Why medical experts worry about President Trump touting chloroquine

https://www.politifact.com/article/2020/apr/07/why-medical-experts-worry-about-president-trump-to/?fbclid=IwAR2mxG7HzUAZgmfrwsC9cZtNL2-q8_xQSj6jbdjF45Aod7x8848A3voRYVw

Trump touts hydroxychloroquine as a cure for Covid-19. Don't ...

IF YOUR TIME IS SHORT

• Already, an Arizona man died and his wife was hospitalized after self-administering a variant of chloroquine, prompting the Centers for Disease Control and Prevention to send out a warning.

The American Medical Association says it “strongly opposes” prophylactically prescribing chloroquine as well as pharmacies and hospitals “purchasing excessive amounts” of the medication.

• Some people have health conditions that mean they shouldn’t take chloroquine because of potential side effects. 

• Putting too much focus on one specific treatment could make Americans lax about following social distancing guidelines.

In more than half a dozen public events since March 19, President Donald Trump has touted a possible treatment for coronavirus infection — using the malaria drug chloroquine or a related drug hydroxychloroquine, sometimes in combination with the antibiotic azithromycin.

“I hope they use the hydroxychloroquine, and they can also do it with Z-Pak (azithromycin), subject to your doctor’s approval and all of that,” Trump said at an April 4 briefing. “But I hope they use it, because I’ll tell you what: What do you have to lose?”

Trump reiterated praise for chloroquine in his April 5 briefing: “A lot of people are saying that … if you’re a doctor, a nurse, a first responder, a medical person going into hospitals, they say taking it before the fact is good.”

When a reporter asked Trump for “the conclusive medical evidence” to support his optimism, Trump dismissed the question as “fake news.”

Trump isn’t wrong that this drug combination might prove helpful, at least based on preliminary evidence. The treatment is currently being studied in clinical trials, according to the Centers for Disease Control and Prevention.

But randomized tests — the gold standard of medical evidence — have not been completed, and the lack of rigorous testing as a treatment against coronavirus has led many medical experts to be more cautious than the president. The drug has significant side effects, including damage to the heart and nervous system and suicidal thoughts. And a run on chloroquine could harm patients with lupus and other diseases that the drug is already used for.

Some medical experts are concerned that the president’s words from a White House lectern may be skewing Americans’ perceptions of the best way to fight coronavirus.

Not long after Trump began touting chloroquine, an Arizona man died and his wife was hospitalized after they ingested a fish-tank solvent that includes chloroquine phosphate. The woman told NBC News that they thought the compound was the same as the one Trump cited. Fish-tank cleaners are not the same as the drugs used for malaria, nor are they suitable for human consumption.

A few days later, the CDC released a warning, not just against using the fish-tank cleaner but also the malaria drug itself without a doctor’s orders.

In a statement to PolitiFact, the American Medical Association seconded such concerns, saying that no medication has yet been approved by the Food and Drug Administration for patients with coronavirus, also known as COVID-19. The association said it “strongly opposes” prescribing chloroquine as a preventive measure and also opposes pharmacies and hospitals “purchasing excessive amounts” of the medication.

On several occasions, Trump has reminded viewers of his briefings to consult with doctors about treatments. But at other times, he has trumpeted his own confidence in chloroquine as a treatment.

“I’ve seen things that I sort of like,” he has said. “So what do I know? I’m not a doctor. I’m not a doctor. But I have common sense.”

Experts said Trump’s high-profile endorsement risked overshadowing the views of medical experts.

“The evidence just isn’t there yet to prove that these drugs work, and while the risks from inappropriately prescribing them are rare, they can be serious,” said Joel F. Farley, associate head of the department of pharmaceutical care and health systems at the University of Minnesota College of Pharmacy.

Farley said he even worries about patients going through proper channels.

“Even if prescribed by a physician, I am not convinced that patients are being adequately screened or monitored for some of the more serious side effects, like cardiotoxicity,” he said. “I have heard anecdotal reports of physicians prescribing these medications for friends and family members, which doesn’t always come with an appropriate physical or health screening.”

Another worry among medical specialists is the possible stockpiling of chloroquine. This could harm patients with lupus or rheumatoid arthritis, who depend on the drug to treat their own conditions. “Being just stewards of limited resources is essential,” the American Medical Association said in its statement.

Finally, focusing on one potential treatment could overshadow the nitty-gritty things Americans need to do on a daily basis to stay safe.

“My biggest concern is that people will believe there’s some magic cure and not follow social distancing and other normal precautions in the belief that there’s a drug to ‘fix this,’” said Ally Dering-Anderson, a clinical associate professor at the University of Nebraska College of Pharmacy.

 

 

 

 

As coronavirus spreads, so do reports of companies mistreating workers

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Workers complain of mistreatment as they try to cope with the ...

From nurses to retail salespeople, workers are walking off the job and facing retribution for speaking out.

She could wear her protective mask while seeing her patients. Many were, after all, elderly, with respiratory problems, susceptible to getting severely sick from the novel coronavirus. And so Laura Moreno, a nurse in Oklahoma City, wanted to protect them — as well as herself and her 12-year-old daughter, who has asthma and a thyroid condition.

She could not, however, wear her mask in the hallways, or the cafeteria or any of the hospital’s common areas, because her supervisors told her it would scare patients. “I was told if I wanted to wear a mask, I would not be working there,” she said. “So I said I’m not willing to put my life at risk, and my contract was terminated.”

Since the viral pandemic started ravaging the country in recent weeks, workers, unions and attorneys are seeing a dramatic rise in cases they say illustrate a wave of bad employer behavior, forcing workers into conditions they fear are unsafe, withholding protective equipment, and retaliating against those who speak up or walk out.

Moreno’s case was one of many that her attorney, Rachel Bussett, and her colleagues at the National Employment Lawyers Association have been inundated with as workers grow increasingly fearful of retribution from, as Bussett said, “employers who value the economy over people.”

A handful of workers at a McDonald’s outside San Francisco walked off the job to protest the lack of safety measures. So did about 50 workers at a Perdue chicken plant in Georgia, as well as workers at Instacart and Amazon, while the companies said they were taking steps to ensure their employees’ safety and well-being. (Amazon’s chief executive, Jeff Bezos, owns The Washington Post.)

Meanwhile, employees at several major retailers have circulated petitions urging the companies to close their stores and protect workers. And some workers have said they were fired outright for speaking their minds and pushing companies to look after them.

The complaints come as the virus’s toll mounts and health officials warned that extreme measures, such as lockdowns, would continue. On Sunday, health officials said social distancing guidelines would remain in place through April, and President Trump said the nation “will be well on its way to recovery” by June 1, not Easter, as he had said previously.

“This is a situation we’ve never had to deal with before,” said Heidi Burakiewicz, a D.C. attorney and a member of the employment lawyers association. “We’re doing everything we can to help these employees — not just about protecting jobs. But people’s lives are at stake, and people should never have to be faced with questions about whether they need to risk exposing themselves and their families or losing their jobs.”

The designations for “essential” businesses can vary by state but generally include supermarkets, pharmacies, hardware stores, auto repair shops and the defense industry.

Workers at a number of large retailers — such as craft stores, video-gaming shops and office supply chains — have questioned their employers’ decision to stay open despite stay-at-home orders across the country.

“It is unnecessary and unsafe to be open during a PANDEMIC,” Staples employees wrote in a petition. “We are not an essential store and corporate is fighting and begging to stay open, claiming Staples is essential and putting employees and their families at risk. Staples should temporarily close stores and pay their employees for the time being.”

Staples spokeswoman Meghan McCarrick said the company is “an essential provider of business and educational materials and products, household goods and cleaning supplies.” She said that an intensive care unit at a Baltimore hospital recently purchased ink and toner for a printer at Staples, while a hospital in Virginia bought webcams to set up remote telemedicine offices.

Last week, the Federal Bureau of Prisons turned away employees who said they had taken pain medications such as Advil, Tylenol or Motrin within four hours of reporting for work. That meant guards with balky hips or bad backs were forced to take sick leave, even if they had no fever or other symptoms of the virus, union officials said.

“You have unqualified people asking questions that are medically related,” said Sandy Parr, a union official. “They’re sending people home just because they took Motrin, which is decreasing the staff available to work — and that increases the danger.”

After guard workers complained and The Post inquired about the measure, the Bureau of Prisons said last week that it was discontinuing the practice.

Across the country, some health-care facilities are hoarding masks, goggles and gloves — forcing some workers to bring in their own, use the same equipment again and again, or go without.

“It’s in cabinets locked away, collecting dust while people need it now,” said Rebecca Reindel, the safety and health director of the AFL-CIO, who said the union has raised the issue “in every avenue we can.”

Moreno’s concern wasn’t the availability of the equipment — only her ability to use it. A contract nurse at Select Specialty Hospital, she felt she needed to wear a mask at all times, especially given that the patients she was treating were particularly susceptible to the worst effects of the virus. The hospital’s website says it provides “specialized care for patients with acute or chronic respiratory disorders. Our primary focus is to wean medically complex patients from mechanical ventilation and restore independent breathing.”

The state is under a “safer at home” order, which directs people over 65 and those with underlying medical conditions to stay home and limits gatherings to no more than 10 people, among other restrictions.

On Wednesday, however, Moreno was told her contract was being terminated because the hospital did not want her wearing a mask in common areas of the hospital, she said. But by the next afternoon, after The Post had contacted the hospital, she said hospital officials “had completely changed their tune” and decided to allow nurses to wear masks throughout the hospital and not just in patient rooms.

On Friday, she went back to work. In an email, a hospital spokeswoman said, “The nurse is still engaged with us and her upcoming scheduled shifts have been confirmed.”

The policy change “feels wonderful,” Moreno said, “because I know I will be protected and my friends and co-workers will be protected.”

Kevin Readel, another nurse in Oklahoma City, said he was fired for a similar reason — but in his case it was for insisting on wearing a mask while with patients.

He said he was told “point blank that I can’t wear a mask” because it “could cause fear and anxiety amongst the other nurses and the patients.”

He filed a suit against the Oklahoma Heart Hospital South for wrongful termination, claiming that “the hospital was more concerned about the perception of due diligence than actually performing due diligence.”

A spokesman for the hospital said he could not comment on pending litigation but said the hospital’s “entire focus is on making sure we protect the safety of our patients and health care professionals in preparation for an expected surge in COVID-19 patients. As part of our preparation, we are strictly complying with the guidelines on the personal protective equipment set forth by the World Health Organization and the Centers for Disease Control.”

Lauri Mazurkiewicz, a nurse who lives outside Chicago, grew nervous when she was repeatedly exposed to patients diagnosed with covid-19, the disease caused by the coronavirus. “This is so contagious. It’s spreading so fast. I need an N95 mask,” she said, referring to a specialty mask worn by many health-care workers.

She happened to have an N95 and began wearing it during her rounds at Northwestern Memorial Hospital, she said, but was told the hospital was prohibiting the use of N95 masks and using regular surgical masks instead.

She sent an email warning her colleagues that those masks were less effective. She was fired shortly afterward — the result, she alleged in a lawsuit against the hospital, of her attempts to “disclose public corruption and/or wrongdoing.”

A spokesman for the hospital declined to comment on the specifics of her complaint in the lawsuit, but said it is “committed to the safety of our employees who are on the frontlines of this global health care crisis.” He added that it follows “CDC guidance regarding the use of personal protective equipment for our health care providers.”

In a statement Monday, the American College of Emergency Physicians said it was “shocked and outraged by the growing reports of employers retaliating against frontline health workers who are trying to ensure they and their colleagues are protected while caring for patients in this pandemic. … Not only does this type of retribution remove healthy physicians from the frontlines, it encourages others to work in unsafe conditions, increasing their likelihood of getting sick.”

In the retail sector, employees at Michaels crafts stores said they were told the company’s shops would remain open because they serve “people who are bored at home” and double as UPS drop-off sites, according to an employee at a Phoenix store who is awaiting results for a coronavirus test.

The worker, who spoke on the condition of anonymity, has been home with a low-grade fever, cough and chest pain but says store managers have not been supportive.

“Every time I call in sick, there’s just an incredibly disappointed sound on the other end,” she said. “This is not an essential business — nobody in the history of mankind has ever dropped dead from boredom. They need to close their doors.”

Anjanette Coplin, a spokeswoman for Michaels, said its stores provide necessary products and services for parents and small-business owners. “We want to support and remain a lifeline for the teachers, parents and small businesses who rely on Michaels and our products to enable creative learning,” she said. Michaels is offering curbside pickup and has temporarily closed locations in certain states, including California, New York and Pennsylvania.

JoAnn craft stores, GameStop, Office Depot and Guitar Center have also come under fire for keeping stores open. A spokesman for Office Depot said the company is not requiring retail employees to come to work if they are not comfortable. Guitar Center, which furloughed 9,000 workers on Monday, said it is following state and local rules regarding store closures. JoAnn and GameStop did not respond to requests for comment.

In Plain City, Ohio, workers at a TenPoint Complete call center who administer automotive surveys by phone have been instructed to report to work even after the state issued a stay-at-home order, according to one employee who spoke on the condition of anonymity because she feared reprisal.

Her work, she said, consists of calling customers to ask about their experience at the body shop.

“This is not an essential job,” she said.

TenPoint Complete did not respond to a request for comment.

Even as other department stores, such as Nordstrom and Kohl’s, have temporarily shut their doors and kept paying their workers, Dillard’s has kept locations operating where government authorities allow it, making it one of the few remaining mall-based stores to remain open despite the pandemic, employees say.

That has sparked concern from employees, social media outrage by community members and a petition drive urging it to close that alleges, “Unlike other retailers who care about the safety and well-being of their employees and the guests they serve everyday, Dillard’s is choosing to run a blind eye in order to keep money funneling into their greedy pockets.”

Some employees who work for the company expressed fear about the stores remaining open, saying that they have been offered no assurances of pay if their stores close and that they had to pay more for their health insurance as their hours were cut.

One full-time Dillard’s employee based in Colorado, who requested anonymity to preserve her job, said that before her store closed in the middle of last week, she tried to use the vacation time she has accumulated to take off two weeks, but was told she couldn’t because the store was short-staffed. Her store has since closed because of local restrictions for nonessential businesses, and she said they were not being paid during the closure, other than for earned vacation leave. They have received little clear information about whether they would get their jobs back when the stores reopened, she said.

An employee in her 60s based in southwest Florida said she has not yet accumulated any paid time off, so if she were to get sick, she would have no paid leave. “They say you’re more than welcome to stay home, but that’s, of course, without pay,” at least for her.

She said the company has done little to directly encourage social distancing from customers making purchases. “They’re just telling us to relay to customers — politely — to stand back,” she said, but not putting up signage or tape to mark where customers should stand. “They are providing us at each register with a little small bottle of hand sanitizer. Mine has about a quarter of it left.”

In an email, Julie Johnson Guymon, a company spokeswoman, said “direct communication” with associates began Monday. In an earlier statement, she said Dillard’s is “fully cooperating with any government directives in our markets and promptly closing under those guidelines. Importantly, we are strictly following CDC guidelines for the safety of our associates and the customers who choose to visit us where open. No associate who is uncomfortable working is required to do so. We believe continuing to operate using current safety standards is the best thing we can do long term for our associates and for the economy.”

 

 

 

First Sign of Civilization in a Culture

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Years ago, anthropologist Margaret Mead was asked by a student what she considered to be the first sign of civilization in a culture. The student expected Mead to talk about fishhooks or clay pots or grinding stones.

But no. Mead said that the first sign of civilization in an ancient culture was a femur (thighbone) that had been broken and then healed. Mead explained that in the animal kingdom, if you break your leg, you die. You cannot run from danger, get to the river for a drink or hunt for food. You are meat for prowling beasts. No animal survives a broken leg long enough for the bone to heal.

A broken femur that has healed is evidence that someone has taken time to stay with the one who fell, has bound up the wound, has carried the person to safety and has tended the person through recovery. Helping someone else through difficulty is where civilization starts, Mead said.”

We are at our best when we serve others. Be civilized.

– Ira Byock.

Hospitals consider universal do-not-resuscitate orders for coronavirus patients

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Worry that ‘all hands’ responses may expose doctors and nurses to infection prompts debate about prioritizing the survival of the many over the one.

Hospitals on the front lines of the pandemic are engaged in a heated private debate over a calculation few have encountered in their lifetimes — how to weigh the “save at all costs” approach to resuscitating a dying patient against the real danger of exposing doctors and nurses to the contagion of coronavirus.

The conversations are driven by the realization that the risk to staff amid dwindling stores of protective equipment — such as masks, gowns and gloves — may be too great to justify the conventional response when a patient “codes,” and their heart or breathing stops.

Northwestern Memorial Hospital in Chicago has been discussing a do-not-resuscitate policy for infected patients, regardless of the wishes of the patient or their family members — a wrenching decision to prioritize the lives of the many over the one.

Richard Wunderink, one of Northwestern’s intensive-care medical directors, said hospital administrators would have to ask Illinois Gov. J.B. Pritzker for help in clarifying state law and whether it permits the policy shift.

“It’s a major concern for everyone,” he said. “This is something about which we have had lots of communication with families, and I think they are very aware of the grave circumstances.”

Officials at George Washington University Hospital in the District say they have had similar conversations, but for now will continue to resuscitate covid-19 patients using modified procedures, such as putting plastic sheeting over the patient to create a barrier. The University of Washington Medical Center in Seattle, one of the country’s major hot spots for infections, is dealing with the problem by severely limiting the number of responders to a contagious patient in cardiac or respiratory arrest.

Several large hospital systems — Atrium Health in the Carolinas, Geisinger in Pennsylvania and regional Kaiser Permanente networks — are looking at guidelines that would allow doctors to override the wishes of the coronavirus patient or family members on a case-by-case basis due to the risk to doctors and nurses, or a shortage of protective equipment, say ethicists and doctors involved in those conversations. But they would stop short of imposing a do-not-resuscitate order on every coronavirus patient. The companies declined to comment.

Lewis Kaplan, president of the Society of Critical Care Medicine and a University of Pennsylvania surgeon, described how colleagues at different institutions are sharing draft policies to address their changed reality.

“We are now on crisis footing,” he said. “What you take as first-come, first-served, no-holds-barred, everything-that-is-available-should-be-applied medicine is not where we are. We are now facing some difficult choices in how we apply medical resources — including staff.”

The new protocols are part of a larger rationing of lifesaving procedures and equipment — including ventilators — that is quickly becoming a reality here as in other parts of the world battling the virus. The concerns are not just about health-care workers getting sick but also about them potentially carrying the virus to other patients in the hospital.

R. Alta Charo, a University of Wisconsin-Madison bioethicist, said that while the idea of withholding treatments may be unsettling, especially in a country as wealthy as ours, it is pragmatic. “It doesn’t help anybody if our doctors and nurses are felled by this virus and not able to care for us,” she said. “The code process is one that puts them at an enhanced risk.”

Wunderink said all of the most critically ill patients in the 12 days since they had their first coronavirus case have experienced steady declines rather than a sudden crash. That allowed medical staff to talk with families about the risk to workers and how having to put on protective gear delays a response and decreases the chance of saving someone’s life.

A consequence of those conversations, he said, is that many family members are making the difficult choice to sign do-not-resuscitate orders.

Code blue

Health-care providers are bound by oath — and in some states, by law — to do everything they can within the bounds of modern technology to save a patient’s life, absent an order, such as a DNR, to do otherwise. But as cases mount amid a national shortage of personal protective equipment, or PPE, hospitals are beginning to implement emergency measures that will either minimize, modify or completely stop the use of certain procedures on patients with covid-19.

Some of the most anxiety-provoking minutes in a health-care worker’s day involve participating in procedures that send virus-laced droplets from a patient’s airways all over the room.

These include endoscopies, bronchoscopies and other procedures in which tubes or cameras are sent down the throat and are routine in ICUs to look for bleeds or examine the inside of the lungs.

Changing or eliminating those protocols is likely to decrease some patients’ chances for survival. But hospital administrators and doctors say the measures are necessary to save the most lives.

The most extreme of these situations is when a patient, in hospital lingo, “codes.”

When a code blue alarm is activated, it signals that a patient has gone into cardiopulmonary arrest and typically all available personnel — usually somewhere around eight but sometimes as many as 30 people — rush into the room to begin live-saving procedures without which the person would almost certainly perish.

“It’s extremely dangerous in terms of infection risk because it involves multiple bodily fluids,” explained one ICU physician in the Midwest, who did not want her name used because she was not authorized to speak by her hospital.

Fred Wyese, an ICU nurse in Muskegon, Mich., describes it like a storm:

A team of nurses and doctors, trading off every two minutes, begin the chest compressions that are part of cardiopulmonary resuscitation or CPR. Someone punctures the neck and arms to access blood vessels to put in new intravenous lines. Someone else grabs a “crash cart” stocked with a variety of lifesaving medications and equipment ranging from epinephrine injectors to a defibrillator to restart the heart.

As soon as possible, a breathing tube will be placed down the throat and the person will be hooked up to a mechanical ventilator. Even in the best of times, a patient who is coding presents an ethical maze; there’s often no clear cut answer for when there’s still hope and when it’s too late.

In the process, heaps of protective equipment is used — often many dozens of gloves, gowns, masks, and more.

Bruno Petinaux, chief medical officer at George Washington University Hospital, said the hospital has had a lot of discussion about how — and whether — to resuscitate covid-19 patients who are coding.

“From a safety perspective you can make the argument that the safest thing is to do nothing,” he said. “I don’t believe that is necessarily the right approach. So we have decided not to go in that direction. What we are doing is what can be done safely.”

However, he said, the decision comes down to a hospital’s resources and “every hospital has to assess and evaluate for themselves.” It’s still early in the outbreak in the Washington area, and GW still has sufficient equipment and manpower. Petinaux said he cannot rule out a change in protocol if things get worse.

GW’s procedure for responding to coronavirus patients who are coding includes using a machine called a Lucas device, which looks like a bumper, to deliver chest compressions. But the hospital has only two. If the Lucas devices are not readily accessible, doctors and nurses have been told to drape plastic sheeting — the 7-mil kind available at Home Depot or Lowe’s — over the patient’s body to minimize the spread of droplets and then proceed with chest compressions. Because the patient would presumably be on a ventilator, there is no risk of suffocation.

In Washington state which had the nation’s first covid-19 cases, UW Medicine’s chief medical officer, Tim Dellit, said the decision to send in fewer doctors and nurses to help a coding patient is about “minimizing use of PPE as we go into the surge.” He said the hospital is monitoring health-care workers’ health closely. So far, the percentage of infections among those tested is less than in the general population, which, he hopes, means their precautions are working.

‘It is a nightmare’

Bioethicist Scott Halpern at the University of Pennsylvania is the author of one widely circulated model guideline being considered by many hospitals. In an interview, he said a blanket stop to resuscitations for infected patients is too “draconian” and may end up sacrificing a young person who is otherwise in good health. However, health-care workers and limited protective equipment cannot be ignored.

“If we risk their well-being in service of one patient, we detract from the care of future patients, which is unfair,” he said.

Halpern’s document calls for two physicians, the one directly taking care of a patient and one who is not, to sign off on do-not-resuscitate orders. They must document the reason for the decision, and the family must be informed but does not have to agree.

Wyese, the Michigan ICU nurse, said his own hospital has been thinking about these issues for years but still is unprepared.

“They made us do all kinds of mandatory education and fittings and made it sound like they are prepared,” he said. “But when it hits the fan, they don’t have the supplies so the plans they had in place aren’t working.”

Over the weekend, Wyese said, a suspected covid-19 patient was rushed in and put into a negative pressure room to prevent the virus spread. In normal times, a nurse in full hazmat-type gear would sit with the patient to care for him, but there was little equipment to spare. So Wyese had to monitor him from the outside. Before he walked inside, he said, he would have to put on a face shield, N95 mask, and other equipment and slather antibacterial foam on his bald head as the hospital did not have any more head coverings. Only one powered air-purifying respirator or PAPR was available for the room and others nearby that could be used when performing an invasive procedure — but it was 150 feet away.

While he said his hospital’s policy still called for a full response to patients whose heart or breathing stopped, he worried any efforts would be challenging, if not futile.

“By the time you get all gowned up and double-gloved the patient is going to be dead,” he said. “We are going to be coding dead people. It is a nightmare.”

 

 

 

 

COVID-19 threatens to overwhelm hospitals. They’re weighing how best to ration care.

https://www.healthcaredive.com/news/covid-19-threatens-to-overwhelm-hospitals-theyre-weighing-how-best-to-rat/574489/

The coronavirus outbreak is forcing the U.S., a nation largely unaccustomed to scarcity, to have tough conversations about how to allocate limited medical resources as hospitals warn its only a matter of time before they’re inundated with COVID-19 patients.

Across the country, hospital officials are discussing ethical dilemmas and attempting to draft policies about rationing care when patients needing ventilators and other resources dwarf the supply, several hospital ethicists told Healthcare Dive. In addition to issues of mortality, questions also are being raised about whether medical workers can opt out of treating patients with COVID-19, particularly if they don’t have the right personal protective equipment.

“They are having these conversations at the policy level,” Kelly Dineen, director of the health law program at Creighton University and a member of COVID-19 Ethics Advisory Committee at the University of Nebraska Medical Center​, told Healthcare Dive.

Ethical dilemmas are usually tackled by a hospital’s ethics committee, which, in an ideal scenario, encompasses a variety of workers from across the hospital, including clinicians, ethicists and social workers. 

No federal mandate exists requiring hospitals to have such committees. However, many do to meet accreditation standards that require facilities to have some sort of mechanism for ethics conflicts and decision making. Many choose to meet that standard by having an ethics committee, though not all do, according to one expert.

Hospitals are at risk of not having the capacity to care for a surge of COVID-19 patients if an outbreak similar to Wuhan or Italy occurs here. New York Gov. Andrew Cuomo has pleaded with the federal government to allow the Army Corps of Engineers to build back-up facilities as the COVID-19 rapidly spreads through areas of the hard-hit state. Similarly, California Gov. Gavin Newsom has requested a Navy hospital ship and two mobile hospitals to address a surge in patients.

Federal officials are urging Americans to do their part by retreating to their homes to socially distance themselves from others in an effort to hamper the disease’s reach. CMS also last week urged hospitals to put off non-essential elective surgeries to prepare for an onslaught of cases. Years of culling hospital beds in a shift to outpatient care has the nation’s facilities short of meeting expected demand under some prediction models.

The concern about scarce resources is not unfounded. Italy’s healthcare system has been pushed to the brink and many see parallels in terms of the trajectory of the spread. Overwhelmed with sick patients, Italy’s society of anesthesiology and intensive care published recommendations on how to prioritize patients and not just serve the first in the door.

China, the first country to report cases of the disease, feverishly began building hospitals to meet demand.

And the U.S. has far fewer hospital beds per 1,000 residents than China or Italy.

It’s important facilities across the country start having conversations about allocating resources now before clinicians are pushed to their limits, ethicists said.

“Any time you have that kind of pressure and load … it’s going to be hard to also be thinking about all of the ethical implications and what that means in a way that might otherwise not be so hard,” Dineen said.

The struggle will be effectively communicating those policies throughout a system or hospital, Erica Salter, associate professor and program director of the doctorate program for healthcare ethics at St. Louis University, told Healthcare Dive.

“It’s wise to anticipate failures of communication and protect against those,” Salter said.

Ultimately, those policies will vary by institution, though ethicists said it’s important to be proactive rather than reactive. And hospitals should also be prepared to be held to account for decisions that are made, Dineen said.

Patients and their loved ones will want to know there was a process and that it was fair, not arbitrary. 

“There’s no reason we can’t be prepared with a process, even if we don’t necessarily have a better answer,” she said.

Still, despite the most well-intentioned plans it will always be the doctor’s call, Arthur Caplan, head of the division of medical ethics at NYU School of Medicine, told Healthcare Dive.  

“You’re going to see variation in what is decided floor to floor, doctor to doctor, hospital to hospital,” Caplan said.

Still, some hospitals are hesitant to issue overly broad guidance because of the liabilities that might come later. However, depending on the state, emergency orders issued during a pandemic may help shield providers or systems from liability as standard of care decisions were made during a unique situation.

And, though Americans may struggle to talk about the end of life and mortality, the medical profession is used to tough conversations about scarce resources.

For example, when dialysis machines were first developed, the technology was not widely available for everyone with end-stage kidney failure. A decision had to be made about which patients were granted access to the lifesaving treatment and which ones were not. It’s a conversation that continues today for those needing transplants.

“The principles guiding these decisions are not new,” Salter said. “We’ve been dealing with issues of scarce resources for many decades.”

 

 

 

 

4 ETHICAL DILEMMAS FOR HEALTHCARE ORGANIZATIONS DURING THE COVID-19 PANDEMIC

https://www.healthleadersmedia.com/clinical-care/4-ethical-dilemmas-healthcare-organizations-during-covid-19-pandemic

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There has already been rationing of testing in the United States and rationing of critical care resources is likely if severely ill COVID-19 patients surge significantly.


KEY TAKEAWAYS

Rationing of care for novel coronavirus patients has been reported in China and Italy.

Medical utility based on scientific patient profiles should guide decisions to ration critical care resources such as ventilators, medical ethicist James Tabery says.

In a pandemic, public health considerations should drive decisions on prioritizing who is tested for disease, he says.

The novel coronavirus (COVID-19) pandemic is raising thorny medical ethics dilemmas.

In China and Italy, there have been reports of care rationing as the supply of key resources such as ventilators has been outstripped by the number of hospitalized COVID-19 patients. China, the epicenter of the pandemic, has the highest reported cases of COVID-19 at more than 80,800 as of March 17, according to worldometer. Italy has the second-highest number of COVID-19 cases at nearly 28,000 cases.

The severest form of COVID-19 includes pneumonia, which can require admission to an ICU and mechanical ventilation. “Those are not just things, there are expertly trained healthcare workers who man those domains. There just isn’t enough of these resources than what we anticipate needing,” says James Tabery, PhD, associate professor in the University of Utah Department of Philosophy and the University of Utah School of Medicine’s Program in Medical Ethics and Humanities.

He says the COVID-19 outbreak poses four primary ethical challenges in the healthcare sector.

1. TREATMENT

In the United States, caring for the anticipated surge of seriously ill COVID-19 patients is likely to involve heart-wrenching decisions for healthcare professionals, Tabery says. “The question is how do you ration these resources fairly? With treatment—we are talking about ICUs, ventilators, and the staff—the purpose is you are trying to save the severely sick. You are trying to save as many of the severely sick as you can.”

The first step in managing critical care resources is screening out patients who are unlikely to need critical care and urging them to self-quarantine at home, he says.

“But eventually, you bump up to a place where you not only have screened out all of the folks who are at low risk of serious illness, but you have millions of people across the country who fall into high-risk groups. If they get infected, many are going to need access to ventilators, and the way you do that ethically is you screen patients based on medical utility,” Tabery says.

Medical utility is based on scientific assessments, he says. “You basically look at the cases and try to evaluate as quickly and efficiently as possible the likelihood that you can improve a patient’s condition quickly.”

Rationing of critical care resources would be jarring for U.S. clinical staff.

Under most standard scenarios, a patient who is admitted to an ICU and placed on mechanical ventilation stays on the machine as long as the doctors think the patient is going to get better, Tabery says.

However, the COVID-19 pandemic could drive U.S. caregivers into an agonizing emergency scenario.

“When there are 10 people in the emergency room waiting to get on a ventilator, it is entirely feasible that you would be removing people from ventilators knowing that they are going to die. But you remove people from ventilators when your evaluation of the medical situation suggests that patients are not improving. If a patient is not improving, and it doesn’t look like using this scarce resource is a wise investment, then you try it out on another patient who might have better luck,” he says.

2. TESTING

There has been rationing of COVID-19 testing in the United States since the first novel coronavirus patient was diagnosed in January.

While there are clinical benefits to COVID-19 testing such as determining what actions should be taken for low- and high-risk patients, the primary purpose of testing during a pandemic is advancing public health, Tabery says.

“The primary purpose of the test is pure public health epidemiology. It’s about keeping track of who has COVID-19 in service of trying to limit the spread of the disease to other people. When that is the purpose, the prioritization isn’t so much about who is at greatest risk. It’s about who is more likely to interact with lots of people, or who is more likely to have interacted with more people.”

A classic example of rationing COVID-19 testing based on public health considerations is the first reported infection of an NBA player, he says.

“For the Utah Jazz player who had symptoms, it made sense to test him very quickly because it was clear that he had interacted with a lot of people. Once he tested positive, the testing of the other players was not because public health officials thought the players were more valuable than the average person on the street. It was because the players had come into contact with more people than the average person on the street.”

3. HEALTHCARE WORKERS

The COVID-19 pandemic involves competing obligations for healthcare workers, Tabery says. “On the one hand, they have a set of obligations that inclines them to go to work when they get the call. On the other hand, healthcare workers have their own interests—they don’t want to get sick, which can incline them not to work,” he says.

“The punchline is there is an ethical consensus that healthcare workers have a prima facie duty to work because of everything that has been invested in them, because of their unique position where not just anybody can replace them, because society looks to them to serve this function, and because they went into this profession and are expected to go into work,” he says.

However, the obligation of healthcare workers to show up for their jobs is not absolute, Tabery says. “If hospitals don’t have personal protective equipment, they are in no position to tell their staff to show up and work. If a hospital cannot provide even a basic level of safety for their employees to do their job, then they are turning their hospital not into a place to treat patients—they are turning it into a hub to exacerbate the problem.”

4. VACCINE

When a vaccine becomes available, policymakers, public health officials, and healthcare providers will face rationing decisions until there is sufficient supply to treat the entire U.S. population, Tabery says.

“When the vaccine comes out, the first group you are going to want to prioritize are healthcare workers, who are at risk of getting infected by doing their jobs and saving lives. You would also want to prioritize people who serve essential functions to keep society going—the people who keep the water running, the lights on, police, and firefighters. Then you want to start looking at the high-risk groups,” he says.