Ethical Dilemmas in Covid-19 Medical Care: Is a Problematic Triage Protocol Better or Worse than No Protocol at All?

Ethical care in patients with Covid-19: A grounded theory

BACKGROUND

Providing ethical care during the Covid-19 pandemic has become an inevitable challenge due to facing limitations such as fear of contracting the disease, lack of equipment and emergence of ethical conflicts; So that there is no clear picture of how to provide ethical care for patients with Covid-19. The study aimed to explain the ethical care process of patients with Covid-19.

METHOD

This qualitative study was conducted in 2021-2023 using the grounded theory research method. Data were collected through conducting 21 semi-structured interviews with 19 participants (16 staff nurses, and 3 supervisor). Sampling was started purposively and continued theoretically. Data analysis was performed by the method proposed by Strauss and Corbin.

RESULTS

The results indicated that starting the process with a problem means a challenge of how to do the right or correct thing for the patient. This process is driven by the feeling of duty and inner commitment to do the right thing. The sense of responsibility or commitment is directly related to the degree of faith in a person. The actions that a nurse takes to fulfill her sense of commitment is called the faith-based behavior process. The process of behavior based on faith is done through two steps. Attaining the satisfaction of God and as well as the satisfaction of one's conscience is the nurses' ultimate goal of doing the right work and being committed.

CONCLUSION

The process of ethical care of patients with Covid-19 can be different according to the degree of faith and environmental conditions. A higher level of faith and more helpful environmental conditions, the greater the nurse's inner commitments in the first and second steps, as a result, the satisfaction of God and conscience will be greater.

Is It Possible to Allocate Life? Triage, Ageism, and Narrative Identity

Triage protocols can exclude older patients for the sake of effectiveness and this may be defended as the older have already had their fair share of life, which can mean fair amounts or complete lives. Nevertheless, if life is considered as a narrative, mentioning amounts might be nonsensical. Narratives have a quality of unity; so, life events are fragments whose meanings are dependent on the meaning of the whole. Thus, time units do not represent a reliable measure of the content of life. In addition, people's experience is different from the external flow of time, making its significance relative. Moreover, to compare the completeness of lives qualitatively, it is necessary to have a common cultural understanding, which is improbable to agree on in a modern society. Therefore, basic assumptions of the accounts that refer to fair shares of lives are mistaken, and these accounts do not support age-based rationing.

Differences in US Regional Healthcare Allocation Guidelines During the COVID-19 Pandemic

BACKGROUND

Hospitals faced unprecedented scarcity of resources without parallel in modern times during the COVID-19 pandemic. This scarcity led healthcare systems and states to develop or modify scarce resource allocation guidelines that could be implemented during "crisis standards of care" (CSC). CSC describes a significant change in healthcare operations and the level of care provided during a public health emergency.

OBJECTIVE

Our study provides a comprehensive examination of the latest CSC guidelines in the western region of the USA, where Alaska and Idaho declared CSC, focusing on ethical issues and health disparities.

DESIGN

Mixed-methods survey study of physicians and/or ethicists and review of healthcare system and state allocation guidelines.

PARTICIPANTS

Ten physicians and/or ethicists who participated in scarce resource allocation guideline development from seven healthcare systems or three state-appointed committees from the western region of the USA including Alaska, California, Idaho, Oregon, and California.

RESULTS

All sites surveyed developed allocation guidelines, but only four (40%) were operationalized either statewide or for specific scarce resources. Most guidelines included comorbidities (70%), and half included adjustments for socioeconomic disadvantage (50%), while only one included specific priority groups (10%). Allocation tiebreakers included the life cycle principle and random number generators. Six guidelines evolved over time, removing restrictions such as age, severity of illness, and comorbidities. Additional palliative care (20%) and ethics (50%) resources were planned by some guidelines.

CONCLUSIONS

Allocation guidelines are essential to support clinicians during public health emergencies; however, significant deficits and differences in guidelines were identified that may perpetuate structural inequities and racism. While a universal triage protocol that is equally accepted by all communities is unlikely, the lack of regional agreement on standards with justification and transparency has the potential to erode public trust and perpetuate inequity.

Operative public values as a tool for healthcare decisions: the social value and clinical criteria of triage

With the current pandemic, many scholars have contended that clinical criteria offer the best way to implement triage. Further, they dismiss the criteria of social value as a good one for triage. In this paper, I respond to refute this perspective. In particular, I present two sets of arguments. Firstly, I argue that the objections to the social value criteria they present apply to the clinical criteria they favor. Secondly, they exaggerate the negative aspects of the social value criteria, while I suggest it is reasonable to use this. I end the article by recommending how operative public values can be a good way to make triaging decisions.

Making complex decisions in uncertain times: experiences of Dutch GPs as gatekeepers regarding hospital referrals during COVID-19-a qualitative study

BACKGROUND

General practitioners often act as gatekeeper, authorizing patients' access to hospital care. This gatekeeping role became even more important during the current COVID-19 crisis as uncertainties regarding COVID-19 made estimating the desirability of hospital referrals (for outpatient or inpatient hospitalization) complex, both for COVID and non-COVID suspected patients. This study explored Dutch general practitioners' experiences and ethical dilemmas faced in decision making about hospital referrals in times of the COVID-19 pandemic.

METHODS

Semi-structured interviews with Dutch general practitioners working in the Netherlands were conducted. Participants were recruited via purposive sampling. Thematic analysis was conducted using content coding.

RESULTS

Fifteen interviews were conducted, identifying four themes: one overarching regarding (1) COVID-19 uncertainties, and three themes about experienced ethical dilemmas: (2) the patients' self-determination vs. the general practitioners' paternalism, (3) the general practitioners' duty of care vs. the general practitioners' autonomy rights, (4) the general practitioners' duty of care vs. adequate care provision.

CONCLUSIONS

Lack of knowledge about COVID-19, risks to infect loved ones, scarcity of hospital beds and loneliness of patients during hospital admission were central in dilemmas experienced. When developing guidelines for future crises, this should be taken into account.

Allocation plans for crisis triage: How well would they actually work?

COVID-19 has forced US state governments to create plans for rationing critical care resources that ensure the greatest population benefit. But a study by Jezmir and colleagues in this issue of Cell Reports Medicine raises doubts about whether these plans can distinguish those who would most benefit.

A Journal of the COVID-19 (Plague) Year

The essays in this special issue of HEC Forum provide reflections that make explicit the implicit anthropology that our current pandemic has brought but which in the medical ethics literature around COVID-19 has to a great extent ignored. Three of the essays are clearly “journalistic” as a literary genre: one by a hospital chaplain, one by a medical student in her pre-clinical years, and one by a fourth-year medical student who reports her experience as she completed her undergraduate clerkships and applied for positions in graduate medical education. Other essays explore the pandemic from historical, sociological, and economic perspectives, particularly how triage policies have been found to be largely blind to structural healthcare disparities, while simultaneously unable to appropriately address those disparities. Central issues that need to be addressed in triage are not just whether a utilitarian response is the most just response, but what exactly is the greatest good for the greatest number? Together, the essays in this special issue of HEC Forum create a call for a more anthropological approach to understanding health and healthcare. The narrow approach of viewing health as resulting primarily from healthcare will continue to hinder advances and perpetuate disparities. Health outcomes result from a complex interaction of various social, economic, cultural, historical, and political factors. Advancing healthcare requires contextualizing the health of populations amongst these factors. The COVID-19 pandemic has made us keenly aware of how interdependent our health as a society can be.

Allocating scarce intensive care resources during the COVID-19 pandemic: practical challenges to theoretical frameworks

The COVID-19 pandemic strained health-care systems throughout the world. For some, available medical resources could not meet the increased demand and rationing was ultimately required. Hospitals and governments often sought to establish triage committees to assist with allocation decisions. However, for institutions operating under crisis standards of care (during times when standards of care must be substantially lowered in the setting of crisis), relying on these committees for rationing decisions was impractical—circumstances were changing too rapidly, occurring in too many diverse locations within hospitals, and the available information for decision making was notably scarce. Furthermore, a utilitarian approach to decision making based on an analysis of outcomes is problematic due to uncertainty regarding outcomes of different therapeutic options. We propose that triage committees could be involved in providing policies and guidance for clinicians to help ensure equity in the application of rationing under crisis standards of care. An approach guided by egalitarian principles, integrated with utilitarian principles, can support physicians at the bedside when they must ration scarce resources.