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.

Coronavirus and ethics: 'Act so that most people survive'

Georg Marckmann
dw.com
Originally posted 24 March 20

Here is an excerpt:

Triage, a word used in military medicine, means classification. What groups do you classify the patients into?

There are several categories. Critically-ill patients are treated immediately, the treatment of seriously-ill patients is delayed, and patients who are slightly ill are treated later. Patients with no chance of survival receive purely palliative care.

The crucial element of situations involving a large number of sick people that we can no longer care for adequately is that we have to switch from a patient-centered approach to a group- or population-oriented approach. In a patient-centered approach, we try to adjust treatment as best we can to ensure the well-being of the individual patient and accommodate their wishes.

In a group-centered approach, we try to ensure that the incidence of illness and death within a population group is as low as possible. This places a strain on those making these decisions, because they're not used to it.

As a basic rule, we try to act in such a way that the largest number of people survive, because that is in the public interest.

The info is here.

Human Trafficking Survivor Settles Lawsuit Against Motel Where She Was Held Captive

Todd Bookman
npr.org
Originally posted 20 Feb 20

Here is an excerpt:

Legal experts and anti-trafficking groups say her 2015 case was the first filed against a hotel or motel for its role in a trafficking crime.

"It is not that any hotel is liable just because trafficking occurred on their premises," explains Cindy Vreeland, a partner at the firm WilmerHale, which handled Ricchio's case pro bono. "The question is whether the company that's been sued knew or should have known about the trafficking."

After a number of appeals and delays, the case finally settled in December 2019 with Ricchio receiving an undisclosed monetary award. Owners of the Shangri-La Motel didn't respond to a request for comment.

"I never thought it would be, like, an eight-year process," Ricchio says. "Anything in the court system seems to take forever."

That slow process isn't deterring other survivors of trafficking from bringing their own suits.

According to the Human Trafficking Institute, there were at least 25 new cases filed nationwide against hotels and motels last year under the TVPA.

Some of the named defendants include major chains such as Hilton, Marriott and Red Roof Inn.

"You can't just let anything happen on your property, turn a blind eye and say, 'Too bad, so sad, I didn't do it, so I'm not responsible,' " says Paul Pennock with the firm Weitz & Luxenberg.

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.

Italian nurse with coronavirus dies by suicide over fear of infecting others

Yaron Steinbuch
nypost.com
Originally published 25 March 20

A 34-year-old Italian nurse working on the front lines of the coronavirus pandemic took her own life after testing positive for the illness and was terrified that she had infected others, according to a report.

Daniela Trezzi had been suffering “heavy stress” amid fears she was spreading the deadly bug while treating patients at the San Gerardo Hospital in Monza in the hard-hit region of Lombardy, the Daily Mail reported.

She was working in the intensive care unit while under quarantine after being diagnosed with COVID-19, according to the UK news site.

The National Federation of Nurses of Italy expressed its “pain and dismay” over Trezzi’s death, which came as the country’s mounting death toll surged with 743 additional fatalities Tuesday.

“Each of us has chosen this profession for good and, unfortunately, also for bad: we are nurses,” the federation said.

The info is here.

COVID-19 and the Impossibility of Morality

John Danaher
philosophical disquisitions
Originally published 16 March 20

The stories coming out of Italy over the past two weeks have been chilling. With their healthcare system overwhelmed by COVID-19 cases, Italian doctors are facing tragic triage decisions on a daily basis. In severe cases of COVID-19 patients need ventilators to survive. But there are only so many ventilators to go around. What if you don’t have enough? Who should you save? The 80 year old with COPD and other medical complications or the slightly healthier 50 year old without them? The 45 year old mother of two or the 55 year old single man? The 29 year old healthcare worker or the 38 year old diabetes patient?

Questions like these might sound like thought experiments cooked up in a first year ethics class, but they are not. Indeed, decision-making of this sort is not uncommon in crisis situations. For example, infamous tales are told about what happened at the Memorial Medical Center in New Orleans during Hurricane Katrina in 2005. With rising flood waters, no electricity and several critically ill patients who could not be evacuated, medical workers at Memorial had to make some tough decisions: abandon patients and leave them die in agony or administer euthanizing drugs to end their suffering more quickly? The suspicion is that many chose the latter course of action.

And medical decisions are just the tip of the iceberg. As we are all now being asked to isolate ourselves for the common good, many of us will find ourselves confronting similar, albeit less high stakes decisions. Which is more important: my duty to care for my elderly parents or my duty to protect them (and others) from potential transmission of disease? My duty to work to ensure that other people have the essential services they need or my duty to myself and my family to protect them from illness? We may not like to ask these questions, but we cannot avoid them.

But what are the answers? What should people do in cases like this? I don't know that I have much in the way of specific guidance to offer, but I do have a point that I think is worth making. It's at times like this that the essentially tragic nature of much moral decision-making reveals itself. This tragedy lurks in the background most of the time, but it is brought into sharp relief at times like this. Once we are aware of this ineluctable tragedy we might be inclined to change some of our common moral practices. We might be less inclined to blame others for the choices they make; and we might be more conscious of the pain of moral regret.

The info is here.

What Should Health Care Organizations Do to Reduce Billing Fraud and Abuse?

K. Drabiak and J. Wolfson

AMA J Ethics. 2020;22(3):E221-231.
doi: 10.1001/amajethics.2020.221.

Abstract

Whether physicians are being trained or encouraged to commit fraud within corporatized organizational cultures through contractual incentives (or mandates) to optimize billing and process more patients is unknown. What is known is that upcoding and misrepresentation of clinical information (fraud) costs more than $100 billion annually and can result in unnecessary procedures and prescriptions. This article proposes fraud mitigation strategies that combine organizational cultural enhancements and deployment of transparent compliance and risk management systems that rely on front-end data analytics.

Fraud in Health Care

Growth in corporatization and profitization in medicine, insurance company payment rules, and government regulation have fed natural proclivities, even among physicians, to optimize profits and reimbursements (Florida Department of Health, oral communication, September 2019). According to the most recent Health Care Fraud and Abuse Control Program Annual Report, in one case a management company “pressured and incentivized” dentists to meet specific production goals through a system that disciplined “unproductive” dentists and awarded cash bonuses tied to the revenue from procedures—including many allegedly medically unnecessary services—they performed. This has come at a price: escalating costs, fraud and abuse, medically unnecessary services, adverse effects on patient safety, and physician burnout.

Breaking the cycle of bad behaviors that are induced in part by financial incentives speaks to core ethical issues in the practice of medicine that can be addressed through a combination of organizational and cultural enhancements and more transparent practice-based compliance and risk management systems that rely on front-end data analytics designed to identify, flag, and focus investigations on fraud and abuse at the practice site. Here, we discuss types of health care fraud and their impact on health care costs and patient safety, how this behavior is incentivized and justified within current and evolving medical practice settings, and a 2-pronged strategy for mitigating this behavior.

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.

Sen. Kelly Loeffler Dumped Millions in Stock After Coronavirus Briefing

L. Markay, W. Bredderman, & S. Bordy
thedailybeast.com
Updated 20 March 20

The Senate’s newest member sold off seven figures’ worth of stock holdings in the days and weeks after a private, all-senators meeting on the novel coronavirus that subsequently hammered U.S. equities.

Sen. Kelly Loeffler (R-GA) reported the first sale of stock jointly owned by her and her husband on Jan. 24, the very day that her committee, the Senate Health Committee, hosted a private, all-senators briefing from administration officials, including the CDC director and Anthony Fauci, the head of the National Institute of Allergy and Infectious Diseases, on the coronavirus.

“Appreciate today’s briefing from the President’s top health officials on the novel coronavirus outbreak,” she tweeted about the briefing at the time.

That first transaction was a sale of stock in the company Resideo Technologies valued at between $50,001 and $100,000. The company’s stock price has fallen by more than half since then, and the Dow Jones Industrial Average overall has shed approximately 10,000 points, dropping about a third of its value.

It was the first of 29 stock transactions that Loeffler and her husband made through mid-February, all but two of which were sales. One of Loeffler’s two purchases was stock worth between $100,000 and $250,000 in Citrix, a technology company that offers teleworking software and which has seen a small bump in its stock price since Loeffler bought in as a result of coronavirus-induced market turmoil.

The info is here.