scholarly journals Ethical Guidance for Hard Decisions: A Critical Review of Early International COVID-19 ICU Triage Guidelines

Author(s):  
Yves Saint James Aquino ◽  
Wendy A. Rogers ◽  
Jackie Leach Scully ◽  
Farah Magrabi ◽  
Stacy M. Carter

AbstractThis article provides a critical comparative analysis of the substantive and procedural values and ethical concepts articulated in guidelines for allocating scarce resources in the COVID-19 pandemic. We identified 21 local and national guidelines written in English, Spanish, German and French; applicable to specific and identifiable jurisdictions; and providing guidance to clinicians for decision making when allocating critical care resources during the COVID-19 pandemic. US guidelines were not included, as these had recently been reviewed elsewhere. Information was extracted from each guideline on: 1) the development process; 2) the presence and nature of ethical, medical and social criteria for allocating critical care resources; and 3) the membership of and decision-making procedure of any triage committees. Results of our analysis show the majority appealed primarily to consequentialist reasoning in making allocation decisions, tempered by a largely pluralistic approach to other substantive and procedural values and ethical concepts. Medical and social criteria included medical need, co-morbidities, prognosis, age, disability and other factors, with a focus on seemingly objective medical criteria. There was little or no guidance on how to reconcile competing criteria, and little attention to internal contradictions within individual guidelines. Our analysis reveals the challenges in developing sound ethical guidance for allocating scarce medical resources, highlighting problems in operationalising ethical concepts and principles, divergence between guidelines, unresolved contradictions within the same guideline, and use of naïve objectivism in employing widely used medical criteria for allocating ICU resources.

2021 ◽  
pp. medethics-2021-107333
Author(s):  
Luca Valera ◽  
María A. Carrasco ◽  
Ricardo Castro

The COVID-19 pandemic highlights the relevance of adequate decision making at both public health and healthcare levels. A bioethical response to the demand for medical care, supplies and access to critical care is needed. Ethically sound strategies are required for the allocation of increasingly scarce resources, such as rationing critical care beds. In this regard, it is worth mentioning the so-called ‘last bed dilemma’. In this paper, we examine this dilemma, pointing out the main criteria used to solve it and argue that we cannot face these ethical issues as though they are only a dilemma. A more complex ethical view regarding the care of COVID-19 patients that is focused on proportional and ordinary treatments is required. Furthermore, discussions and forward planning are essential because deliberation becomes extremely complex during an emergency and the physicians’ sense of responsibility may be increased if it is faced only as a moral dilemma.


2020 ◽  
Vol 18 (7) ◽  
pp. 31-35
Author(s):  
Ali Mulla, MD, MSc ◽  
Blair L. Bigham, MD, MSc, DTMH ◽  
Andrea Frolic, MA, PhD ◽  
Michael D. Christian, MD, MSc, FRCPC

Introduction: Local and regional policies to guide the allocation of scarce critical care resources have been developed, but the views of prospective users are not understood. We sought to investigate the perspectives of Canadian acute care physicians toward triaging scarce critical care resources in the COVID-19 pandemic.Methods: We rapidly deployed a brief survey to Canadian emergency and critical care physicians in April 2020 to investigate current attitudes toward triaging scarce critical care resources and identify subsequent areas for improvement. Descriptive and between-group analyses along with thematic coding were used.Results: The survey was completed by 261 acute care physicians. Feelings of anxiety related to the pandemic were common (65 percent), as well as fears of psychological distress if required to triage scarce resources (77 percent). Only 49 percent of respondents felt confident in making resource allocation decisions. Both critical care and emergency physicians favored multidisciplinary teams over single physicians to allocate scarce critical care resources. Critical care physicians were supportive of decision making by teams not involved in patient care (3.4/5 versus 2.9/5 p = 0.04), whereas emergency physicians preferred to maintain their involvement in such decisions (3.4/5 versus 4.0/5 p = 0.007). Free text responses identified five themes for subsequent action including the need for further guidance on existing triage policies, ethical support in decision making, medicolegal protection, additional tools for therapeutic communications, and healthcare provider psychological support.Conclusion: There is an urgent need for collaboration between policymakers and frontline physicians to develop critical care resource triage policies that wholly consider the diversity of provider perspectives across practice environments.


2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 869.1-870
Author(s):  
S. Ahmed Narikkoottungal ◽  
A. Siddiqui ◽  
A. Constantin ◽  
S. Farrow ◽  
K. Ahmed

Background:The COVID-19 pandemic has caught us all by surprise – from governments to individuals; the medical fraternity being no exception. It has affected all walks of life; with its immense contagiosity, diverse and intriguing pathogenesis and manifestations differing from other viruses. It has indeed left humanity in dark, unchartered waters; particularly in the early months of the pandemic.Objectives:This article shares the experience, in a Rheumatology department in a District General Hospital (DGH) in the United Kingdom, of managing patients on Biologic (b) and Targeted Synthetic (ts) DMARDs, in the midst of the COVID-19 Pandemic.Methods:All Rheumatology patients at the Princess Alexandra Hospital (PAH) in Harlow newly started on a biologic or targeted synthetic DMARD between 3rd July and 3rd Oct 2020 were identified. These patients had active inflammatory arthritis. Each patient was discussed in a dedicated Multi-Disciplinary Team (MDT) meeting and a consensus on treatment reached in-line with local and National guidelines.Figure 1.A slide presented at the Essex Rheumatology Association (ERA) meeting explaining the process adopted at the Rheumatology Department at Harlow during the peak of COVID-19 pandemic with new b/ts DMARD patients.Results:Of the 50 patients identified; 39 had Rheumatoid Arthritis, 6 had Ankylosing Spondylitis and 5 had Psoriatic Arthritis. Of these 50 patients, 5 patients decided against treatment during the stage of ‘Enhanced Verbal Consent’. These patients were flaring recurrently and were in regular contact with the department. However, they were afraid to start new Biologic treatment because of the risks of Covid-19. The breakdown of the biologic agents used in the remaining 45 patients were as follows: Adalimumab:11, Rituximab: 10, Etanercept: 9, Tofacitinib: 11, Tocilizumab SC: 3, Tocilizumab IV: 1, Sarilumab: 2, Secukinumab: 1, Infliximab: 1, Baricitinib: 1, Apremilast: 1Figure 2.Breakdown of the various b/ts DMARD agents newly started in the 45 patients between 3/7/20 - 3/10/20 at PA Hospital, Harlow, UKConclusion:The over-riding principle that guided the Department during the COVID crisis was: primum non nocere (first, do no harm). The adherence to the Case Based Discussions (CBDs) positively impacted on decision making, ensuring safe initiation of Biologic DMARDs even during the height of the pandemic. This is vital to achieve early disease remission. The MDT meetings comprising Doctors, Specialist Pharmacist and Nurse Specialists ensured prompt risk stratification of individual patients. It gave patients the opportunity to be part of the decision-making - evident in the five of the fifty patients, who opted to defer the start date of their treatments. The choice of the new Biologic agent was based on the latest National COVID-19 guidelines. The agents with the shortest half-life were selected. Moreover, patients for Rituximab were given one pulsed infusion, as opposed to two infusions. Only one of the 45 patients started on a Biologic agent over this period, either was tested positive or had symptoms suggestive of COVID-19.References:[1]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7261974[2]https://rmdopen.bmj.com/content/6/2/e001314[3]https://www.nejm.org/doi/full/10.1056/nejmc2009567[4]https://www.jrheum.org/content/early/2020/05/13/jrheum.200527[5]https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-care-of-adult-patients-with-systemic-rheumatic-disease[6]www.england.nhs.uk/clinical-guide-rheumatology-patients-v1-19-march-2020.pdf[7]https://www.rheumatology.org.uk/practice-quality/covid-19-guidance[8]https://www.nice.org.uk/guidance/ng167/chapter/4-Treatment-considerations[9]https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/decision-making-and-consentAcknowledgements:We acknowledge the whole Rheumatology Dept at Harlow for their sincere team work during the COVID-19 pandemic – Sabaa Naz (Rheumatology Pharmacist), Mona Kamal Zou (Biologics Nurse Specialist), Lily Robinson (DMARD Nurse Specialist), Mary Surendran (Osteoporosis Nurse Specialist), Janet Bell (Secretary to Dr Ahmed) and Claire Stroud (Secretary to Dr Farrow).Disclosure of Interests:None declared.


Author(s):  
Iris E. Beldhuis ◽  
Ramesh S. Marapin ◽  
You Yuan Jiang ◽  
Nádia F. Simões de Souza ◽  
Artemis Georgiou ◽  
...  

2021 ◽  
Vol 13 (1) ◽  
Author(s):  
Martijn van den Hurk ◽  
Peter Pelzer ◽  
Rianne Riemens

Abstract Background Merwede is an envisioned neighbourhood in Utrecht (the Netherlands) that provides an instructive case to learn about the governance challenges of digital mobility platforms. Unique about Merwede is how the development of a mobility platform is envisioned to be integrated into the development of a new neighbourhood. Methodology This article discusses the case of Merwede and provides insights into its proposed mobility platform and how it is made. It illuminates governance challenges relevant to the design and operation of an unconventional mobility concept by disentangling outstanding practical issues concerning three key governance dimensions—organizational structures, decision-making processes, and instruments. Results The research provides an empirical illustration of governance questions that come up when mobility becomes a service and is integrated into the urban fabric from the very beginning of a development process. Already in the plan development stage, Merwede illustrates that difficult decisions are to be made and competing interests come to the fore.


2016 ◽  
Vol 30 (1) ◽  
pp. 52-57 ◽  
Author(s):  
Kristi J. Stinson

Completed as part of a larger dissertational study, the purpose of this portion of this descriptive correlational study was to examine the relationships among registered nurses’ clinical experiences and clinical decision-making processes in the critical care environment. The results indicated that there is no strong correlation between clinical experience in general and clinical experience in critical care and clinical decision-making. There were no differences found in any of the Benner stages of clinical experience in relation to the overall clinical decision-making process.


2021 ◽  
Author(s):  
Shir Dekel ◽  
Micah Goldwater ◽  
Dan Lovallo ◽  
Bruce Burns

Previous research found that anecdotes are more persuasive than statistical data—the anecdotal bias effect. Separate research found that anecdotes that are similar to a target problem are more influential on decision-making than dissimilar anecdotes. Further, previous investigations on anecdotal bias primarily focused on medical decision-making with very little focus on business decision-making. Therefore, we investigated the effect of anecdote similarity on anecdotal bias in capital allocation decisions. Participants were asked to allocate a hypothetical budget between two business projects. One of the projects (the target project) was clearly superior in terms of the provided statistical measures, but some of the participants also saw a description of a project with a conflicting outcome (the anecdotal project). This anecdotal project was always from the same industry as the target project. The anecdote description, however, either contained substantive connections to the target or not. Further, the anecdote conflicted with the statistical measures because it was either successful (positive anecdote) or unsuccessful (negative anecdote). The results showed that participants’ decisions were influenced by anecdotes only when they believed that they were actually relevant to the target project. Further, they still incorporated the statistical measures into their decision. This was found for both positive and negative anecdotes. Further, participants were given information about the way that the anecdotes were sampled that suggested that the statistical information should have been used in all cases. Participants did not use this information in their decisions and still showed an anecdotal bias effect. Therefore, people seem to appropriately use anecdotes based on their relevance, but do not understand the implications of certain statistical concepts.


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