Canadian emergency medicine and critical care physician perspectives on pandemic triage in COVID-19

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.

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Canadian Emergency Medicine and Critical Care Physician Perspectives on Pandemic Triage in COVID-19

10.21203/rs.3.rs-50315/v1 ◽

2020 ◽

Author(s):

Ali Mulla ◽

Blair L. Bigham ◽

Andrea Frolic ◽

Michael D. Christian

Keyword(s):

Decision Making ◽

Critical Care ◽

Acute Care ◽

Legal Protection ◽

Care Physician ◽

Multidisciplinary Teams ◽

Free Text ◽

Emergency Physicians ◽

Provider Perspectives ◽

Critical Care Resource

Abstract Purpose: 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 towards 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 towards 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%), as well as fears of psychological distress if required to triage scarce resources (77%). Only 49% 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 vs 2.9/5 p=0.04), whereas emergency physicians preferred to maintain their involvement in such decisions (3.4/5 vs 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, medico-legal 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.

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Critical-care resource allocation during the coronavirus disease 2019 pandemic in Singapore: A brief narrative review

Proceedings of Singapore Healthcare ◽

10.1177/2010105820947439 ◽

2020 ◽

pp. 201010582094743

Author(s):

Elisha Wan Ying Chia ◽

Kuang Teck Tay

Keyword(s):

Health Care ◽

Resource Allocation ◽

Critical Care ◽

Health Care Professionals ◽

Narrative Review ◽

Conduct Literature ◽

Ethical Guidelines ◽

Scarce Resources ◽

Literature Searches ◽

Critical Care Resource

In the midst of the coronavirus disease 2019 (COVID-19) pandemic, where cases continue to increase exponentially every day, it is important to consider the future implications that this may have on the health-care system, the most feared situation being a shortage of critical-care resources, where difficult decisions have to be made about the allocation of scarce resources. In this brief narrative review, we conduct literature searches for COVID-19 ethical guidelines on critical-care resource allocation. Synthesising this information, we evaluate the relevant ethical principles and thereafter provide recommendations contextualised to Singapore. This brief narrative review aims to serve as a useful set of guiding principles for health-care professionals in Singapore, should the need for allocation of scarce resources arise.

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Fallacy of the last bed dilemma

Journal of Medical Ethics ◽

10.1136/medethics-2021-107333 ◽

2021 ◽

pp. medethics-2021-107333

Author(s):

Luca Valera ◽

María A. Carrasco ◽

Ricardo Castro

Keyword(s):

Public Health ◽

Decision Making ◽

Critical Care ◽

Medical Care ◽

Ethical Issues ◽

Moral Dilemma ◽

Scarce Resources ◽

Ethical View

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.

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Negotiating Transitions: Involvement of Critical Care Outreach Teams in End-of-Life Decision Making

American Journal of Critical Care ◽

10.4037/ajcc2015715 ◽

2015 ◽

Vol 24 (3) ◽

pp. 232-240 ◽

Cited By ~ 16

Author(s):

Natalie Pattison ◽

Geraldine O’Gara ◽

Timothy Wigmore

Keyword(s):

Decision Making ◽

Critical Care ◽

Medical Treatment ◽

End Of Life ◽

End Of Life Care ◽

Free Text ◽

Life Care ◽

End Of Life Decision ◽

Life Decision ◽

Critical Care Outreach

Background Little research has examined the involvement of critical care outreach teams in end-of-life decision making. Objective To establish how much time critical care outreach teams spend with patients who are subsequently subject to limitation of medical treatment and end-of-life decisions and how much influence the teams have on those decisions. Methods A single-center retrospective review, with qualitative analysis, in a large cancer center. Data from all patients referred emergently for critical care outreach from October 2010 to October 2011 who later had limitation of medical treatment or end-of-life care were retrieved. Findings were analyzed by using SPSS 19 and qualitative free-text analysis. Results Of 890 patients referred for critical care outreach from October 2010 to October 2011, 377 were referred as an emergency; 108 of those had limitation of medical treatment and were included in the review. Thirty-five patients (32.4%) died while hospitalized. As a result of outreach intervention and a decision to limit medical treatment, 56 (51.9%) of the 108 patients received a formal end-of-life care plan (including care pathways, referral to palliative care team, hospice). About a fifth (21.5%) of clinical contact time is being spent on patients who subsequently are subject to limitation of medical treatment. Qualitative document analysis showed 5 emerging themes: difficulty of discussions about not attempting cardiopulmonary resuscitation, complexities in coordinating multiple teams, delays in referral and decision making, decision reversals and opaque decision making, and technical versus ethical imperatives. Conclusion A considerable amount of time is being spent on these emergency referrals, and decisions to limit medical treatment are common. The appropriateness of escalation of levels of care is often not questioned until patients become critically or acutely unwell, and outreach teams subsequently intervene.

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HANDLING COVID-19 PANDEMIC WITH LIMITED HEALTH AND CRITICAL CARE RESOURCE BY JUDICIAL USE AND FAIR ALLOCATION

10.36106/ijar/2503827 ◽

2020 ◽

pp. 1-2

Author(s):

Abhishek Singh ◽

Preeti Deedwania

Keyword(s):

Critical Care ◽

Care Physician ◽

World Health ◽

Community Resources ◽

Critical Care Physician ◽

Effective Utilization ◽

Critical Care Resource ◽

History Of ◽

Limited Health ◽

Health Organization

Covid-19 has been officially declared as pandemic by the World health organization. At present Covid – 19 has spread to more than 185 countries affecting millions of people. Since it is a novel disease a lot is unknown about the natural history of the disease. Considering its impact and clinical manifestation, we are certain that our critical care resources will soon get exhausted. Such types of viral pandemics place us at a sustained demand of healthcare infrastructure and essential community resources. Such demands lead to the development of situation where we need to judiciously allocate our resources, equipment and manpower for their effective utilization and better outcome. It's the responsibility of critical care physician to rise to the occasion and make a long lasting impact while managing covid-19 pandemic.

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

Health Care Analysis ◽

10.1007/s10728-021-00442-0 ◽

2021 ◽

Author(s):

Yves Saint James Aquino ◽

Wendy A. Rogers ◽

Jackie Leach Scully ◽

Farah Magrabi ◽

Stacy M. Carter

Keyword(s):

Decision Making ◽

Critical Care ◽

Development Process ◽

National Guidelines ◽

Scarce Resources ◽

Medical Need ◽

Ethical Guidance ◽

Pluralistic Approach ◽

Procedural Values ◽

Allocation Decisions

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.

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How multidisciplinary are multidisciplinary case reviews in cancer care? Feasibility analysis of a theory-driven team decision-making fidelity framework

10.31234/osf.io/3xwnd ◽

2019 ◽

Author(s):

Tayana Soukup ◽

Ged Murtagh ◽

Ben W Lamb ◽

James Green ◽

Nick Sevdalis

Keyword(s):

Decision Making ◽

Cancer Care ◽

Recent Decade ◽

Individual Case ◽

Multidisciplinary Teams ◽

Final Decision ◽

Political Climate ◽

Implementation Framework ◽

Feasibility Evaluation ◽

The Uk

Background Multidisciplinary teams (MDTs) are a standard cancer care policy in many countries worldwide. Despite an increase in research in a recent decade on MDTs and their care planning meetings, the implementation of MDT-driven decision-making (fidelity) remains unstudied. We report a feasibility evaluation of a novel method for assessing cancer MDT decision-making fidelity. We used an observational protocol to assess (1) the degree to which MDTs adhere to the stages of group decision-making as per the ‘Orientation-Discussion-Decision-Implementation’ framework, and (2) the degree of multidisciplinarity underpinning individual case reviews in the meetings. MethodsThis is a prospective observational study. Breast, colorectal and gynaecological cancer MDTs in the Greater London and Derbyshire (United Kingdom) areas were video recorded over 12-weekly meetings encompassing 822 case reviews. Data were coded and analysed using frequency counts.Results Eight interaction formats during case reviews were identified. case reviews were not always multi-disciplinary: only 8% of overall reviews involved all five clinical disciplines present, and 38% included four of five. The majority of case reviews (i.e. 54%) took place between two (25%) or three (29%) disciplines only. Surgeons (83%) and oncologists (8%) most consistently engaged in all stages of decision-making. While all patients put forward for MDT review were actually reviewed, a small percentage of them (4%) either bypassed the orientation (case presentation) and went straight into discussing the patient, or they did not articulate the final decision to the entire team (8%). Conclusions Assessing fidelity of MDT decision-making at the point of their weekly meetings is feasible. We found that despite being a set policy, case reviews are not entirely MDT-driven. We discuss implications in relation to the current eco-political climate, and the quality and safety of care. Our findings are in line with the current national initiatives in the UK on streamlining MDT meetings, and could help decide how to re-organise them to be most efficient.

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The use of a Domain Ontology for the Management of Essential Hypertension (Preprint)

10.2196/preprints.25427 ◽

2020 ◽

Author(s):

Emma Chavez ◽

Vanessa Perez ◽

Angélica Urrutia

Keyword(s):

Decision Making ◽

Essential Hypertension ◽

Medical History ◽

Medical Records ◽

Medical Training ◽

Relevant Information ◽

Domain Ontology ◽

Free Text ◽

Snomed Ct ◽

History Of

BACKGROUND : Currently, hypertension is one of the diseases with greater risk of mortality in the world. Particularly in Chile, 90% of the population with this disease has idiopathic or essential hypertension. Essential hypertension is characterized by high blood pressure rates and it´s cause is unknown, which means that every patient might requires a different treatment, depending on their history and symptoms. Different data, such as history, symptoms, exams, etc., are generated for each patient suffering from the disease. This data is presented in the patient’s medical record, in no order, making it difficult to search for relevant information. Therefore, there is a need for a common, unified vocabulary of the terms that adequately represent the diseased, making searching within the domain more effective. OBJECTIVE The objective of this study is to develop a domain ontology for essential hypertension , therefore arranging the more significant data within the domain as tool for medical training or to support physicians’ decision making will be provided. METHODS The terms used for the ontology were extracted from the medical history of de-identified medical records, of patients with essential hypertension. The Snomed-CT’ collection of medical terms, and clinical guidelines to control the disease were also used. Methontology was used for the design, classes definition and their hierarchy, as well as relationships between concepts and instances. Three criteria were used to validate the ontology, which also helped to measure its quality. Tests were run with a dataset to verify that the tool was created according to the requirements. RESULTS An ontology of 310 instances classified into 37 classes was developed. From these, 4 super classes and 30 relationships were obtained. In the dataset tests, 100% correct and coherent answers were obtained for quality tests (3). CONCLUSIONS The development of this ontology provides a tool for physicians, specialists, and students, among others, that can be incorporated into clinical systems to support decision making regarding essential hypertension. Nevertheless, more instances should be incorporated into the ontology by carrying out further searched in the medical history or free text sections of the medical records of patients with this disease.

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Nursing Home Staff’s Perceptions of Healthcare Decision Making for Unbefriended Residents

Innovation in Aging ◽

10.1093/geroni/igaa057.1237 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

pp. 384-384

Author(s):

Hyejin Kim ◽

Molly Perkins ◽

Thaddeus Pope ◽

Patricia Comer ◽

Mi-Kyung Song

Keyword(s):

Decision Making ◽

Geographic Area ◽

Care Physician ◽

Healthcare Decision ◽

Do Not Resuscitate ◽

Best Interest ◽

Care Plans ◽

Course Of Action ◽

Healthcare Decision Making ◽

Facility Level

Abstract ‘Unbefriended’ adults are those who lack decision-making capacity and have no surrogates or advance care plans. Little data exist on nursing homes (NHs)’ healthcare decision-making practices for unbefriended residents. This study aimed to describe NH staff’s perceptions of healthcare decision making on behalf of unbefriended residents. Sixty-six staff including administrators, physicians, nurses, and social workers from three NHs in one geographic area of Georgia, USA participated in a 31-item survey. Their responses were analyzed using descriptive statistics and conventional content analysis. Of 66 participants, eleven had been involved in healthcare decision-making for unbefriended residents. The most common decision was do-not-resuscitate orders. Decisions primarily were made by relying on the resident’s primary care physician and/or discussing within a facility interdisciplinary team. Key considerations in the decision-making process included “evidence that the resident would not have wanted further treatment” and the perception that “further treatment would not be in the resident’s best interest”. Compared with decision making for residents with surrogates, participants perceived decision making for unbefriended residents to be equally-more difficult. Key barriers to making decisions included uncertainty regarding what the resident would have wanted in the given situation and concerns regarding the ethically and legally right course of action. Facilitators (reported by 52 participants) included some information/knowledge about the resident, an understanding regarding decision-making-related law/policy, and facility-level support. The findings highlight the complexity and difficulty of healthcare decision making for unbefriended residents and suggest more discussions among all key stakeholders to develop practical strategies to support decision-making practices in NHs.

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