Coronavirus and Ethics: Mapping the Moral Dimensions of an Outbreak Dr. William Harper, Internal Medicine Dr. Simon Oczkowski, Critical Care Dr. Julija Kelecevic, Regional Ethicist Dr. Andrea Frolic, Director, Office of Clinical & Organizational Ethics
Take a Breath… How is your body feeling? Can you release tension? Can you focus on the present? How can you take care of yourself now? What is your intention? 2
Objectives ► Map some of the major ethical issues arising in outbreaks and pandemics ► Articulate the values that inform ethical decision-making in situations of ambiguity, uncertainty and overwhelm ► Discuss policies that can support social solidarity, protection of the vulnerable and wise resource allocation ► Describe practical resilience strategies to support yourself and your community 3
Ethical Issues in Substantive and Pandemic Procedural Values Response 4
Action is being taken at all levels of the healthcare system Nation Province Region My My Team Me Organization
Ethical Issues in Pandemic Response ► How to reduce rate of spread, balancing social/economic disruption with public health needs? ► How to protect the most vulnerable? ► How to balance individual liberty and communal good? ► How to support and protect front-line workers? ► How to allocate scarce resources (medicine, ventilators, vaccines)? ► How to support fair, evidence-based, practical decision-making in situations of overwhelm? 6
http://jcb.utoronto.ca/news/covid-19.shtml 7
Ethical Values Substantive Values : Procedural Values: ► Social Solidarity ► Reasonable ► Fairness and Equity ► Open & Transparent ► Protection of the public from ► Inclusive harm ► Responsive ► Proportionality ► Accountable ► Duty to provide care and protect others ► Reciprocity ► Trust ► Stewardship of resources ► Individual Liberty 8
COVID-19 and Protecting the Precautionary Vulnerable and the Healthcare System Principles 9
Coronavirus disease 2019 (COVID-19) • Virus: Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) • Outbreak epicenter: Huanan Wholesale Market December 2019 (bats, pangolins?) • Spread respiratory droplets from coughing or sneezing with R0 2-3 (influenza R0 1.3) • Incubation period range 1-14d, median 5-6d – Asymptomatic infectious phase 1-2d? • Diagnosis: rt-PCR nasal swab or sputum, serology • Treatment: supportive, glucocorticoids if ARDS – Experimental: remdesivir, choloroquine?
Critical Care Putting Procedural Resource Values and Evidence into Practice Allocation 18
tri·age | \ trē - ˈ äzh a: the sorting of and allocation of treatment to patients and especially battle and disaster victims according to a system of priorities designed to maximize the number of survivors b: the sorting of patients (as in an emergency room) according to the urgency of their need for care
Triage is a process which already happens every day, with every stay … in a pandemic, the focus shifts from individual ➝ societal interests Triage should be reasonable, inclusive, transparent, responsive, and accountable
1. Clinical need & benefit • need for respiratory support (ventilators) and hemodynamic support (vasopressors and inotropes) • is the patient sick enough to benefit or too sick to benefit? (initial and ongoing assessment, using standardized criteria, eg. SOFA) • does the patient have a condition which limits survivability? • is there evidence this patient is more likely to survive and function than others? 2. Supplementary factors???? • multiplier effect — is the patient an essential service whose survival will help care for future patients? • workplace exposure — did they contact the disease while working in essential services? • caregivers — is the individual a caregiver for whom survival could impact the care of their dependents? • fair-innings/life-cycle: are they at an earlier stage in their life cycle than others requiring care now?
Note: -repeated patient assessment -provision for deliberation and transparent lottery process -ongoing committee review to ensure quality
Example: Ontario MoHLTC 2008 NOTE: Requires adjustment of standard of care, including consent requirements for withdrawing/withholding treatment to maximize benefit for greatest number.
Clinicians are at serious risk when these conditions are sustained under pandemic conditions • exhaustion • personal (& family) risk • moral injury • depersonalization • decision fatigue We need to support and protect our team: -shared decision-making -transparent, fair process -clear documentation
On Solidarity in #inthistogether Crisis 25
“Collective forethought and a board consensus would go far in helping to tackle the unique moral and ethical dilemmas that will arise when a catastrophic event occurs” (Iserson and Pesik, 2003)
Solidarity (from “ Ethical Framework for Resource Allocation During the Drug Supply Shortage” ) • Build, preserve and strengthen inter-professional, inter- institutional, inter-sectoral, and where appropriate, inter- provincial/territorial collaborations and partnerships by: • Embracing a shared commitment to the well-being of patients regardless of care setting or geographic location • Establishing, encouraging, and enabling open lines of communication and coordination amongst health professionals, health institutions, and health sectors • Encouraging sharing of resources across health sectors, health institutions, and, where appropriate, provinces/territories • Supporting each other’s allocation decisions consistent with the ethical framework
Solidarity • as a substantive value • as a readjustment in “WE - OTHERS” concept • as an intentional practice of cooperation
Resilience Protective Be the Vector of Care Equipment (RPE) 30
What is Resilience? The strength and speed of one’s positive adaptation to adversity and the capacity to persevere. Requires a conscious choice to cope, find meaning and hope and to do one’s best. An internal growth process and the ability to make meaning, become stronger or burn brighter than before. RESILIENCE IS CATCHING!! 31
Personal Resources and Preparedness ► Physical preparation: sleep, hydration, nourishment, play, exercise ► Practical preparation: Do you have food and supplies for self- isolation for 14 days (including a functional thermometer!)? Can you log-in from your home computer to support your team at a distance? ► Social preparation : Arrangements for child care, elder care, travel, social gatherings. How to stay connected while apart? ► Mental and emotional preparation: Who are my support people? How can I activate my self-care practices? 32
Be a Vector of Care! I am contagious…in my fears, moods, intentions, actions … * What are the values relevant to this situation? * What do I want my legacy to be in this situation? * How can I be a vector of…solidarity, calm, compassion, care, wisdom? #vectorsofcare For my family For my team For my community
RPE: Resilience Protective Equipment! ► Practice Gratitude: small Calm your nervous system so you make good decisions for yourself pleasures, moments of joy, and others! working together, spring! ► Be Aware: How are you? ► Connect from the heart: Where has your mind gone? Think about the people you Can you come back to this love. Reach out to connect with moment? This is the moment eyes, smiles, words, gestures. you can make a difference! ► Self-compassion : “This is ► Ground yourself: Connect tough, but I have been through with breath. Feet on the floor. tough things before. I am not Release tension. Hand on alone. May I be well. May we be well together.” heart. ► Set intention: What values do I want to embody now? 34
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#ResilienceProtectiveEquipment #InThisTogether #VectorofCare 36
Resources on Novel Coronavirus • Joint Centre for Bioethics: http://jcb.utoronto.ca/news/covid-19.shtml • Public health Ontario: https://www.publichealthontario.ca/en/diseases-and- conditions/infectious-diseases/respiratory-diseases/novel-coronavirus • Public Health Agency of Canada: https://www.canada.ca/en/public- health.html • HHS hub: https://hub.hhsc.ca/
www.hamiltonhealthsciences.ca www.hamiltonhealthsciences.ca
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