Coffee with Katarina- COVID-19

April 28 2020

Welcome to Socially Distanced Coffee with Katarina- a COVID-19 discussion. Katarina Lee-Ameduri, Clinical Ethicist for St. Boniface Hospital and the Catholic Health Corporation of Manitoba as well as an Assistant Professor in the Department of Family Medicine at the University of Manitoba.

During this difficult time, if you are struggling with an ethical issue and would like to discuss it with Katarina, please do not hesitate to reach out via email at klee13@sbgh.mb.ca or phone at 204.794.2511

With the limited data that we have in relation to COVID-19, an unprecedented global pandemic, it’s hard to create policies and regulations that have extensive research behind them. We’ve heard a lot about flattening the curve, keeping the demand on hospitals at a reasonable level, to assure everyone in need, can receive care. Ventilators seem to me a piece of equipment that we hear about in the media and from our governments. How are some of these triage decisions made?

The way that we have looked at ventilators, and who should receive one if supplies are limited, started in recent years with H1N1. The New York State  Department of Health and the New York State Task Force on Life and the Law created a document that is widely regarded as a very robust guidance for who may have access to critical medical equipment, if there is a shortage in global health crises, like a pandemic. If you are interested in reading the whole document, it can be found here

A summary of a few of the issues from this document are things like:

  • Who is excluded? An example may be people who are terminally ill and not likely to survive, even with the help of a ventilator. Who is included? What medical factors should be taken into consideration?
  • The principle of Reciprocity – should an essential worker, such as health care workers receive a ventilator before another person? During the H1N1 crisis, the pandemic was arguably shorter, and the chances of a healthcare worker catching H1N1, recovering and being able to get back to work to help with the crisis was very low. With COVID-19, the likelihood is much higher as unfortunately most modeling is suggesting we will be addressing Covid-19 for many more months. There is a lot of room for debate as to whether essential workers ought to receive priority. There is significant support to provide easier access to health care providers to Covid-19 testing, but whether they ought to receive medical intervention sooner is ethically challenging.

The New York document also discusses triage suggestions for the dissemination of medical equipment, such as ventilators.

A lottery system– anyone who is in need, is entered into a lottery and picked at random. All things being equal, if there are seven patients needing ventilators (and they are all clinically similar), five will be picked at random to receive a ventilator. The suggested use of a lottery system occurs when there are too many people with the same condition and limited amounts of resources. Methods like a lottery system have been considered in places like Italy where the medical system was completely overwhelmed by Covid-19.

A first come first serve situation– if you were in the hospital before the next person, you would receive the ventilator. For example, if there are seven people who need a ventilator, the first five will receive a ventilator and the last two to enter the hospital will not. This model, while the easiest to implement raises ethical issues of fairness. Those who live closer to health care centers benefit compared to those in rural settings.

Life age– receiving a ventilator on the basis of age, example a 40 year old would receive the medical equipment before a 50 year old would. That’s quite debatable, looking at a person’s health isn’t necessarily reflective of age and vice-versa. Someone who is 50 without any previous health issues and someone who is 40 with multiple health issues could be an example. Many ethicists, myself included, find age to be often problematic when considering pandemic ethics. Remarkably, H1N1 impacted younger people more dramatically than elderly. Interestingly, almost half of the individuals in the US who were on a ventilator due to Covid-19 were young people.

As you can see- lots of discussions, debates and ways to look at it!

In Manitoba, fortunately so far, we have been able to avoid this kind of difficult decision-making. By continuing to take measures to flatten the curve and ease the burden on the health care system, we can avoid it all together.

While this pandemic has created a very difficult situation, it has also given our province the opportunity to evaluate the equipment that we have and what we could possibly need in the future, ventilators, ECMO machines and other life-saving devices.

Another area where we are seeing rapid policy change is within Personal Protective Equipment (PPE), can you help provide some insight?

Essentially health care institutions have an ethical obligation to protect their staff, including with the provision of PPE. The “sticky” issue with PPE in Covid-19 is that suggestions about PPE change as we continue to learn more about the virus, and at the same time health care institutions have to balance supply-chain considerations.

From my perspective, the least amount of PPE that can be used safely is the most appropriate. For example, we wouldn’t want someone who is cleaning a hallway to be in full gear at this point in time, but someone who is intubating a patient ought to have a greater amount of PPE because the activity they are doing is riskier. We need to prudential with our resources.

Of course, there can be situations that pose questions such as- what if I don’t have the recommended PPE? Am I obligated to continue to work? Interestingly, many professions such as nursing and medicine have codes of ethics that somewhat touch on these issues, but often these types of circumstances are left to the individual provider to determine.

One question that we can look at addressing:

Are there particular health care providers with certain skill sets but they may have their own vulnerabilities, such as underlying health conditions, children, elderly parents? If so, is there a way to triage amongst our health care providers who is going to assume these types of risk. Thankfully in Manitoba we have PPE and we haven’t had a huge surge in cases, but in places like New York these are very real considerations.

Covid-19 has been an immensely tragic and traumatic worldwide event. Health care workers as well as many others in Manitoba have my immense gratitude for their work.

Katarina is now working remotely, and is available via email and telephone at klee13@sbgh.mb.ca or 204.794.2511

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