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1.
Hastings Cent Rep ; 51(5): 56-57, 2021 09.
Article in English | MEDLINE | ID: covidwho-1413927

ABSTRACT

I was a member of the Massachusetts advisory working group that wrote the Commonwealth's crisis standards of care guidance for the Covid-19 pandemic, and I was proud of the work we did, thinking carefully about whether age should matter and whether priority should be given to essential workers if there was a scarcity of medical resources, about whether protocols should address issues of structural racism, and so forth. But as a critical care physician, I have concluded that, no matter how sophisticated the ethical analysis, the fundamental approach we proposed was flawed and virtually impossible to implement. All the existing allocation protocols that states developed are based on the assumption that clinicians will be faced with the task of selecting which patients will be offered a ventilator from among a population of patients who are each in need of one. The protocols then assign patients a priority category, and the protocols specify "tie-breaking" criteria to be used when necessary. The problem with this approach for ventilator allocation is that it has no relationship whatsoever to what happens in the real world.


Subject(s)
Bioethics , COVID-19 , Humans , Pandemics , SARS-CoV-2 , Triage , Ventilators, Mechanical
2.
Brain ; 144(11): 3291-3310, 2021 12 16.
Article in English | MEDLINE | ID: covidwho-1341106

ABSTRACT

Neuroethical questions raised by recent advances in the diagnosis and treatment of disorders of consciousness are rapidly expanding, increasingly relevant and yet underexplored. The aim of this thematic review is to provide a clinically applicable framework for understanding the current taxonomy of disorders of consciousness and to propose an approach to identifying and critically evaluating actionable neuroethical issues that are frequently encountered in research and clinical care for this vulnerable population. Increased awareness of these issues and clarity about opportunities for optimizing ethically responsible care in this domain are especially timely given recent surges in critically ill patients with prolonged disorders of consciousness associated with coronavirus disease 2019 around the world. We begin with an overview of the field of neuroethics: what it is, its history and evolution in the context of biomedical ethics at large. We then explore nomenclature used in disorders of consciousness, covering categories proposed by the American Academy of Neurology, the American Congress of Rehabilitation Medicine and the National Institute on Disability, Independent Living and Rehabilitation Research, including definitions of terms such as coma, the vegetative state, unresponsive wakefulness syndrome, minimally conscious state, covert consciousness and the confusional state. We discuss why these definitions matter, and why there has been such evolution in this nosology over the years, from Jennett and Plum in 1972 to the Multi-Society Task Force in 1994, the Aspen Working Group in 2002 and the 2018 American and 2020 European Disorders of Consciousness guidelines. We then move to a discussion of clinical aspects of disorders of consciousness, the natural history of recovery and ethical issues that arise within the context of caring for people with disorders of consciousness. We conclude with a discussion of key challenges associated with assessing residual consciousness in disorders of consciousness, potential solutions and future directions, including integration of crucial disability rights perspectives.


Subject(s)
Bioethical Issues , Consciousness Disorders/classification , Neurology/ethics , COVID-19 , Consciousness Disorders/diagnosis , Humans , SARS-CoV-2
5.
Crit Care Med ; 48(8): 1196-1202, 2020 08.
Article in English | MEDLINE | ID: covidwho-972845

ABSTRACT

OBJECTIVES: Coronavirus disease 2019 patients are currently overwhelming the world's healthcare systems. This article provides practical guidance to front-line physicians forced to make critical rationing decisions. DATA SOURCES: PubMed and Medline search for scientific literature, reviews, and guidance documents related to epidemic ICU triage including from professional bodies. STUDY SELECTION: Clinical studies, reviews, and guidelines were selected and reviewed by all authors and discussed by internet conference and email. DATA EXTRACTION: References and data were based on relevance and author consensus. DATA SYNTHESIS: We review key challenges of resource-driven triage and data from affected ICUs. We recommend that once available resources are maximally extended, triage is justified utilizing a strategy that provides the greatest good for the greatest number of patients. A triage algorithm based on clinical estimations of the incremental survival benefit (saving the most life-years) provided by ICU care is proposed. "First come, first served" is used to choose between individuals with equal priorities and benefits. The algorithm provides practical guidance, is easy to follow, rapidly implementable and flexible. It has four prioritization categories: performance score, ASA score, number of organ failures, and predicted survival. Individual units can readily adapt the algorithm to meet local requirements for the evolving pandemic. Although the algorithm improves consistency and provides practical and psychologic support to those performing triage, the final decision remains a clinical one. Depending on country and operational circumstances, triage decisions may be made by a triage team or individual doctors. However, an experienced critical care specialist physician should be ultimately responsible for the triage decision. Cautious discharge criteria are proposed acknowledging the difficulties to facilitate the admission of queuing patients. CONCLUSIONS: Individual institutions may use this guidance to develop prospective protocols that assist the implementation of triage decisions to ensure fairness, enhance consistency, and decrease provider moral distress.


Subject(s)
Betacoronavirus , Coronavirus Infections/therapy , Health Care Rationing/methods , Intensive Care Units/organization & administration , Pandemics , Pneumonia, Viral/therapy , Triage/methods , Adult , COVID-19 , Coronavirus Infections/epidemiology , Critical Care/standards , Health Care Rationing/standards , Humans , Patient Acceptance of Health Care/statistics & numerical data , Pneumonia, Viral/epidemiology , Practice Guidelines as Topic , SARS-CoV-2 , Triage/standards
8.
Lancet Respir Med ; 8(7): 717-725, 2020 07.
Article in English | MEDLINE | ID: covidwho-276408

ABSTRACT

Global health care is experiencing an unprecedented surge in the number of critically ill patients who require mechanical ventilation due to the COVID-19 pandemic. The requirement for relatively long periods of ventilation in those who survive means that many are considered for tracheostomy to free patients from ventilatory support and maximise scarce resources. COVID-19 provides unique challenges for tracheostomy care: health-care workers need to safely undertake tracheostomy procedures and manage patients afterwards, minimising risks of nosocomial transmission and compromises in the quality of care. Conflicting recommendations exist about case selection, the timing and performance of tracheostomy, and the subsequent management of patients. In response, we convened an international working group of individuals with relevant expertise in tracheostomy. We did a literature and internet search for reports of research pertaining to tracheostomy during the COVID-19 pandemic, supplemented by sources comprising statements and guidance on tracheostomy care. By synthesising early experiences from countries that have managed a surge in patient numbers, emerging virological data, and international, multidisciplinary expert opinion, we aim to provide consensus guidelines and recommendations on the conduct and management of tracheostomy during the COVID-19 pandemic.


Subject(s)
Betacoronavirus , Coronavirus Infections/therapy , Infectious Disease Transmission, Patient-to-Professional/prevention & control , Internationality , Pneumonia, Viral/therapy , Practice Guidelines as Topic , Tracheostomy/methods , COVID-19 , Coronavirus Infections/prevention & control , Critical Care/methods , Humans , Pandemics/prevention & control , Pneumonia, Viral/prevention & control , SARS-CoV-2
9.
Chest ; 158(1): 212-225, 2020 07.
Article in English | MEDLINE | ID: covidwho-46588

ABSTRACT

Public health emergencies have the potential to place enormous strain on health systems. The current pandemic of the novel 2019 coronavirus disease has required hospitals in numerous countries to expand their surge capacity to meet the needs of patients with critical illness. When even surge capacity is exceeded, however, principles of critical care triage may be needed as a means to allocate scarce resources, such as mechanical ventilators or key medications. The goal of a triage system is to direct limited resources towards patients most likely to benefit from them. Implementing a triage system requires careful coordination between clinicians, health systems, local and regional governments, and the public, with a goal of transparency to maintain trust. We discuss the principles of tertiary triage and methods for implementing such a system, emphasizing that these systems should serve only as a last resort. Even under triage, we must uphold our obligation to care for all patients as best possible under difficult circumstances.


Subject(s)
Coronavirus Infections , Pandemics , Pneumonia, Viral , Resource Allocation/organization & administration , Triage/organization & administration , Betacoronavirus/isolation & purification , COVID-19 , Coronavirus Infections/epidemiology , Coronavirus Infections/therapy , Critical Care/methods , Humans , Pneumonia, Viral/epidemiology , Pneumonia, Viral/therapy , Public Health/ethics , Public Health/methods , Public Health/standards , SARS-CoV-2 , Surge Capacity/ethics , Surge Capacity/organization & administration
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