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

Ariana Eunjung Cha

The Washington Post
Originally posted 25 March 20

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.

The info is here.

Respirators, our rights, right and wrong: Medical ethics in an age of coronavirus

Dan Sulmasy

nydailynews.com

Originally posted 22 March 20

The coronavirus pandemic is upon us. This novel virus has disrupted lives, killed people, and wreaked havoc with our economy. COVID-19 has also raised novel ethical questions and generated ethical duties for the public, health professionals and the government. Just as our health system has been caught off guard, so have our ethics.

The general principles that guide care for individual patients are the duty to help the sick and respect their autonomy. The general principles that guide public health ethics are concern for the common good and justice. In the current crisis, these principles all come into play. We are in this together. Even if the personal risk for an individual is not great, the risk to the common good is immense. But the measures taken to mitigate the effects of the virus must be just and fair.

The duties for the general public are not arbitrary. They might seem mundane, but they are important and ought to be considered truly ethical duties. Obey the rules: We owe this to each other. Wash your hands. Keep six feet away from strangers. Don’t shake hands with, kiss or hug strangers or acquaintances. Disinfect surfaces where the coronavirus might linger. Self-quarantine if you become sick. Call or email your doctor through an encrypted system or telemedicine connection.

Unless you are experiencing life-threatening distress, don’t rush to the emergency room where you could infect people having heart attacks or complications of cancer. Don’t hoard food, disinfectant wipes, or toilet paper. Don’t spread false and alarming rumors on social media.

The info is here.

The effectiveness of moral messages on public health behavioral intentions during the COVID-19 pandemic

J. Everett, C. Colombatta, & others

PsyArXiv PrePrints
Originally posted 20 March 20

Abstrac
With the COVID-19 pandemic threatening millions of lives, changing our behaviors to prevent the spread of the disease is a moral imperative. Here, we investigated the effectiveness of messages inspired by three major moral traditions on public health behavioral intentions. A sample of US participants representative for age, sex and race/ethnicity (N=1032) viewed messages from either a leader or citizen containing deontological, virtue-based, utilitarian, or non-moral justifications for adopting social distancing behaviors during the COVID-19 pandemic. We measured the messages’ effects on participants’ self-reported intentions to wash hands, avoid social gatherings, self-isolate, and share health messages, as well as their beliefs about others’ intentions, impressions of the messenger’s morality and trustworthiness, and beliefs about personal control and responsibility for preventing the spread of disease. Consistent with our pre-registered predictions, deontological messages had modest effects across several measures of behavioral intentions, second-order beliefs, and impressions of the messenger, while virtue-based messages had modest effects on personal responsibility for preventing the spread. These effects were observed for messages from leaders and citizens alike. Our findings are at odds with participants’ own beliefs about moral persuasion: a majority of participants predicted the utilitarian message would be most effective. We caution that these effects are modest in size, likely due to ceiling effects on our measures of behavioral intentions and strong heterogeneity across all dependent measures along several demographic dimensions including age, self-identified gender, self-identified race, political conservatism, and religiosity. Although the utilitarian message was the least effective among those tested, individual differences in one key dimension of utilitarianism—impartial concern for the greater good—were strongly and positively associated with public health intentions and beliefs. Overall, our preliminary results suggest that public health messaging focused on duties and responsibilities toward family, friends and fellow citizens will be most effective in slowing the spread of COVID-19 in the US. Ongoing work is investigating whether deontological persuasion generalizes across different populations, what aspects of deontological messages drive their persuasive effects, and how such messages can be most effectively delivered across global populations.

The research is here.

Changes in risk perception and protective behavior during the first week of the COVID-19 pandemic in the United States

T. Wise, T. Zbozinek, & others

PsyArXiv
Originally posted 19 March 20

Abstract

By mid-March 2020, the COVID-19 pandemic spread to over 100 countries and all 50 states in the US. Government efforts to minimize the spread of disease emphasized behavioral interventions, including raising awareness of the disease and encouraging protective behaviors such as social distancing and hand washing, and seeking medical attention if experiencing symptoms. However, it is unclear to what extent individuals are aware of the risks associated with the disease, how they are altering their behavior, factors which could influence the spread of the virus to vulnerable populations. We characterized risk perception and engagement in preventative measures in 1591 United States based individuals over the first week of the pandemic (March 11th-16th 2020) and examined the extent to which protective behaviors are predicted by individuals’ perception of risk. Over 5 days, subjects demonstrated growing awareness of the risk posed by the virus, and largely reported engaging in protective behaviors with increasing frequency. However, they underestimated their personal risk of infection relative to the average person in the country. We found that engagement in social distancing and hand washing was most strongly predicted by the perceived likelihood of personally being infected, rather than likelihood of transmission or severity of potential transmitted infections. However, substantial variability emerged among individuals, and using data-driven methods we found a subgroup of subjects who are largely disengaged, unaware, and not practicing protective behaviors. Our results have implications for our understanding of how risk perception and protective behaviors can facilitate early interventions during large-scale pandemics.

From the Discussion:

One explanation for our results is the optimism bias.  This bias is associated with the belief that we are less likely to acquire a disease than others, and has been shown across a variety of diseases including lung  cancer. Indeed,  those  who  show  the  optimism  bias  are  less  likely  to  be  vaccinated  against disease. Recent evidence suggests that this may also be the case for COVID-19 and could result in a failure to engage in behaviors that contribute to the spread this highly contagious disease.  Our results extend  on  these  findings  by  showing  that behavior  changes  over  the  first  week  of  the  COVID-19 pandemic such that as individuals perceive an increase in personal risk they increasingly engage in risk-prevention  behaviors.   Notably,  we  observed  rapid  increases  in  risk  perception  over  a  5-day  period, indicating that public health messages spread through government and the media can be effective in raising awareness of the risk.

The research is here.

Moral Courage in the Coronavirus: A Guide for Medical Providers and Institutions

Holly Tabor & Alyssa Burgard
Just Security
Originally published 18 March 20

Times of crisis generate extreme moral dilemmas: situations we can’t begin to imagine, unthinkable choices emerging between options that all seem bad, each with harms and negative outcomes. During the COVID-19 pandemic, these moral dilemmas are experienced across the healthcare landscape — from bedside encounters to executive suites of hospitals and health systems. Who gets put on a ventilator? Who transitions to comfort care? What does end of life care look like when high flow oxygen can’t be used because of viral spread? Who gets a hospital bed? How do we choose which sick person, with or without COVID-19, gets treated? Which patients should be enrolled in research? How do we support patients when their families cannot visit them? We will turn away people who, in any other circumstance in a U.S. medical facility, we would have been obliged to treat. We will second guess these decisions, and perhaps be haunted by them forever. We only know one thing for sure: people will suffer and die regardless of which decisions we make.

How should we confront these intense challenges? Many institutions are doing what they can to provide guidance. But “guidelines” by design are intended to provide broad parameters to aid in decision making, and therefore rarely address the exact situations clinicians face. Certainly no guidelines can reduce the pain of having to actually carry out recommendations that affect an individual patient.  For other decisions, front line providers will have no guidance at all, or will have ill-informed, or even potentially harmful guidance. In perhaps the worst case scenario, they may even be encouraged to keep quiet about their concerns or observations rather than raise them to others’ attention.

As bioethicists, we know that moral dilemmas require personal moral courage, that is, the ability to take action for moral reasons, despite the risk of adverse consequences. We have already seen several stark examples of moral courage from doctors, nurses, and researchers in this outbreak. In late December in Wuhan, China, a 34 year-old ophthalmologist, Dr. Li Wenliang, raised the alarm in a chat group of doctors about a new virus he was seeing. He was subsequently punished by the Chinese government. He continued to share his story via social media, even from his hospital bed, and was repeatedly censored. Dr. Wenliang died of the virus on February 7.

The info is here.