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1.
Contemp Clin Trials ; 103: 106319, 2021 04.
Article in English | MEDLINE | ID: covidwho-1081174

ABSTRACT

INTRODUCTION: The technologies used to treat the millions who receive care in intensive care unit (ICUs) each year have steadily advanced. However, the quality of ICU-based communication has remained suboptimal, particularly concerning for Black patients and their family members. Therefore we developed a mobile app intervention for ICU clinicians and family members called ICUconnect that assists with delivering need-based care. OBJECTIVE: To describe the methods and early experiences of a clustered randomized clinical trial (RCT) being conducted to compare ICUconnect vs. usual care. METHODS AND ANALYSIS: The goal of this two-arm, parallel group clustered RCT is to determine the clinical impact of the ICUconnect intervention in improving outcomes overall and for each racial subgroup on reducing racial disparities in core palliative care outcomes over a 3-month follow up period. ICU attending physicians are randomized to either ICUconnect or usual care, with outcomes obtained from family members of ICU patients. The primary outcome is change in unmet palliative care needs measured by the NEST instrument between baseline and 3 days post-randomization. Secondary outcomes include goal concordance of care and interpersonal processes of care at 3 days post-randomization; length of stay; as well as symptoms of depression, anxiety, and post-traumatic stress disorder at 3 months post-randomization. We will use hierarchical linear models to compare outcomes between the ICUconnect and usual care arms within all participants and assess for differential intervention effects in Blacks and Whites by adding a patient-race interaction term. We hypothesize that both compared to usual care as well as among Blacks compared to Whites, ICUconnect will reduce unmet palliative care needs, psychological distress and healthcare resource utilization while improving goal concordance and interpersonal processes of care. In this manuscript, we also describe steps taken to adapt the ICUconnect intervention to the COVID-19 pandemic healthcare setting. ENROLLMENT STATUS: A total of 36 (90%) of 40 ICU physicians have been randomized and 83 (52%) of 160 patient-family dyads have been enrolled to date. Enrollment will continue until the end of 2021.


Subject(s)
COVID-19 , Family , Intensive Care Units , Internet-Based Intervention , Mobile Applications , Palliative Care , Physician-Patient Relations/ethics , COVID-19/psychology , COVID-19/therapy , Family/ethnology , Family/psychology , Female , Humans , Intensive Care Units/ethics , Intensive Care Units/organization & administration , Male , Middle Aged , Outcome Assessment, Health Care , Palliative Care/methods , Palliative Care/psychology , SARS-CoV-2 , Social Support , Stress Disorders, Post-Traumatic/psychology , Stress Disorders, Post-Traumatic/rehabilitation
2.
Med Decis Making ; 41(4): 393-407, 2021 05.
Article in English | MEDLINE | ID: covidwho-1072866

ABSTRACT

BACKGROUND: During the COVID-19 pandemic, many intensive care units have been overwhelmed by unprecedented levels of demand. Notwithstanding ethical considerations, the prioritization of patients with better prognoses may support a more effective use of available capacity in maximizing aggregate outcomes. This has prompted various proposed triage criteria, although in none of these has an objective assessment been made in terms of impact on number of lives and life-years saved. DESIGN: An open-source computer simulation model was constructed for approximating the intensive care admission and discharge dynamics under triage. The model was calibrated from observational data for 9505 patient admissions to UK intensive care units. To explore triage efficacy under various conditions, scenario analysis was performed using a range of demand trajectories corresponding to differing nonpharmaceutical interventions. RESULTS: Triaging patients at the point of expressed demand had negligible effect on deaths but reduces life-years lost by up to 8.4% (95% confidence interval: 2.6% to 18.7%). Greater value may be possible through "reverse triage", that is, promptly discharging any patient not meeting the criteria if admission cannot otherwise be guaranteed for one who does. Under such policy, life-years lost can be reduced by 11.7% (2.8% to 25.8%), which represents 23.0% (5.4% to 50.1%) of what is operationally feasible with no limit on capacity and in the absence of improved clinical treatments. CONCLUSIONS: The effect of simple triage is limited by a tradeoff between reduced deaths within intensive care (due to improved outcomes) and increased deaths resulting from declined admission (due to lower throughput given the longer lengths of stay of survivors). Improvements can be found through reverse triage, at the expense of potentially complex ethical considerations.


Subject(s)
COVID-19/therapy , Critical Care , Health Care Rationing , Hospitalization , Intensive Care Units , Pandemics , Triage , Adolescent , Adult , Aged , Aged, 80 and over , COVID-19/mortality , Computer Simulation , Critical Care/ethics , Ethics, Clinical , Female , Health Care Rationing/ethics , Health Care Rationing/methods , Humans , Intensive Care Units/ethics , Male , Middle Aged , Pandemics/ethics , Prognosis , SARS-CoV-2 , Triage/ethics , Triage/methods , United Kingdom , Young Adult
3.
BMJ Support Palliat Care ; 11(2): 133-137, 2021 Jun.
Article in English | MEDLINE | ID: covidwho-1066896

ABSTRACT

The COVID-19 pandemic has made unprecedented global demands on healthcare in general and especially the intensive care unit (ICU). the virus is spreading out of control. To this day, there is no clear, published directive for doctors regarding the allocation of ICU beds in times of scarcity. This means that many doctors do not feel supported by their government and are afraid of the medicolegal consequences of the choices they have to make. Consequently, there has been no transparent discussion among professionals and the public. The thought of being at the mercy of absolute arbitrariness leads to fear among the population, especially the vulnerable groups.


Subject(s)
COVID-19/therapy , Intensive Care Units/ethics , Pandemics/ethics , Triage/ethics , Triage/methods , COVID-19/diagnosis , Humans , SARS-CoV-2
4.
Bioethics ; 35(2): 125-134, 2021 02.
Article in English | MEDLINE | ID: covidwho-1066621

ABSTRACT

In March 2020, the rapid increase in severe COVID-19 cases overwhelmed the healthcare systems in several European countries. The capacities for artificial ventilation in intensive care units were too scarce to care for patients with acute respiratory disorder connected to the disease. Several professional associations published COVID-19 triage recommendations in an extremely short time: in 21 days between March 6 and March 27. In this article, we compare recommendations from five European countries, which combine medical and ethical reflections on this situation in some detail. Our aim is to provide a detailed overview on the ethical elements of the recommendations, the differences between them and their coherence. In more general terms we want to identify shortcomings in regard to a common European response to the current situation.


Subject(s)
COVID-19/therapy , Health Care Rationing , Standard of Care/ethics , Triage/ethics , Age Factors , COVID-19/epidemiology , Europe/epidemiology , Health Personnel/ethics , Health Personnel/psychology , Health Priorities , Hospitalization , Human Rights , Humans , Intensive Care Units/ethics , Practice Guidelines as Topic , SARS-CoV-2/physiology , Treatment Outcome , Ventilators, Mechanical/supply & distribution , Withholding Treatment/ethics
5.
J Neurosurg Anesthesiol ; 33(1): 77-81, 2021 Jan.
Article in English | MEDLINE | ID: covidwho-1029805

ABSTRACT

BACKGROUND: The World Health Organisation declared a coronavirus disease 2019 (COVID-19) pandemic on March 11, 2020. Following activation of the UK pandemic response, our institution began planning for admission of COVID-19 patients to the neurointensive care unit (neuro-ICU) to support the local critical care network which risked being rapidly overwhelmed by the high number of cases. This report will detail our experience of repurposing a neuro-ICU for the management of severely ill patients with COVID-19 while retaining capacity for urgent neurosurgical and neurology admissions. METHODS: We conducted a retrospective process analysis of the repurposing of a quaternary level neuro-ICU during the early stages of the COVID-19 pandemic in the United Kingdom. We retrieved demographic data, diagnosis, and outcomes from the electronic health care records of all patients admitted to the ICU between March 1, 2020 and April 30, 2020. Processes for increase in surge capacity, reduction in ICU demand, and staff redeployment and rapid training are reported. RESULTS: Over a 10-day period, total ICU capacity was increased by 21.7% (from 23 to 28 beds) while the capacity to provide mechanical ventilation was increased by 77% (from 13 to 23 beds). There were 30 ICU admissions of 29 COVID-19 patients between March 1 and April 30, 2020; median (range) length of ICU stay was 9.9 (1.3 to 32) days, duration of mechanical ventilation 11 (1 to 27) days, and ICU mortality rate 41.4%. There was a 44% reduction in urgent neurosurgical and neurology admissions compared with the same period in 2019. CONCLUSIONS: It is possible to repurpose a dedicated neuro-ICU for the management of critically ill non-neurological patients during a pandemic response, while maintaining access for urgent neuroscience referrals.


Subject(s)
COVID-19/therapy , Intensive Care Units/organization & administration , Nervous System Diseases/therapy , Adult , Aged , COVID-19/mortality , Critical Care , Female , Hospital Bed Capacity , Hospital Mortality , Humans , Intensive Care Units/ethics , Male , Medication Therapy Management , Middle Aged , Pandemics , Patient Admission , Referral and Consultation , Respiration, Artificial , Retrospective Studies , Treatment Outcome , United Kingdom
6.
Int Nurs Rev ; 68(2): 181-188, 2021 Jun.
Article in English | MEDLINE | ID: covidwho-966526

ABSTRACT

AIM: To identify factors underlying ethical conflict occurring during the current COVID-19 pandemic in the critical care setting. BACKGROUND: During the first wave of the COVID-19 outbreak, Spanish and Italian intensive care units were overwhelmed by the demand for admissions. This fact revealed a crucial problem of shortage of health resources and rendered that decision-making was highly complex. SOURCES OF EVIDENCE: Applying a nominal group technique this manuscript identifies a series of factors that may have played a role in the emergence of the ethical conflicts in critical care units during the COVID-19 pandemic, considering ethical principles and responsibilities included in the International Council of Nurses Code of Ethics. The five factors identified were the availability of resources; the protection of healthcare workers; the circumstances surrounding decision-making, end-of-life care, and communication. DISCUSSION: The impact of COVID-19 on health care will be long-lasting and nurses are playing a central role in overcoming this crisis. Identifying these five factors and the conflicts that have arisen during the COVID-19 pandemic can help to guide future policies and research. CONCLUSIONS: Understanding these five factors and recognizing the conflicts, they may create can help to focus our efforts on minimizing the impact of the ethical consequences of a crisis of this magnitude and on developing new plans and guidelines for future pandemics. IMPLICATIONS FOR NURSING PRACTICE AND POLICY: Learning more about these factors can help nurses, other health professionals, and policymakers to focus their efforts on minimizing the impact of the ethical consequences of a crisis of this scale. This will enable changes in organizational policies, improvement in clinical competencies, and development of the scope of practice.


Subject(s)
COVID-19/therapy , Decision Making/ethics , Ethics, Institutional , Intensive Care Units/ethics , Pneumonia, Viral/therapy , Terminal Care/ethics , COVID-19/epidemiology , Humans , Italy/epidemiology , Pandemics , Pneumonia, Viral/epidemiology , Pneumonia, Viral/virology , SARS-CoV-2 , Spain/epidemiology
7.
Ann Am Thorac Soc ; 18(5): 838-847, 2021 05.
Article in English | MEDLINE | ID: covidwho-922722

ABSTRACT

Rationale: During the coronavirus disease (COVID-19) pandemic, many intensive care units (ICUs) have shifted communication with patients' families toward chiefly telehealth methods (phone and video) to reduce COVID-19 transmission. Family and clinician perspectives about phone and video communication in the ICU during the COVID-19 pandemic are not yet well understood. Increased knowledge about clinicians' and families' experiences with telehealth may help to improve the quality of remote interactions with families during periods of hospital visitor restrictions during COVID-19.Objectives: To explore experiences, perspectives, and attitudes of family members and ICU clinicians about phone and video interactions during COVID-19 hospital visitor restrictions.Methods: We conducted a qualitative interviewing study with an intentional sample of 21 family members and 14 treating clinicians of cardiothoracic and neurologic ICU patients at an academic medical center in April 2020. Semistructured qualitative interviews were conducted with each participant. We used content analysis to develop a codebook and analyze interview transcripts. We specifically explored themes of effectiveness, benefits and limitations, communication strategies, and discordant perspectives between families and clinicians related to remote discussions.Results: Respondents viewed phone and video communication as somewhat effective but inferior to in-person communication. Both clinicians and families believed phone calls were useful for information sharing and brief updates, whereas video calls were preferable for aligning clinician and family perspectives. Clinicians and families expressed discordant views on multiple topics-for example, clinicians worried they were unsuccessful in conveying empathy remotely, whereas families believed empathy was conveyed successfully via phone and video. Communication strategies suggested by families and clinicians for remote interactions include identifying a family point person to receive updates, frequently checking family understanding, positioning the camera on video calls to help family see the patient and their clinical setting, and offering time for the family and patient to interact without clinicians participating.Conclusions: Telehealth communication between families and clinicians of ICU patients appears to be a somewhat effective alternative when in-person communication is not possible. Use of communication strategies specific to phone and video can improve clinician and family experiences with telehealth.


Subject(s)
COVID-19 , Family/psychology , Infection Control/organization & administration , Intensive Care Units , Professional-Family Relations/ethics , Telecommunications , Attitude of Health Personnel , COVID-19/epidemiology , COVID-19/psychology , COVID-19/therapy , Communication , Emotional Intelligence , Female , Humans , Intensive Care Units/ethics , Intensive Care Units/organization & administration , Male , Middle Aged , Pennsylvania , Physical Distancing , Qualitative Research , SARS-CoV-2 , Telecommunications/ethics , Telecommunications/standards , Telemedicine
10.
Medwave ; 20(5): e7935, 2020 Jun 16.
Article in Spanish, English | MEDLINE | ID: covidwho-608950

ABSTRACT

The current COVID-19 pandemic has the potential to overwhelm the capacity of hospitals and Intensive Care Units in Chile and Latin America. Thus local authorities have an ethical obligation to be prepared by implementing pertinent measures to prevent a situation of rationing of scarce healthcare resources, and by defining ethically acceptable and socially legitimate criteria for the allocation of these resources. This paper responds to recent ethical guidelines issued by a Chilean academic institution and discusses the main moral principles for the ethical foundations of criteria for rationing during the present crisis. It argues that under exceptional circumstances such as the current pandemic, the traditional patient-centered morality of medicine needs to be balanced with ethical principles formulated from a public health perspective, including the principles of social utility, social justice and equity, among others. The paper concludes with some recommendations regarding how to reach an agreement about rationing criteria and about their implementation in clinical practice.


La actual pandemia por COVID-19 tiene el potencial de sobrepasar la capacidad de hospitales y unidades de cuidados intensivos en Chile y América Latina. Por lo tanto, las autoridades locales tienen la obligación ética de estar preparadas mediante la implementación de medidas tendientes a evitar una situación de racionamiento de recursos sanitarios escasos, y a través de la definición de criterios éticamente aceptables y socialmente legítimos para la asignación de estos recursos. Este artículo presenta una respuesta a orientaciones éticas recientes emitidas por una institución académica chilena y analiza los principios éticos relevantes para la fundamentación ética de criterios de racionamiento. Se argumenta que, frente a circunstancias excepcionales como la actual pandemia, la moral centrada en el paciente de la medicina tradicional necesita ser ponderada con principios éticos formulados desde una perspectiva de salud pública, incluyendo los principios de utilidad social, justicia social y equidad, entre otros. Se concluye con algunas recomendaciones sobre cómo llegar a acuerdo sobre criterios de racionamiento y sobre la implementación de estos en la práctica clínica.


Subject(s)
Coronavirus Infections/therapy , Health Care Rationing/ethics , Pneumonia, Viral/therapy , Public Health/ethics , Surge Capacity/statistics & numerical data , COVID-19 , Chile , Coronavirus Infections/epidemiology , Guidelines as Topic , Hospitals/ethics , Hospitals/statistics & numerical data , Humans , Intensive Care Units/ethics , Intensive Care Units/statistics & numerical data , Latin America , Pandemics , Pneumonia, Viral/epidemiology , Social Justice
11.
Hastings Cent Rep ; 50(3): 71-72, 2020 May.
Article in English | MEDLINE | ID: covidwho-619891

ABSTRACT

Ethicists and physicians all over the world have been working on triage protocols to plan for the possibility that the Covid-19 pandemic will result in shortages of intensive care unit beds, ventilators, blood products, or medications. In reflecting on those protocols, many health care workers have noticed that, outside the pandemic shortage situation, we routinely supply patients in the ICU with invasive and painful care that will not help the patients survive even their hospitalization. This is the kind of pointless care that even the most basic protocol would triage against. Perhaps this widespread reflection on triage standards will draw our attention to our ongoing custom of supplying burdensome and inefficacious care to those near the end of life-care that most health care providers would not want for themselves. This essay argues that reflecting on triage could help us improve end-of-life care.


Subject(s)
Coronavirus Infections/epidemiology , Health Care Rationing/ethics , Intensive Care Units/ethics , Pneumonia, Viral/epidemiology , Terminal Care/ethics , Triage/ethics , Betacoronavirus , COVID-19 , Health Care Rationing/organization & administration , Humans , Intensive Care Units/organization & administration , Pandemics , SARS-CoV-2 , Terminal Care/organization & administration , Triage/organization & administration
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