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Moyal-Smith R, Barnett DJ, Toner ES, Marsteller JA, Yuan CT. Embedding Equity into the Hospital Incident Command System: A Narrative Review. Jt Comm J Qual Patient Saf 2024; 50:49-58. [PMID: 38044219 DOI: 10.1016/j.jcjq.2023.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 10/21/2023] [Accepted: 10/23/2023] [Indexed: 12/05/2023]
Abstract
BACKGROUND Disasters exacerbate health inequities, with historically marginalized populations experiencing unjust differences in health care access and outcomes. Health systems plan and respond to disasters using the Hospital Incident Command System (HICS), an organizational structure that centralizes communication and decision-making. The HICS does not have an equity role or considerations built into its standard structure. The authors conducted a narrative review to identify and summarize approaches to embedding equity into the HICS. METHODS The peer-reviewed (PubMed, SCOPUS) and gray literature was searched for articles from high-income countries that referenced the HICS or Incident Command System (ICS) and equity, disparities, or populations that experience inequities in disasters. The primary focus of the search strategy was health care, but the research also included governmental and public health system articles. Two authors used inductive thematic analysis to assess commonalities and refined the themes based on feedback from all authors. RESULTS The database search identified 479 unique abstracts; 76 articles underwent full-text review, and 11 were included in the final analysis. The authors found 5 articles through cited reference searching and 13 from the gray literature search, which included websites, organizations, and non-indexed journal articles. Three themes from the articles were identified: including equity specialists in the HICS, modifying systems to promote equity, and sensitivity to the local community. CONCLUSION Several efforts to embed equity into the HICS and disaster preparedness and response were discovered. This review provides practical strategies health system leaders can include in their HICS and emergency preparedness plans to promote equity in their disaster response.
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McNeilly BP, Lawner BJ, Chizmar TP. The Chronicity of Emergency Department Crowding and Rethinking the Temporal Boundaries of Disaster Medicine. Ann Emerg Med 2023; 81:282-285. [PMID: 36117010 DOI: 10.1016/j.annemergmed.2022.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 06/06/2022] [Accepted: 07/18/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Bryan P McNeilly
- Department of Emergency Medicine, University of Maryland Medical Center, Baltimore, MD.
| | - Benjamin J Lawner
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Timothy P Chizmar
- Maryland Institute for Emergency Medical Services Systems, Baltimore, MD
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3
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O'Sullivan L, Aldasoro E, O'Brien Á, Nolan M, McGovern C, Carroll Á. Ethical values and principles to guide the fair allocation of resources in response to a pandemic: a rapid systematic review. BMC Med Ethics 2022; 23:70. [PMID: 35799187 PMCID: PMC9261249 DOI: 10.1186/s12910-022-00806-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 06/17/2022] [Indexed: 11/21/2022] Open
Abstract
Background The coronavirus 2019 pandemic placed unprecedented pressures on healthcare services and magnified ethical dilemmas related to how resources should be allocated. These resources include, among others, personal protective equipment, personnel, life-saving equipment, and vaccines. Decision-makers have therefore sought ethical decision-making tools so that resources are distributed both swiftly and equitably. To support the development of such a decision-making tool, a systematic review of the literature on relevant ethical values and principles was undertaken. The aim of this review was to identify ethical values and principles in the literature which relate to the equitable allocation of resources in response to an acute public health threat, such as a pandemic. Methods A rapid systematic review was conducted using MEDLINE, EMBASE, Google Scholar, LitCOVID and relevant reference lists. The time period of the search was January 2000 to 6th April 2020, and the search was restricted to human studies. January 2000 was selected as a start date as the aim was to capture ethical values and principles within acute public health threat situations. No restrictions were made with regard to language. Ethical values and principles were extracted and examined thematically. Results A total of 1,618 articles were identified. After screening and application of eligibility criteria, 169 papers were included in the thematic synthesis. The most commonly mentioned ethical values and principles were: Equity, reciprocity, transparency, justice, duty to care, liberty, utility, stewardship, trust and proportionality. In some cases, ethical principles were conflicting, for example, Protection of the Public from Harm and Liberty. Conclusions Allocation of resources in response to acute public health threats is challenging and must be simultaneously guided by many ethical principles and values. Ethical decision-making strategies and the prioritisation of different principles and values needs to be discussed with the public in order to prepare for future public health threats. An evidence-based tool to guide decision-makers in making difficult decisions is required. The equitable allocation of resources in response to an acute public health threat is challenging, and many ethical principles may be applied simultaneously. An evidence-based tool to support difficult decisions would be helpful to guide decision-makers. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-022-00806-8.
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Affiliation(s)
- Lydia O'Sullivan
- School of Medicine, University College Dublin, Dublin 4, Ireland. .,Health Research Board-Trials Methodology Research Network, National University of Ireland Galway, Galway, Ireland.
| | - Edelweiss Aldasoro
- International Foundation for Integrated Care, Annexe Offices, Linton Road, Oxford, OX2 6UD, England
| | | | - Maeve Nolan
- National Rehabilitation Hospital, Dun Laoghaire, Dublin, A96 E2H2, Ireland
| | - Cliona McGovern
- School of Medicine, University College Dublin, Dublin 4, Ireland
| | - Áine Carroll
- School of Medicine, University College Dublin, Dublin 4, Ireland.,International Foundation for Integrated Care and the National Rehabilitation Hospital, Dun Laoghaire, Dublin, Ireland
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4
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Blakely B, Rogers W, Johnson J, Grundy Q, Hutchison K, Clay-Williams R, Richards B, Maddern G. Ethical and regulatory implications of the COVID-19 pandemic for the medical devices industry and its representatives. BMC Med Ethics 2022; 23:31. [PMID: 35321720 PMCID: PMC8942156 DOI: 10.1186/s12910-022-00771-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 03/13/2022] [Indexed: 11/29/2022] Open
Abstract
The development and deployment of medical devices, along with most areas of healthcare, has been significantly impacted by the COVID-19 pandemic. This has had variable ethical implications, two of which we will focus on here. First, medical device regulations have been rapidly amended to expedite approvals of devices ranging from face masks to ventilators. Although some regulators have issued cessation dates, there is inadequate discussion of triggers for exiting these crisis standards, and evidence that this may not be feasible. Given the relatively low evidence standards currently required for regulatory approval of devices, this further indefinite reduction in standards raises serious ethical issues. Second, the pandemic has disrupted the usual operations of device representatives in hospitals, providing an opportunity to examine and refine this potentially ethically problematic practice. In this paper we explain and critically analyse the ethical implications of these two pandemic-related impacts on medical devices and propose suggestions for their management. These include an endpoint for pandemic-related adjustments to device regulation or a mechanism for continued refinement over time, together with a review of device research conducted under crisis conditions, support for the removal and replacement of emergency approved devices, and a review of device representative credentialling.
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Affiliation(s)
- Brette Blakely
- Department of Philosophy, Macquarie University, North Ryde, NSW, Australia. .,The Macquarie University Research Centre for Agency, Values, and Ethics (CAVE), Macquarie University, North Ryde, NSW, Australia.
| | - Wendy Rogers
- Department of Philosophy, Macquarie University, North Ryde, NSW, Australia.,The Macquarie University Research Centre for Agency, Values, and Ethics (CAVE), Macquarie University, North Ryde, NSW, Australia.,School of Medicine, Macquarie University, North Ryde, NSW, Australia
| | - Jane Johnson
- Department of Philosophy, Macquarie University, North Ryde, NSW, Australia.,The Macquarie University Research Centre for Agency, Values, and Ethics (CAVE), Macquarie University, North Ryde, NSW, Australia
| | - Quinn Grundy
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Katrina Hutchison
- Department of Philosophy, Macquarie University, North Ryde, NSW, Australia.,The Macquarie University Research Centre for Agency, Values, and Ethics (CAVE), Macquarie University, North Ryde, NSW, Australia
| | - Robyn Clay-Williams
- Australian Institute of Health Innovation, Macquarie University, North Ryde, NSW, Australia
| | - Bernadette Richards
- Adelaide Law School, The University of Adelaide, Adelaide, SA, Australia.,Future Health Technologies of the Singapore-ETH Centre at CREATE, Singapore, Singapore
| | - Guy Maddern
- Discipline of Surgery, The University of Adelaide, Adelaide, SA, Australia.,The Queen Elizabeth Hospital, Woodville South, SA, Australia
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5
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Tian YJA. The Ethical Unjustifications of COVID-19 Triage Committees. JOURNAL OF BIOETHICAL INQUIRY 2021; 18:621-628. [PMID: 34964927 PMCID: PMC8715149 DOI: 10.1007/s11673-021-10132-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 07/05/2021] [Indexed: 06/14/2023]
Abstract
The ever-debated question of triage and allocating the life-saving ventilator during the COVID-19 pandemic has been repeatedly raised and challenged within the ethical community after shortages propelled doctors before life and death decisions (Anderson-Shaw and Zar 2020; Huxtable 2020; Jongepier 2020; Peterson, Largent, and Karlawish 2020). The British Medical Association's ethical guidance highlighted the possibility of an initial surge of patients that would outstrip the health system's ability to deliver care "to existing standards," where utilitarian measures have to be applied, and triage decisions need to maximize "overall benefit" (British Medical Association 2020, 3) In these emergency circumstances, triage that "grades according to their needs and the probable outcomes of intervention" will prioritize or eliminate patients for treatment, and health professionals may be faced with obligations to withhold or withdraw treatments to some patients in favour of others (British Medical Association 2020, 4). This piece is a response and extension to articles published on the manner of involvement for ethics and ethicists in pandemic triage decisions, particularly examining the ability and necessity of establishing triage committees to ameliorate scarce allocation decisions for physicians.
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Affiliation(s)
- Yi Jiao Angelina Tian
- Institute for Biomedical Ethics, University of Basel, Bernouillistrasse 28, CH-4056, Basel, Switzerland.
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6
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Ghanbari V, Ardalan A, Zareiyan A, Nejati A, Hanfling D, Bagheri A, Rostamnia L. Fair prioritization of casualties in disaster triage: a qualitative study. BMC Emerg Med 2021; 21:119. [PMID: 34645418 PMCID: PMC8513386 DOI: 10.1186/s12873-021-00515-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 10/05/2021] [Indexed: 11/30/2022] Open
Abstract
Background Disasters may result in mass casualties and an imbalance between health care demands and supplies. This imbalance necessitates the prioritization of the victims based on the severity of their condition. Contributing factors and their effect on decision-making is a challenging issue in disaster triage. The present study seeks to address criteria for ethical decision-making in the prioritization of patients in disaster triage. Methods This conventional content analysis study was conducted in 2017. Subjects were selected from among Iranian experts using purposeful and snowball sampling methods. Data were collected using semi-structured interviews and were analyzed by the content analysis. Results Efficient and effective triage and priority-oriented triage were the main categories. These categories summarized a number of medical and nonmedical factors that should be considered in the prioritization of the victims in disaster triage. Conclusion A combination of measures should be considered to maximize the benefits of the prioritization of causalities in disasters. None of these measures alone would suffice to explain all aspects of ethical decision-making in disaster triage. Further investigations are needed to elaborate on these criteria in decision-making. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-021-00515-2.
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Affiliation(s)
- Vahid Ghanbari
- Emergency Nursing Department, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Ali Ardalan
- Health in Disaster and Emergencies Department, School of Public Health, Tehran University of Medical Sciences, Avecina Ave, Keshavarz Boulevard, Tehran, Iran
| | - Armin Zareiyan
- Health in Disaster and Emergencies Department, School of Nursing, AJA University of Medical Sciences, Ehtemadzadeh st, West Fatemi St, Tehran, Iran.
| | - Amir Nejati
- Department of Emergency Medicine, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Dan Hanfling
- Clinical Professor of Emergency Medicine, George Washington University, Washington, DC, USA
| | - Alireza Bagheri
- Center for Medical Ethics and History of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Leili Rostamnia
- Nursing Department, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Ghanbari V, Ardalan A, Zareiyan A, Nejati A, Hanfling D, Bagheri A, Rostamnia L. Perceptions on principle of priority setting in disaster triage: A Q-method study. Int Emerg Nurs 2021; 59:101064. [PMID: 34563940 DOI: 10.1016/j.ienj.2021.101064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 07/23/2021] [Accepted: 07/29/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION An ethical plan is required to make decisions regarding setting the priority for assisting injured patients through triage. The aim of this study was to explore the measures used to sort patients for ethical decision-making in disaster triage. METHOD The participants were 54 clinicians and non-clinicians among the Iranian experts. Q-statements were selected from a literature review and face-to-face interviews. Data were analyzed by principal components factor analysis (PCA), Varimax, and hand-rotation techniques. RESULTS Distinct perspectives included: Saving patients with greater medical needs, survivability of patients and the community, providing effective treatment based on available capacity, maximizing health gain, supporting the human generation and productive and independent lives. Approximately 61% of the variance in decision is explained by these factors. CONCLUSION A combination of saving more people and more positive outcomes has been accepted to make an ethical decision in triage. Public engagement needs to reach a more acceptable view of patients' prioritizing factors in a scarce-resource situation.
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Affiliation(s)
- Vahid Ghanbari
- Emergency Nursing Department, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran.
| | - Ali Ardalan
- Health in Disaster and Emergencies Department, School of Public Health, Tehran University of Medical Sciences, Avecina Ave, Keshavarz Boulevard, Tehran, Iran.
| | - Armin Zareiyan
- Health in Disaster and Emergencies Department, School of Nursing, AJA University of Medical Sciences, Tehran, Iran
| | - Amir Nejati
- Department of Emergency Medicine, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Dan Hanfling
- MD; Clinical Professor of Emergency Medicine, George Washington University, Washington, DC, United States
| | - Alireza Bagheri
- Center for Medical Ethics and History of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Leili Rostamnia
- Nursing Department, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
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8
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Ditwiler RE, Swisher LL, Hardwick DD. Professional and Ethical Issues in United States Acute Care Physical Therapists Treating Patients With COVID-19: Stress, Walls, and Uncertainty. Phys Ther 2021; 101:6267722. [PMID: 33956143 PMCID: PMC8136052 DOI: 10.1093/ptj/pzab122] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/23/2021] [Accepted: 04/14/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To the authors' knowledge, no peer-reviewed research has explored professional and ethical issues encountered by physical therapists in treating patients with COVID-19. The purpose of this study was to explore the experiences of physical therapists regarding the professional and ethical issues they encountered during the COVID-19 pandemic. METHODS The current study used reflexive thematic analysis, a qualitative research design developed by Braun and Clarke, to analyze individual interviews. RESULTS Analysis of the coded interviews produced 6 primary themes (uncertainty, physical therapist's role, ethical dilemmas and moral distress, emotions, providing care and working conditions, and management and leadership influence) and associated subthemes. CONCLUSION Physical therapists reported numerous professional and ethical issues across the individual, organizational, and societal realms during the COVID-19 pandemic. This study highlights the need for education and resources to prepare physical therapists for professional and ethical issues encountered during pandemics. Specifically, there is a need to define the physical therapist's role in pandemics and prepare physical therapy personnel for dealing with ethical issues, stress, uncertainty, and organizational changes associated with pandemics. Ethical guidelines would support organizations in delineating fair processes for triage and allocation of scarce resources for acute care physical therapy during health care emergencies. IMPACT The COVID-19 pandemic has produced significant changes in health care and physical therapist practice. This study reports results of the first, to our knowledge, research study focusing on professional and ethical issues experienced by physical therapists in acute care during the COVID-19 pandemic. As the United States faces an unprecedented spike in COVID-19 cases and deaths, results of this study may contribute to physical therapists' preparation for and response to professional and ethical issues encountered in acute care during the pandemic.
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Affiliation(s)
- Rebecca E Ditwiler
- Address all correspondence to R. E. Ditwiler, PT, DPT, OCS, Associate Professor, School of Physical Therapy and Rehabilitation Sciences, USF Health Morsani College of Medicine, University of South Florida,
| | - Laura L Swisher
- School of Physical Therapy and Rehabilitation Sciences, University of South Florida, Morsani College of Medicine, Tampa, FL
| | - Dustin D Hardwick
- School of Physical Therapy and Rehabilitation Sciences, University of South Florida, Morsani College of Medicine, Tampa, FL
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9
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Kearns AJ. The principle of salvage in the context of COVID-19. Nurs Inq 2020; 28:e12389. [PMID: 33222346 PMCID: PMC7744901 DOI: 10.1111/nin.12389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 10/01/2020] [Accepted: 10/03/2020] [Indexed: 11/29/2022]
Abstract
The prioritisation of scarce resources has a particular urgency within the context of the COVID‐19 pandemic crisis. This paper sets out a hypothetical case of Patient X (who is a nurse) and Patient Y (who is a non‐health care worker). They are both in need of a ventilator due to COVID‐19 with the same clinical situation and expected outcomes. However, there is only one ventilator available. In addressing the question of who should get priority, the proposal is made that the answer may lie in how the pandemic is metaphorically described using military terms. If nursing is understood to take place at the ‘frontline’ in the ‘battle’ against COVID‐19, a principle of military medical ethics—namely the principle of salvage—can offer guidance on how to prioritise access to a life‐saving resource in such a situation. This principle of salvage purports a moral direction to return wounded soldiers back to duty on the battlefield. Applying this principle to the hypothetical case, this paper proposes that Patient X (who is a nurse) should get priority of access to the ventilator so that he/she can return to the ‘frontline’ in the fight against COVID‐19.
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Affiliation(s)
- Alan J Kearns
- School of Theology, Philosophy, and Music, Dublin City University, Dublin, Ireland
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10
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CJEM Debate Series: #HallwayMedicine - Our responsibility to assess patients is not limited to those in beds; emergency physicians must assess patients in the hallway and the waiting room when traditional bed spaces are unavailable. CAN J EMERG MED 2020; 21:580-586. [PMID: 31551101 DOI: 10.1017/cem.2019.356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Dudzinski DM, Hoisington BY, Brown CE. Ethics Lessons From Seattle's Early Experience With COVID-19. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:67-74. [PMID: 32552455 DOI: 10.1080/15265161.2020.1764137] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Ethics consultants and critical care clinicians reflect on Seattle's early experience as the United States' first epicenter of COVID-19. We discuss ethically salient issues confronted at UW Medicine's hospitals and provide lessons for other health care institutions that may soon face what we have faced.
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Xafis V, Schaefer GO, Labude MK, Zhu Y, Hsu LY. The Perfect Moral Storm: Diverse Ethical Considerations in the COVID-19 Pandemic. Asian Bioeth Rev 2020; 12:65-83. [PMID: 32837550 PMCID: PMC7255635 DOI: 10.1007/s41649-020-00125-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 12/20/2022] Open
Abstract
The COVID-19 pandemic has both exposed and created deep rifts in society. It has thrust us into deep ethical thinking to help justify the difficult decisions many will be called upon to make and to protect from decisions that lack ethical underpinnings. This paper aims to highlight ethical issues in six different areas of life highlighting the enormity of the task we are faced with globally. In the context of COVID-19, we consider health inequity, dilemmas in triage and allocation of scarce resources, ethical issues associated with research, ethical considerations relating to tracing apps, and exit strategies such as immunity passports and COVID-19 vaccines. Finally, we consider environmental issues in light of COVID-19. The paper also offers some ethical reflection on these areas as many parts of the world contemplate the recovery phase.
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Affiliation(s)
- Vicki Xafis
- SHAPES Initiative, Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - G. Owen Schaefer
- SHAPES Initiative, Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Markus K. Labude
- SHAPES Initiative, Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yujia Zhu
- SHAPES Initiative, Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Li Yan Hsu
- SHAPES Initiative, Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
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Practicing Mass Casualty Scenarios: Experience From a Developing Level 1 Trauma Center in the Himalayan Foothills. Disaster Med Public Health Prep 2020; 15:421-426. [PMID: 32349840 DOI: 10.1017/dmp.2020.38] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Uttarakhand is an Indian state in the Himalayan foothills, a favored adventure destination in the country due to abundant natural beauty. However, the terrain has also conferred an increased risk of earthquakes, flash floods, and major road tragedies, resulting in as many as 8 major natural disasters in the state in the preceding 20 years. AIIMS Rishikesh, an autonomous central institute, has been entrusted to build a Level 1 Trauma Center in Uttarakhand, which would help improve the response, coordination, and hence outcome in mass casualty scenarios (MCSs). METHODS As a step toward the achievement of this larger goal, a workshop on MCS and management was conducted by the Department of Trauma Surgery in collaboration with Rambam Hospital, Haifa. We hereby present our template for conducting MCS drills in low resource settings like ours and the lessons learnt. RESULTS Process, logistics, limitations, workforce, scheduling, overview, and report of the MCS drill conducted are discussed hereafter. CONCLUSION This template may be replicated by hospitals that intend to conduct similar MCS drills in low resource settings, realizing the real threat of MCS occurrence in our country at anytime.
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14
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Ethical prioritization of patients during disaster triage: A systematic review of current evidence. Int Emerg Nurs 2019; 43:126-132. [PMID: 30612846 DOI: 10.1016/j.ienj.2018.10.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 08/17/2018] [Accepted: 10/21/2018] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Triage is a dynamic and complex decision-making process in order to determine priority of access to medical care in a disaster situation. The elements which should govern an ethical decision-making in prioritizing of victims have been debated for a long time. This paper aims to identify ethical principles guiding patient prioritization during disaster triage. METHOD Electronic databases were searched via structured search strategy from 1990 until July 2017. The studies investigating patients' prioritization in disaster situation were eligible for inclusion. All types of articles and guidelines were included. RESULT Of 7167 titles identified in the search, 35 studies were included. The important factors identified in patient prioritization were grouped into two categories: medical measures (medical need, likelihood of benefit and survivability) and Nonmedical measures (saving the most lives, youngest first, preserving function of society, protecting vulnerable groups, required resources and unbiased selection). Demographic characteristics, health status of patients, social value of patient, and unbiased selection are discriminatory factors in disaster triage. CONCLUSION Various factors have been introduced to consider ethical patient prioritization in disaster triage. Providers' engagement, public education, and ongoing training are required to reach a fair decision.
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Cusack L, Gebbie K. Call for national dialogue: Adapting standards of care in extreme events. We are not ready. Collegian 2018; 24:93-100. [PMID: 29218967 PMCID: PMC7110603 DOI: 10.1016/j.colegn.2015.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Clinical practices are based on a common understanding of nursing's professional standards in all aspects of patient care, no matter what the circumstances are. Circumstances can however, change dramatically due to emergencies, disasters, or pandemics and may make it difficult to meet the standard of care in the way nurses are accustomed. The Australian nursing profession has not yet facilitated a broad discussion and debate at the professional and institutional level about adapting standards of care under extreme conditions, a dialogue which goes beyond the content of basic emergency and disaster preparedness. The purpose of this paper is to encourage discussion within the nursing profession on this important ethical and legal issue. A comprehensive review of the literature was undertaken to determine the state of the evidence in relation to adapting standards of care under extreme conditions. Content analysis of the literature identified categories related to adapting standards of care that have been considered by individuals or groups that should be considered in Australia, should a dialogue be undertaken. The categories include ethical expectations of professional practice; legal interpretation of care requirements, resource priority between hospital and public health and informing communities. Literature reviews and commentary may provide the background for a national dialogue on the nursing response in an extreme event. However, it is only with the engagement of a broadly representative segment of the professional nursing community that appropriate guidance on adapting standards of care under extreme conditions can be developed and then integrated into the professional worldview of nursing in Australia.
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Bower WA, Hendricks K, Pillai S, Guarnizo J, Meaney-Delman D. Clinical Framework and Medical Countermeasure Use During an Anthrax Mass-Casualty Incident. MMWR Recomm Rep 2015; 64:1-22. [DOI: 10.15585/mmwr.rr6404a1] [Citation(s) in RCA: 337] [Impact Index Per Article: 37.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
| | - William A. Bower
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases
| | - Katherine Hendricks
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases
| | - Satish Pillai
- Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Diseases
| | - Julie Guarnizo
- Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Diseases
| | - Dana Meaney-Delman
- Office of the Director, National Center for Emerging and Zoonotic Infectious Diseases
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Christian MD, Sprung CL, King MA, Dichter JR, Kissoon N, Devereaux AV, Gomersall CD. Triage: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest 2015; 146:e61S-74S. [PMID: 25144591 PMCID: PMC7127536 DOI: 10.1378/chest.14-0736] [Citation(s) in RCA: 135] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Pandemics and disasters can result in large numbers of critically ill or injured patients who may overwhelm available resources despite implementing surge-response strategies. If this occurs, critical care triage, which includes both prioritizing patients for care and rationing scarce resources, will be required. The suggestions in this chapter are important for all who are involved in large-scale pandemics or disasters with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials. METHODS The Triage topic panel reviewed previous task force suggestions and the literature to identify 17 key questions for which specific literature searches were then conducted to identify studies upon which evidence-based recommendations could be made. No studies of sufficient quality were identified. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. Suggestions from the previous task force that were not being updated were also included for validation by the expert panel. RESULTS The suggestions from the task force outline the key principles upon which critical care triage should be based as well as a path for the development of the plans, processes, and infrastructure required. This article provides 11 suggestions regarding the principles upon which critical care triage should be based and policies to guide critical care triage. CONCLUSIONS Ethical and efficient critical care triage is a complex process that requires significant planning and preparation. At present, the prognostic tools required to produce an effective decision support system (triage protocol) as well as the infrastructure, processes, legal protections, and training are largely lacking in most jurisdictions. Therefore, critical care triage should be a last resort after mass critical care surge strategies.
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Affiliation(s)
- Michael D. Christian
- Royal Canadian Medical Service, Canadian Armed Forces and Mount Sinai Hospital, Toronto, ON, Canada
- Critical Care and Infectious Diseases, Mount Sinai Hospital, 600 University Ave, Room 18-232-1, Toronto, ON, M5G 1X5, Canada
| | | | - Mary A. King
- University of Washington, Harborview Medical Center, Seattle, WA
| | | | - Niranjan Kissoon
- BC Children's Hospital and Sunny Hill Health Centre, University of British Columbia, Vancouver, BC, Canada
| | | | - Charles D. Gomersall
- The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
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Informing the gestalt: an ethical framework for allocating scarce federal public health and medical resources to states during disasters. Disaster Med Public Health Prep 2014; 8:79-88. [PMID: 24612854 DOI: 10.1017/dmp.2014.9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
During catastrophic disasters, government leaders must decide how to efficiently and effectively allocate scarce public health and medical resources. The literature about triage decision making at the individual patient level is substantial, and the National Response Framework provides guidance about the distribution of responsibilities between federal and state governments. However, little has been written about the decision-making process of federal leaders in disaster situations when resources are not sufficient to meet the needs of several states simultaneously. We offer an ethical framework and logic model for decision making in such circumstances. We adapted medical triage and the federalism principle to the decision-making process for allocating scarce federal public health and medical resources. We believe that the logic model provides a values-based framework that can inform the gestalt during the iterative decision process used by federal leaders as they allocate scarce resources to states during catastrophic disasters.
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Abstract
AbstractDocumentation of the patient encounter is a traditional component of health care practice, a requirement of various regulatory agencies and hospital oversight committees, and a necessity for reimbursement. A disaster may create unexpected challenges to documentation. If patient volume and acuity overwhelm health care providers, what is the acceptable appropriate documentation? If alterations in scope of practice and environmental or resource limitations occur, to what degree should this be documented? The conflicts arising from allocation of limited resources create unfamiliar situations in which patient competition becomes a component of the medical decision making; should that be documented, and, if so, how?In addition to these challenges, ever-present liability worries are compounded by controversies over the standards to which health care providers will be held. Little guidance is available on how or what to document. We conducted a search of the literature and found no appropriate references for disaster documentation, and no guidelines from professional organizations. We review here the challenges affecting documentation during disasters and provide a rationale for specific patient care documentation that avoids regulatory and legal pitfalls. (Disaster Med Public Health Preparedness. 2013;0:1–7)
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Abstract
General concepts about medical disasters, public health and triage are outlined. Triage is described in the context of public health emergencies and disaster settings, and the main ethical values at stake in triage are discussed. Possible conflicts between competing values are outlined. Special attention is given to possible conflicts between the protection of individual interests (typical of clinical ethics), and the pursuit of collective interests (typical of public health and triage). Hippocratic ethics is compared to utilitarian ethics and to perspectives that emphasize the principle of justice. Three ethical attitudes are suggested that may contribute to a resolution of competing values: protection of human dignity, precaution and, especially, solidarity. Personalism promotes the collective good by safeguarding and giving value to the well-being of each individual. A personalistic perspective is suggested as a way to deepen the concept of solidarity as a pillar both of clinical and public health ethics.
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Affiliation(s)
- Carlo Petrini
- Istituto Superiore di Sanità (National Institute of Health), Bioethics Unit, Office of the President, Via Giano della Bella 34, 00162, Rome, Italy.
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Christian MD, Hamielec C, Lazar NM, Wax RS, Griffith L, Herridge MS, Lee D, Cook DJ. A retrospective cohort pilot study to evaluate a triage tool for use in a pandemic. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R170. [PMID: 19874595 PMCID: PMC2784402 DOI: 10.1186/cc8146] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2009] [Revised: 10/14/2009] [Accepted: 10/29/2009] [Indexed: 01/26/2023]
Abstract
Introduction The objective of this pilot study was to assess the usability of the draft Ontario triage protocol, to estimate its potential impact on patient outcomes, and ability to increase resource availability based on a retrospective cohort of critically ill patients cared for during a non-pandemic period. Methods Triage officers applied the protocol prospectively to 2 retrospective cohorts of patients admitted to 2 academic medical/surgical ICUs during an 8 week period of peak occupancy. Each patient was assigned a treatment priority (red -- 'highest', yellow -- 'intermediate', green -- 'discharge to ward', or blue/black -- 'expectant') by the triage officers at 3 separate time points (at the time of admission to the ICU, 48, and 120 hours post admission). Results Overall, triage officers were either confident or very confident in 68.4% of their scores; arbitration was required in 54.9% of cases. Application of the triage protocol would potentially decrease the number of required ventilator days by 49.3% (568 days) and decrease the total ICU days by 52.6% (895 days). On the triage protocol at ICU admission the survival rate in the red (93.7%) and yellow (62.5%) categories were significantly higher then that of the blue category (24.6%) with associated P values of < 0.0001 and 0.0003 respectively. Further, the survival rate of the red group was significantly higher than the overall survival rate of 70.9% observed in the cohort (P < 0.0001). At 48 and 120 hours, survival rates in the blue group increased but remained lower then the red or yellow groups. Conclusions Refinement of the triage protocol and implementation is required prior to future study, including improved training of triage officers, and protocol modification to minimize the exclusion from critical care of patients who may in fact benefit. However, our results suggest that the triage protocol can help to direct resources to patients who are most likely to benefit, and help to decrease the demands on critical care resources, thereby making available more resources to treat other critically ill patients.
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Affiliation(s)
- Michael D Christian
- Department of National Defence, Canadian Forces, Mount Sinai Hospital Toronto/University Health Network, University of Toronto, 600 University Avenue, Toronto, ON, Canada.
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The Needs of Children in Natural or Manmade Disasters. INTENSIVE AND CRITICAL CARE MEDICINE 2009. [PMCID: PMC7120869 DOI: 10.1007/978-88-470-1436-7_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Disasters have been described as “events of sufficient scale, asset depletion, or numbers of victims to overwhelm medical resources” [1] or as “a serious disruption of the functioning of a community or a society causing widespread human, material, economic or environmental losses that exceed the ability of the affected community or society to cope using its own resources” [2]. Importantly, that definition goes on to state: “A disaster is a function of the risk process. It results from the combination of hazards, conditions of vulnerability and insufficient capacity or measures to reduce the potential negative consequences of risk.”
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