Phases of a Pandemic Surge: The Experience of an Ethics Service in New York City during COVID-19.

When the COVID-19 surge hit New York City hospitals, the Division of Medical Ethics at Weill Cornell Medical College, and our affiliated ethics consultation services, faced waves of ethical issues sweeping forward with intensity and urgency. In this article, we describe our experience over an eight-week period (16 March through 10 May 2020), and describe three types of services: clinical ethics consultation (CEC); service practice communications/interventions (SPCI); and organizational ethics advisement (OEA). We tell this narrative through the prism of time, describing the evolution of ethical issues and trends as the pandemic unfolded. We delineate three phases: anticipation and preparation, crisis management, and reflection and adjustment. The first phase focused predominantly on ways to address impending resource shortages and to plan for remote ethics consultation, and CECs focused on code status discussions with surrogates. The second phase was characterized by the dramatic convergence of a rapid increase in the number of critically ill patients, a growing scarcity of resources, and the reassignment/redeployment of staff outside their specialty areas. The third phase was characterized by the recognition that while the worst of the crisis was waning, its medium- and long-term consequences continued to pose immense challenges. We note that there were times during the crisis that serving in the role of clinical ethics consultant created a sense of dis-ease as novel as the coronavirus itself. In retrospect we learned that our activities far exceeded the familiar terrain of clinical ethics consultation and extended into other spheres of organizational life in novel ways that were unanticipated before this pandemic. To that end, we defined and categorized a middle level of ethics consultation, which we have termed service practice communication intervention (SPCI). This is an underappreciated dimension of the work that ethics consult services are capable of in times of crisis. We believe that the pandemic has revealed the many enduring ways that ethics consultation services can more robustly contribute to the ethical life of their institutions moving forward.

Ethics and Professionalism 2016.

Whether a reaction to events in the clinical arena, a consequence of technological innovation, or the legitimization of the marked ethos in health care, the field of medical ethics has become a complex domain in our time. Indeed, the ubiquity of ethical dilemmas in the provision of health care is well documented with more than 99% of primary care physicians reporting ethical problems arising in the conduct of their practices (1-3). Although commentary relating to this domain has most often originated in the primary care setting, hospital-based medicine and its ethics committees are another fertile source, as is medical research. Yet when one examines subspecialty medicine, a remarkable dearth of analysis and discourse pertaining to medical ethics emerges. This discussion is an attempt to address this deficit, at least as it pertains to one subspecialty: rheumatology. Leading with a brief overview of medical ethics writ large, perceptions concerning the ethical challenges arising in current rheumatic disease practice will be presented, hopefully enhancing awareness and sensitivity to the ethical challenges arising in modern day medical practice.

Stress Dose Steroids: Myths and Perioperative Medicine.

Perioperative medication management for patients with systemic autoimmune inflammatory diseases has focused on strategies to improve outcomes and mitigate risks. The emphasis has been to minimize the risk of infection associated with most antirheumatic medications, while attempting to avoid flares of disease precipitated by medication withdrawal. Management of glucocorticoids in the perioperative period has been based on an assumption that supraphysiologic increases in dose were always necessary to avoid hypotension and shock in glucocorticoid treated patients, and alternative strategies were rarely considered despite the known infectious, metabolic, and wound healing risks associated with glucocorticoid administration. This paper will review current recommendations for perioperative glucocorticoid administration for glucocorticoid treated patients with systemic inflammatory autoimmune diseases and discuss glucocorticoid physiology to analyze the basis for these recommendations and consider alternative perioperative management strategies.

Ethical considerations in chronic musculoskeletal disease.

Chronic diseases compromise the life of the sufferer, encumber their families, and exert intractable burdens on the health-care system. With the aging of the population, such conditions have become the primary determinants of morbidity and mortality and the leading cause of disability in our society. Despite the serious challenges they impose, the ethical discourse engendered by them has lagged behind that of acute care medicine. Of particular relevance are the challenges to individual autonomy, as the dilemmas arising in the chronic care setting have not only medical but personal and societal dimensions, may require the input of multiple participants, and resolve over longer periods of time. As such, the conventional model of autonomy is often inadequate to address problems in the chronic care setting. This paper deals with this dilemma through an examination of a clinical scenario. A framework for the exploration of ethical problems in the chronic care setting is thus presented.

Perioperative outcomes in patients with rheumatoid versus osteoarthritis for total hip arthroplasty: a population-based study.

OBJECTIVES: Little is known about perioperative outcomes among the subset of patients undergoing total hip arthroplasty (THA) for a diagnosis of rheumatoid arthritis (RA) rather than osteoarthritis (OA). We sought to 1) identify the prevalence of RA in patients undergoing THA, 2) compare their demographics to those being operated on for OA, 3) determine differences in perioperative outcomes and 4) analyse if RA represents an independent risk factor for complications, mortality, utilisation of resources, increased length of stay and cost. METHODS: Entries of patients who underwent elective THA between 2006 and 2010 were identified in a national database and subgrouped according to presence of a concurrent diagnosis of RA. Differences in demographics and perioperative outcomes were analysed. RESULTS: We identified 157,775 entries for patients who underwent THA between 2006 and 2010. RA was present in 3.42% (n=5,400). Patients in the group RA were on average younger [RA: 63.94 years vs. OA: 65.64 years; p<0.0001] and more likely female [RA: 75.47% vs. OA: 56.09%; p<0.0001]. While mortality was not statistically different, perioperative pulmonary and infectious complications occurred more frequently in RA patients. Compared with OA, multivariate logistic regression revealed higher overall odds for complications [OR=1.15 (CI 1.05;1.25), p=0.0037], need for mechanical ventilation [OR=1.42 (CI 1.01;2.00), p=0.0414], transfusion [OR=1.35 (CI 1.26;1.44), p<0.0001], prolonged hospitalisation [OR=1.16 (CI 1.08;1.23), p<0.0001] and increased hospital charges [OR=1.17 (CI 1.09;1.26), p<0.0001]. CONCLUSIONS: In THA patients suffering from RA, perioperative risk for complications and utilization of health care resources continues to be increased compared to OA patients.

Cardiovascular risk in the rheumatic disease patient undergoing orthopedic surgery.

A hallmark of the rheumatic diseases, including systemic lupus erythematosis, spondyloarthritis, and rheumatoid arthritis, has been sustained inflammation, which typically targets the joint and may lead to joint destruction. Inflammation also plays a role in atherosclerotic cardiovascular disease, which is highly prevalent in patients with rheumatic diseases. Total joint arthroplasty, considered an intermediate cardiac risk procedure by the American College of Cardiology, maintains an important role in the management of rheumatic disease patients who progress to end-stage joints. The purpose of this article is to discuss the role of inflammation in cardiovascular disease, the prevalence of cardiovascular disease in patients with systemic rheumatic diseases, and the role of cardiovascular risk assessment when these patients undergo total joint arthroplasty.

Ethical challenges in rheumatology: a survey of the American College of Rheumatology membership.

OBJECTIVE: Despite the frequency of ethical issues arising in patient care, ethical discourse in the rheumatology literature is negligible. To better understand the scope of ethical problems occurring in our specialty, the American College of Rheumatology (ACR) Committee on Ethics and Conflict of Interest surveyed ACR members. Specific objectives of the survey were 1) to learn the perceived frequency of ethical issues in rheumatology, 2) to identify activities that pose ethical problems in rheumatologic practice, 3) to determine the extent of education on, and self-perceived knowledge about, ethics among ACR members, and 4) to determine member interest in, and suggest content for, future ACR-sponsored educational activities related to bioethics. METHODS: The survey included 12 non-open-ended questions addressing 5 core areas: 1) ethical dilemmas in daily practice, 2) ethical concerns in basic and clinical research, 3) influence of industry, 4) ethics of regulatory policies, potential conflicts, and disclosure, and 5) personal education on and interest in ethics. Two open-ended questions were also included, asking respondents to list the ethical issues most relevant to rheumatology and to provide any comments. Data analysis was descriptive. RESULTS: Seven hundred seventy-one responses were received. Respondents believed that ethical issues arise most frequently in practice and in clinical research. The most common ethical issues cited were the high cost of treatment for patients (51% of respondents) and for society (48%), and the practice of defensive medicine (45%). CONCLUSION: The survey results suggest that ethical problems in rheumatology are of concern to the ACR membership. Further, there is a perceived need for educational programs targeted at helping members address such professional challenges.

Cardiac Arrest during Total Hip Arthroplasty in a Patient on an Angiotensin Receptor Antagonist.

Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor antagonists (ARA) are effective and well-tolerated first-line drugs in the therapy of hypertension and, therefore, are frequently encountered in the perioperative setting. Hemodynamic compensation for volume depletion seen in the perioperative period is normally mediated by the renin-angiotensin system, which is blocked by ACEI/ARA. These drugs may contribute to severe hypotension during anesthesia induction and may have contributed to the cardiac arrest seen in this patient. Additional factors such as increased intra-abdominal pressures and respiratory obstructive episodes leading to diminished venous return, as well diuretic use and the fasting state, common in the perioperative orthopedic patient, are likely to have contributed as well. Medication use may be an easily modifiable risk factor for severe hypotension and possible cardiac arrest in the perioperative setting.

Perioperative management of patients with connective tissue disease.

Diseases of the connective tissue are a varied group of disorders with major musculoskeletal manifestations such as joint pain and loss of function. As a consequence of the accompanying inflammatory joint disease, such patients often require surgery. Due to the protean organ-related consequences of these conditions, patients who suffer from chronic connective tissue disease are a highly challenging population in the perioperative context. This paper reviews the management of such patients in this clinical setting.

Complementary and alternative medicine in rheumatoid arthritis: no longer the last resort!

Complementary and alternative medicine (CAM) has become popular with consumers worldwide and accounts for significant private and public health expenditures. According to earlier reports, the prevalence of CAM use by rheumatoid arthritis (RA) patients in the United States is anywhere between 28% and 90%. Extensive use among RA patients and the limited knowledge among physicians had confirmed the need to evaluate the increasing prevalence of various CAM modalities. The primary aim of this study was to identify the incidence of CAM usage among our RA patients. Additionally, we aimed to correlate patient demographics and disease characteristics with the use of specific CAM modalities. An analysis of data extracted from our institution's RA longitudinal registry was performed. The patients were asked to select from a list the modalities they were currently using and/or had used in the past. Of patients, 75.9% reported current or past use of CAM with >10% using 12 different modalities. Nutritional supplements and touch therapies were the most widely used overall, with mind-body therapies more prevalent among younger patients. CAM users were found to have more extra-articular manifestations and fewer comorbidities than non-CAM users. The use of CAM among RA patients is widespread with a broad spectrum of CAM modalities being used in early stages of the disease, frequently in conjunction with mainstream conventional treatments. Therefore, CAM may no longer be considered the rheumatoid patients' last resort.

Perioperative outcomes after unilateral and bilateral total knee arthroplasty.

BACKGROUND: The safety of bilateral total knee arthroplasties (BTKAs) during the same hospitalization remains controversial. The authors sought to study differences in perioperative outcomes between unilateral and BTKA and to further compare BTKAs performed during the same versus different operations during the same hospitalization. METHODS: Nationwide Inpatient Sample data from 1998 to 2006 were analyzed. Entries for unilateral and BTKA procedures performed on the same day (simultaneous) and separate days (staged) during the same hospitalization were identified. Patient and healthcare system-related demographics were determined. The incidences of in-hospital mortality and procedure-related complications were estimated and compared between groups. Multivariate regression was used to identify independent risk factors for morbidity and mortality. RESULTS: Despite younger average age and lower comorbidity burden, procedure-related complications and in-hospital mortality were more frequent after BTKA than after unilateral procedures (9.45% vs. 7.07% and 0.30% vs. 0.14%; P < 0.0001 each). An increased rate of complications was associated with a staged versus simultaneous approach with no difference in mortality (10.30% vs. 9.15%; P < 0.0001 and 0.29% vs. 0.26%; P = 0.2875). Independent predictors for in-hospital mortality included BTKA (simultaneous: odds ratio, 2.23 [95% confidence interval, 1.69-2.95]; P < 0.0001; staged: odds ratio, 2.01 [confidence interval, 1.28-3.41]; P = 0.0031), male sex (odds ratio, 2.02 [confidence interval, 1.75-2.34]; P < 0.0001), age older than 75 yr (odds ratio, 3.96 [confidence interval, 2.77-5.66]; P < 0.0001), and the presence of a number of comorbidities and complications. CONCLUSION: BTKAs carry increased risk of perioperative morbidity and mortality compared with unilateral procedures. Staging BTKA procedures during the same hospitalization offers no mortality benefit and may even expose patients to increased morbidity.

What would a good doctor do? Reflections on the ethics of medicine.

Ethical challenges are prevalent in modern-day medicine. Whether arising in the daily practice of medicine, in the conduct of research, or in our educational practices, physicians need to understand the relevance ethics plays in our professional lives. This paper examines the ethical foundations of medical ethics, suggests qualities that define optimal professionalism, and frames the discussion employing two hypothetic case presentations.