COVID-19-Related Ethics Consultations at a Cancer Center in New York City: A Content Review of Ethics Consultations During the Early Stages of the Pandemic.

PURPOSE: The coronavirus disease 2019 (COVID-19) pandemic has raised a variety of ethical dilemmas for health care providers. Limited data are available on how a patient's concomitant cancer diagnosis affected ethical concerns raised during the early stages of the pandemic. METHODS: We performed a retrospective review of all COVID-related ethics consultations registered in a prospectively collected ethics database at a tertiary cancer center between March 14, 2020, and April 28, 2020. Primary and secondary ethical issues, as well as important contextual factors, were identified. RESULTS: Twenty-six clinical ethics consultations were performed on 24 patients with cancer (58.3% male; median age, 65.5 years). The most common primary ethical issues were code status (n = 11), obligation to provide nonbeneficial treatment (n = 3), patient autonomy (n = 3), resource allocation (n = 3), and delivery of care wherein the risk to staff might outweigh the potential benefit to the patient (n = 3). An additional nine consultations raised concerns about staff safety in the context of likely nonbeneficial treatment as a secondary issue. Unique contextual issues identified included concerns about public safety for patients requesting discharge against medical advice (n = 3) and difficulties around decision making, especially with regard to code status because of an inability to reach surrogates (n = 3). CONCLUSION: During the early pandemic, the care of patients with cancer and COVID-19 spurred a number of ethics consultations, which were largely focused on code status. Most cases also raised concerns about staff safety in the context of limited benefit to patients, a highly unusual scenario at our institution that may have been triggered by critical supply shortages.

Respiratory management in severe acute respiratory syndrome coronavirus 2 infection.

The severe acute respiratory syndrome coronavirus 2 pandemic is to date affecting more than a million of patients and is challenging healthcare professionals around the world. Coronavirus disease 2019 may present with a wide range of clinical spectrum and severity, including severe interstitial pneumonia with high prevalence of hypoxic respiratory failure requiring intensive care admission. There has been increasing sharing experience regarding the patient's clinical features over the last weeks which has underlined the need for general guidance on treatment strategies. We summarise the evidence existing in the literature of oxygen and positive pressure treatments in patients at different stages of respiratory failure and over the course of the disease, including environment and ethical issues related to the ongoing coronavirus disease 2019 infection.

All for One and One Delivery Room Approach for All?

Multiple births are increasing in frequency related to advanced maternal age and fertility treatments, and they have an increased risk for congenital anomalies compared to singleton births. However, twins have the same congenital anomalies <15% of the time. Thus, having multiple births with discordant anomalies is a growing challenge for neonatologists. Although external anomalies can often be spotted quickly at delivery or sex differences between multiples can rapidly identify those with internal anomalies described on prenatal ultrasound, we present a case of male multiples, who would optimally receive different initial resuscitation strategies on the basis of the presence or absence of an internal anomaly. The similar size of 4 extremely preterm quadruplets raises concern for whether accurate, immediate identification of 1 neonate with a congenital diaphragmatic hernia will be reliable in the delivery room. Clinicians discuss the ethical considerations of an "all for one" approach to this resuscitation.

Withholding Treatment From the Dying Patient: The Influence of Medical School on Students' Attitudes.

PURPOSE: To determine motives and attitudes towards life-sustaining treatments (LSTs) by clinical and preclinical medical students. METHODS: This was a scenario-based questionnaire that presented patients with a limited life expectancy. The survey was distributed among 455 medical students in preclinical and clinical years. Students were asked to rate their willingness to perform LSTs and rank the motives for doing so. The effect of medical education was then investigated after adjustment for age, gender, religion, religiosity, country of origin, and marital status. RESULTS: Preclinical students had a significantly higher willingness to perform LSTs in all cases. This was observed in all treatments offered in cases of a metastatic oncologic patient and an otherwise healthy man after a traumatic brain injury (TBI). In the case of an elderly woman on long-term care, preclinical students had higher willingness to supply vasopressors but not perform an intubation, feed with a nasogastric tube, or treat with a continuous positive air-pressure ventilator. Both preclinical and clinical students had high willingness to perform resuscitation on a twelve-year-old boy with a TBI. Differences in motivation factors were also seen. DISCUSSION: Preclinical students had a greater willingness to treat compared to clinical students in all cases and with most medical treatments offered. This is attributed mainly to changes along the medical curriculum. Changes in reasons for supplying LSTs were also documented.

Navigating Goals of Care While Confronting an Urgent, Difficult Intubation: A Case Report.

Urgent airway management is challenging because time constraints limit thorough evaluation and planning before endotracheal intubation. In this report, we describe a case in which an airway history review revealed extraordinarily complex airway anatomy that led to a decision not to attempt intubation in a man with end-stage chronic obstructive pulmonary disease. We emphasize the utility of reviewing history and imaging before attempted urgent intubation. We discuss the importance of a multidisciplinary approach that includes the patient, their family, and consultants when high-risk intubation is contemplated. The ethical role of the anesthesiologist is also discussed.

How Should Refusal of Tracheostomy as Part of an Adolescent's Perioperative Planned Intubation Be Regarded?

Here we present a case of a patient in terminal respiratory failure refusing to consent to emergent tracheostomy in the setting of an anticipated difficult intubation. We examine ethical concerns that arise from deviations from the standard of care in the operative setting and the anesthesiologist's sense of culpability. Finally, we will review the ethical arguments and guidelines that support anesthesiologists' participation in palliative operative procedures when limitations on resuscitation are in place.

Experience in Prehospital Endotracheal Intubation Significantly Influences Mortality of Patients with Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis.

BACKGROUND: Patients with severe traumatic brain injury (TBI) are at high risk for airway obstruction and hypoxia at the accident scene, and routine prehospital endotracheal intubation has been widely advocated. However, the effects on outcome are unclear. We therefore aim to determine effects of prehospital intubation on mortality and hypothesize that such effects may depend on the emergency medical service providers' skill and experience in performing this intervention. METHODS AND FINDINGS: PubMed, Embase and Web of Science were searched without restrictions up to July 2015. Studies comparing effects of prehospital intubation versus non-invasive airway management on mortality in non-paediatric patients with severe TBI were selected for the systematic review. Results were pooled across a subset of studies that met predefined quality criteria. Random effects meta-analysis, stratified by experience, was used to obtain pooled estimates of the effect of prehospital intubation on mortality. Meta-regression was used to formally assess differences between experience groups. Mortality was the main outcome measure, and odds ratios refer to the odds of mortality in patients undergoing prehospital intubation versus odds of mortality in patients who are not intubated in the field. The study was registered at the International Prospective Register of Systematic Reviews (PROSPERO) with number CRD42014015506. The search provided 733 studies, of which 6 studies including data from 4772 patients met inclusion and quality criteria for the meta-analysis. Prehospital intubation by providers with limited experience was associated with an approximately twofold increase in the odds of mortality (OR 2.33, 95% CI 1.61 to 3.38, p<0.001). In contrast, there was no evidence for higher mortality in patients who were intubated by providers with extended level of training (OR 0.75, 95% CI 0.52 to 1.08, p = 0.126). Meta-regression confirmed that experience is a significant predictor of mortality (p = 0.009). CONCLUSIONS: Effects of prehospital endotracheal intubation depend on the experience of prehospital healthcare providers. Intubation by paramedics who are not well skilled to do so markedly increases mortality, suggesting that routine prehospital intubation of TBI patients should be abandoned in emergency medical services in which providers do not have ample training, skill and experience in performing this intervention.

Réplica al artículo «Comentarios al artículo Airtraq como dispositivo de primera elección para un lactante con vía aérea difícil conocida» / Reply to the "AIRTRAQ as the Device of Choice for Infants With Known Difficult Airway"

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Intubación traqueal "a ciegas" a través de dos dispositivos supraglóticos: i-gel frente a mascarilla laríngea de intubación ILMA-Fastrach / Blind tracheal intubation through two supraglottic devices: i-gel versus Fastrach intubating laryngeal mask airway (ILMA)

Introducción y objetivos: El empleo de dispositivos supraglóticos como medida de rescate en pacientes con dificultades para la intubación y/o ventilación se ha incrementado en el ámbito de la anestesia y de la medicina de emergencias. Este estudio se diseñó para evaluar la tasa de éxito de intubación "a ciegas" a través de dos dispositivos supraglóticos: la ILMA-Fastrach y la mascarilla i-gel. Pacientes y métodos: Se incluyó a 80 pacientes (40 por grupo). Tras la colocación, se realizó un test de fugas, se comprobó la visión glótica con un fibrobroncoscopio y se intentó la introducción de un tubo endotraqueal a través del dispositivo. Si el intento resultaba fallido, se retiraba el dispositivo y se repetía el procedimiento. Se evaluaron la ventilación adecuada, el grado de visión fibrobroncoscópica, el éxito en la intubación y las complicaciones observadas tras su uso. Resultados: No hubo diferencias en la incidencia de ventilación adecuada entre los dispositivos. La visión glótica (escala de Brimacombe) fue mejor con i-gel (el 77,78 frente al 68,42%) al segundo intento, pero no en el primero. Se consiguió una mayor porcentaje de intubaciones "a ciegas" con ILMA-Fastrach (el 70 frente al 40%; p = 0,013). La incidencia de dolor de garganta fue similar con ambos dispositivos, pero la disfonía postoperatoria fue más frecuente con i-gel (el 20% frente a 0; p = 0,0053). Conclusiones: Ambos dispositivos fueron igual de eficaces para conseguir una adecuada ventilación; sin embargo, ILMA-Fastrach permitió mayor número de intubaciones que igel con menos incidencia de disfonía postoperatoria(AU)

Background and objectives: The use of supraglottic devices as a means of rescue in patients difficult to intubate or ventilate has increased in the field of anaesthetics and in emergency medicine. This study is designed to evaluate the success rate of blind intubations using two supraglottic devices, the Fastrach ILMA and the i-gel mask. Patients and methods: A total of 80 patients (40 per group) were included. After positioning them a leak test was performed, the glottis view was checked with a fibrobronchoscope, and an attempt was made to introduce an endotracheal tube through the device, and the procedure was repeated. Adequate ventilation was evaluated, as well as the grade of fibrobronchoscope view, the success of the intubation, and the complications observed after their use. Results: There were no differences in the incidence of adequate ventilation with either device. The glottis view (Brimacombe scale) was better with i-gel (77.78% versus 68.42%) at the second attempt, but not on the first. A higher percentage of intubations were achieved with the Fastrach ILMA (70% versus 40%; P=.013). The incidence of throat pain was similar with both devices, but post-operative dysphonia was more frequent with i-gel (20% versus 0; P=.0053). Conclusions: Both devices were equally effective in achieving adequate ventilation; however, the Fastrach ILMA enabled a higher number of intubations to be made than i-gel and with a lower incidence of post-operative dysphonia(AU)

Ethics of re-hearsing procedures on a corpse.

You are the attending surgeon of a homeless pedestrian who sustained multiple injuries when struck by a car. He died soon after being brought to the emergency department. It is late in the evening. A first-year resident and a medical student have been helping with the failed attempt at resuscitation. The emergency department is empty, except for your case. A central line kit lies on the bed, opened but not used. The junior resident asks your permission for herself and the student to practice the technique of subclavian cauterization and tracheal intubation on the fresh cadaver to get a "feel" for the procedures. There is no medical simulation for these procedures at your medical center. The best ethical response is: A. Tell them to go ahead and practice. B. They can only practice intubation because it leaves no external wounds. C. You should supervise them yourself to assure educational benefit. D. They should wait until you get permission from the medical examiner. E. The present case is not appropriate for educational purposes.

Conflictos éticos ante la manifestación verbal de las últimas voluntades / Ethical conflicts over verbal statements regarding last wishes

En nuestra realidad socioprofesional en pocas ocasiones tiene lugar una comunicación sincera del equipo con el paciente y su familia que permita cuestionar, ante un proceso de enfermedad, cuál es su decisión al respecto, es decir, si aceptaría o no una intervención. Las decisiones de representación y los testamentos vitales no son más que una prolongación de la incorporación de la autonomía moral de los pacientes en la toma de decisiones clínicas. Sin embargo, la manera más adecuada de hacer efectivo el derecho de los pacientes no es centrarse en estos documentos, sino conseguir desarrollar procesos integrales que fomenten su participación y toma de decisiones. Partiendo de una discusión en la que se entrelazan varios conflictos éticos que conciernen a las últimas voluntades del paciente, planteamos el siguiente caso clínico, que nos permite reflexionar acerca del tipo de intervención más eficaz, cuál debe ser su duración y su intensidad y cómo debemos ser fieles a los deseos y las expresiones del paciente y la familia en estos casos (AU)

Within our socio-professional framework, there are few occasions in which there is sincere communication between health care teams and patients and their families that allows questions to be raised about decisions made during the process of an illness i.e., whether an intervention, or its omission in certain cases, would be accepted. Decisions regarding representation or living wills are merely an extension of the inclusion of the patients’ moral autonomy in clinical decision making. Nevertheless, the best way to make patients’ rights effective is not by focussing on these documents, but rather by achieving the development of integral processes that promote patient participation and decision making. On the basis of a discussion in which a number of ethical conflicts that concern patients’ last wishes are intertwined, we present the following clinical case that allows reflection on the most effective kind of intervention, the nature of its duration and intensity and the way health care professionals must be faithful to patients’ and families’ desires and expressions in these cases (AU)

An analysis of candidate ethical justifications for allowing inexperienced physicians-in-training to perform invasive procedures.

Allowing relatively inexperienced physicians-in-training to perform invasive medical procedures is a widely accepted practice, generally felt to be justified by the need to train future generations of physicians. The ethical justification of this practice, however, is rarely if ever explored in any depth. This essay examines the moral issues associated with this practice, in the setting of a specific clinical scenario involving the emergency intubation of a critically ill newborn. The practice is ultimately shown to be justified based not only on the needs of society and future patients but also on the best interests of the patient being treated. However, several important qualifications need to be satisfied in order for this practice to be ethically permissible. The arguments and qualifications presented can be extended to clinical situations beyond the specific scenario discussed and are relevant to a wide range of medical and surgical settings.