Running Toward Disasters: One Bioethicist's Experience in Translational Ethics.

Translational ethics is a practice that aims to apply bioethics insights and process to the real-world contexts of clinical medicine, but also government policy, systems issues, and public health. This work has been a career focus for a relatively small number of bioethicists over the years, but it has drawn greater attention due to the pandemic and a greater realization of the impact of health inequities and systemic injustice. This essay discusses the pathway, rewards, and challenges of translational bioethics as experienced by one bioethicist working with state and national groups on a range of translational ethics issues, often related to public health disasters. There is much remaining work to be done, and the goal of the essay is to encourage rising bioethicists to engage in translational bioethics.

Modeling Outcomes Using Sequential Organ Failure Assessment (SOFA) Score-Based Ventilator Triage Guidelines During the COVID-19 Pandemic.

OBJECTIVE: To model performance of sequential organ failure assessment (SOFA) score-based ventilator allocation guidelines during the COVID-19 pandemic. METHODS: A retrospective cohort study design was used. Study sites included three New York City hospitals in a single academic medical center. We included a random sample (205) of adult patients intubated (1002) from 3/25/20-4/29/20. Protocol criteria adapted from New York State's 2015 guidelines were applied to determine which patients would have had mechanical ventilation withheld or withdrawn. RESULTS: 117 (57%) patients would have been identified for ventilator withdrawal or withholding, based on the triage guidelines. Of those 117 patients, 28 (24%) survived hospitalization. Overall, 65 (32%) patients survived to discharge. CONCLUSIONS: Triage protocols aim to maximize survival by redirecting ventilators to those most likely to survive. Over half of this sample would have been identified as candidates for ventilator exclusion. Clinical judgment would therefore still be needed in ventilator reallocation, re-introducing bias and moral distress. These data suggest limited utility for SOFA score-based ventilator rationing. This raises the question of whether there is sufficient ethical justification to impose a life-ending decision based on a SOFA scoring method on some patients to offer potential benefit to a modest number of others.

Primary and Specialist-Level Palliative Care during the spring 2020 COVID-19 Surge: A Single-Center Experience in the Bronx.

INTRODUCTION: The COVID-19 pandemic surge necessitated a rapid increase in provision of goals of care communication for patients with respiratory failure and high risk of death. We aimed to describe the outcomes and incidence of code status changes for mechanically ventilated patients in an acute care hospital after deploying strategies to enhance primary palliative care, including provision of goals of care communication scripts to front-line physicians. METHODS: This is a retrospective cohort study including all patients admitted with COVID-19 disease and requiring mechanical ventilation during a 2-week period in March and April of 2020. RESULTS: Of the 440 total patients, 327 (74.3%) died. 162 patients received a documented attempt at cardiopulmonary resuscitation (CPR) and only 4 (2.5%) of them survived. No patient above the age of 64 survived a CPR attempt. On admission, 404 patients (92.8%) were Full Code. 165 patients (37.5%) had a code status change. Almost half of the patients (n = 219) had a palliative care consult. Patients with a palliative care consult were more likely to have a code status change (56.6% v. 18.6%, χ2 = 68.0, p < 0.01). DISCUSSION: Mechanically ventilated patients had a high mortality, and CPR did not result in survival to discharge in patients over 65. Palliative care specialists are needed to guide goals of care discussions during the COVID-19 pandemic, as there are numerous barriers to equipping primary care teams to lead such discussions. The COVID-19 pandemic has underscored the vital role of palliative care in disaster response.

Older Adults and Covid-19: The Most Vulnerable, the Hardest Hit.

Older adults in the United States have been the age group hardest hit by the Covid pandemic. They have suffered a disproportionate number of deaths; Covid patients eighty years or older on ventilators had fatality rates higher than 90 percent. How could we have better protected older adults? Both the popular press and government entities blamed nursing homes, labeling them "snake pits" and imposing harsh fines and arduous new regulations. We argue that this approach is unlikely to improve protections for older adults. Rather than focusing exclusively on acute and critical resources, including ventilators, a plan that respected the best interests of older adults would have also supported nursing homes, a critical part of the health care system. Better access to protective equipment for staff members, early testing of staff members and patients, and enhanced means of communication with families were what was needed. These preventive measures would have offered greater benefit to the oldest members of our population than the exclusive focus on acute care.

COVID in NYC: What We Could Do Better.

New York City hospitals expanded resources to an unprecedented extent in response to the COVID pandemic. Thousands of beds, ICU beds, staff members, and ventilators were rapidly incorporated into hospital systems. Nonetheless, this historic public health disaster still created scarcities and the need for formal crisis standards of care. These were not available to NY clinicians because of the state's failure to implement, with or without revision, long-standing guidance documents intended for just such a pandemic. The authors argue that public health plans for disasters should be well-funded and based on available research and expertise. Communities should insist that political representatives demonstrate responsible leadership by implementing and updating as needed, crisis standards of care. Finally, surge requirements should address the needs of both those expected to survive and those who will not, by expanding palliative care and other resources for the dying.

"We're Not Ready, But I Don't Think You're Ever Ready." Clinician Perspectives on Implementation of Crisis Standards of Care.

Background: The COVID-19 pandemic has highlighted health care systems' vulnerabilities. Hospitals face increasing risk of periods of scarcity of life-sustaining resources such as ventilators for mechanical respiratory support, as has been the case in Italy as of March, 2020. The National Academy of Medicine has provided guidance on crisis standards of care, which call for the reallocation of scarce medical resources to those who will benefit most during extreme situations. Given that this will require a departure from the usual fiduciary duty of the bedside clinician, we determined and mapped potential barriers to the implementation of the guidelines from stakeholders using an implementation science framework. Methods: A protocol was created to operationalize national and state guidelines for triaging ventilators during crisis conditions. Focus groups and key informant interviews were conducted from July-September 2018 with clinicians at three acute care hospitals of an urban academic medical center. Respiratory therapists, intensivists, nursing leadership and the palliative care interdisciplinary team participated in focus groups. Key informant interviews were conducted with emergency management, respiratory therapy and emergency medicine. Subjects were presented the protocol and their reflections were elicited using a semi-structured interview guide. Data from transcripts and notes were categorized using a coding strategy based on the Theoretical Domains Framework. Results: Participants anticipated that implementing this protocol would challenge their roles and identities as clinicians including both their fiduciary duty to the patient and their decision-making autonomy. Despite this, many participants acknowledged the need for such a protocol to standardize care and minimize bias as well as to mitigate potential consequences for individual clinicians. Participants identified the question of considering patient quality of life in triage decisions as an important and unresolved ethical issue in disaster triage. Conclusion: Clinicians' discomfort with shifting roles and obligations could pose implementation barriers for crisis standards of care.