webinars are broadcast on Thursdays at 10 a.m. eastern time. Past webinars are available for replay, and registration is available for future webinars at supportivecarecoalition.org/. Click on the COVID-19 resource link at the top of the page.

Sulmasy discussed the basic science and epidemiology behind the coronavirus, clinical issues having to do with COVID-19 infection, applicable ethical principles and the importance of virtues including trust, compassion, humility and integrity.

He delved into ethical perspectives around resource allocation and do-not-resuscitate protocols. Sulmasy is the André Hellegers Professor of Biomedical Ethics in the Departments of Medicine and Philosophy at Georgetown University. He also is acting director of the Kennedy Institute of Ethics and a member of the Pellegrino Center for Clinical Bioethics at Georgetown University.

Foundational truths
Sulmasy said that in ordinary circumstances, the most salient principles of medical ethics have to do with the duties to help patients, not to harm them, not to provide futile care and to respect patients as moral agents. While these principles continue to hold true, in extraordinary circumstances — when there is overwhelming need and scarce resources — other principles come to the fore in the decisions of providers, he said. These include the respect for the common good, questions of equity and human dignity and questions of fairness in the allocation of benefits and the imposing of burdens.

"All of these principles are at play in our response to the COVID-19 pandemic," he said. He said such principles are providers' compass and guide.

Sulmasy expanded on the virtues that he said are particularly important to health care providers. They include practical wisdom, defined as the knowledge and application of science; courage; temperance manifest as a steady presence; and justice, or the drive to treat patients equitably while also being good stewards of resources.

He said that medical professionals also are called to be competent, altruistic, faithful to patients, compassionate and humble and to have integrity.

Sulmasy described what it takes to maintain one's virtue and to be professional in the current COVID-19 crisis. He said providers should be brave in caring for the sick, but take precautions to protect themselves and others. Even in the midst of much suffering and death, they should also remain compassionate. And they should practice self-care to sustain themselves during the weeks and months when clinicians in the COVID-19 hot zones face unrelenting patient demands and extraordinary stress. This includes getting rest and exercise, connecting with family and friends and nurturing their spirituality.

Scarce resources
Sulmasy explored ethical concepts surrounding difficult resource allocation decisions that could arise in the event of an overwhelming surge of patients with COVID-19, as resources are becoming scarce in a facility.

He said, if critical resources such as medications and ventilators do become scarce, from an ethical perspective, health care facilities must continue to do all they can reasonably do to benefit patients, to increase the facility's supply of resources, and to investigate "almost-as-good" alternatives to scarce medical and personal protective equipment.

Sulmasy said that resource allocation decisions must be made on the basis of individual patient need, prognosis and the likely effectiveness of treatment. "We should not be pitting groups against each other," such as the wealthy, healthy and young versus the poor, disabled and old. Instead, he said, providers should be "equitably applying rules that apply to all persons."

A questioner in the question and answer portion of the webinar asked whether health care providers should try to address racially based health disparities that set the stage for the type of serious preexisting health conditions that increase the risk of poor outcomes for patients with COVID-19 and do so by prioritizing care of those who were historically among the health care poor. Sulmasy said that it's always problematic to try to solve problems of social injustice at the bedside. He said that such inequities should instead be addressed in a structural way by addressing social determinants of health.

Case-by-case
Sulmasy underscored the need to rely on "ethics as usual."

He said there should be no universal do-not-resuscitate orders for patients with COVID-19. The Washington Post reported that some hospitals had considered such bans because attempts to resuscitate a patient can expose health care workers to an increased risk of infection, particularly when personal protective gear is in short supply.

Late last month, Sr. Mary Haddad, RSM, CHA's president and chief executive officer, released a statement calling such universal do-not-resuscitate orders morally inappropriate.

Sulmasy concurred that decisions on whether to attempt resuscitation should be made on a patient-by-patient basis, with the decision makers prioritizing patients' expressed wishes, and weighing patients' prognosis for survival. He noted that do-not-resuscitate orders may be appropriate for an individual if resuscitation is deemed to be futile care and there are two physicians certifying the decision, or the patient or a surrogate has consented, among other parameters.

When it comes to the potential for allocating scarce ventilators, Sulmasy said, it is morally acceptable to use an objective scoring system to determine a patient's prognosis with ventilator care, but there should be no unilateral policies on who gets and who doesn't get ventilator care based on age or disability. The decisions should be made on a patient-by-patient basis, in concert with ethical practice. He noted that it would be morally problematic to begin ventilator treatment and then discontinue it in order to reassign the equipment to a healthier patient, unless the patient with the ventilator, or the person holding the patient's medical proxy, refuses ongoing extraordinary care or if it becomes clear that the patient is "overwhelmingly unlikely to survive, even with treatment."

 

Sulmasy: Advance care planning is key during crisis, as always

Dr. Daniel P. Sulmasy said during the April 9 webinar that advance care planning should be part of the patient care discussion during the COVID-19 pandemic, just as it should be in usual circumstances of caring for patients with a potentially fatal condition.

If clinicians know of patients' wishes, they can avoid administering care that could be futile and that patients do not want.

Sulmasy provided some guidance on having conversations about advance care planning, without being alarmist:

  • Frame the conversation in terms of patient dignity and agency.
  • Explain that advance care planning is done as a usual practice with patients, not just because a particular patient has COVID-19.
  • Convey that most people recover from COVID-19 — advance care planning is to prepare for the worst, while hoping for the best.
  • Describe how other patients have navigated advance care decisions.
  • Ask whether the patient has expressed their wishes for end-of-life care to a loved one and whether they've assigned a durable power of attorney.

Previous coverage:
Palliative care teams' expertise critical in COVID-19 preparations, response
Palliative care practitioners can stretch resources while defending the integrity of their specialty

 

 

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