Ethical pause as a framework for high-value care of hospitalized COVID-19 patients

Abstract

Caring for hospitalized patients with COVID-19 raises ethical dilemmas in which clinicians must weigh the unknown value of an intervention against the unknown risk of viral transmission. Current guidelines for delivering high-value care in the time of the COVID-19 pandemic do not directly address ethical dilemmas that arise from the unique concerns of individual patients. We propose an “ethical pause” in which clinicians address ethical dilemmas by taking time to ask three questions that invoke the major bioethical principles of beneficence, nonmaleficence, and distributive justice: will this intervention help my patient? Could this intervention harm my patient? Could this intervention harm or help others? Using two exemplar cases, we demonstrate how the process of deliberately asking and answering structured ethical questions is a mindful problem-solving strategy that facilitates delivery of high-value care.

Keywords

Clinical ethics bioethics and medical ethics death and dying health care quality

The COVID-19 pandemic has brought unexpected ethical dilemmas to routine elements of inpatient care. Dilemmas usually hinge on the risk of viral exposure associated with interventions of equivocal utility: does the value derived from performing a physical exam or an imperfect procedure warrant the risk of propagating SARS-CoV-2? A recent Choosing Wisely article issued recommendations for high-value care in the COVID-19 era.¹ Clinicians across the United States and likely across the world agree that constraints generated by COVID-19 may catalyze lasting reform of health systems burdened by costly, low-value care.^2–4 But guidelines for high-value care may fall short when providers are faced with ethical dilemmas rooted in the unique biopsychosocial concerns of individual patients hospitalized with COVID-19. Without a strategy of addressing uncertainty on a case-by-case basis, ethical dilemmas sap precious time and may contribute to provider frustration.

The value of a deliberate pause, or “time-out,” has been demonstrated as a decision-making aid in realms of clinical uncertainty⁵ and has recently been proposed as a method of addressing complex ethical issues in critically-ill patients with COVID-19.⁶ A group pause, or moment of silence, occurs most frequently at our institution after a patient dies, a practice pioneered by Jonathan Bartels that “slows our racing minds, offering mental space.”⁷ The cognitive forcing technique of building value into oral presentations – the “SOAP-V” format – is another example of a deliberate break in workflow that prompts real-time analytical discussion about the value of care being delivered.⁸

Thus, a simple, systematic approach to addressing ethical uncertainty lies in plain sight. We propose an “ethical pause” as a method of reframing ethical uncertainty in patients hospitalized with COVID-19. The ethical pause deliberately invokes the foundational bioethical principles of beneficence, nonmaleficence, and distributive justice. In response to an ethical dilemma of any proportion, the provider pauses to consider: Will the intervention help my patient? (A question of beneficence, the ethical dictum to perform actions that improve the patient’s welfare.) Could the intervention harm my patient? (A question of nonmaleficence, the ethical dictum to inflict no harm.) Could the intervention harm others? (A question of distributive justice, the “fair, equitable, and appropriate distribution of benefits and burdens determined by norms that structure the terms of social cooperation.”⁹) Ethical purists should note that these questions are intentionally framed in simple terms, excluding much subtlety that delineates bioethical principles, in order to facilitate their use in a busy clinical environment. Below, we provide two fictional, exemplar cases in which the process of deliberately posing and answering these questions formulates clear problems from nebulous circumstances, leading to patient-centered, high-value plans of care.

Case one

RF is a forty-six-year-old man with a history of stage III CKD on a transplanted deceased-donor graft, maintained on tacrolimus and mycophenolate, who was admitted for respiratory failure due to COVID-19. Today is day five of hospitalization and day eleven since symptom onset. SpO₂ is 96% on 3 L supplemental O₂ by nasal canula, unchanged for three days. Chest X-ray performed yesterday reveals unchanged bilateral opacities. Over the past several days his eye contact has worsened and he provides monosyllabic answers to questions. Technological glitches have prevented him from reliably seeing his family by video. Should the clinician enter the room to assess RF?

Will this intervention help my patient? In the narrowest diagnostic sense, physical examination would yield little information in a stable patient outside the anticipated window of clinical worsening. An evolving body of literature on the waning quality of physical examination skills further undermines the anticipated benefit of this intervention.¹⁰ Yet the patient’s worsening mood and isolation from his family indicate that he would likely benefit from the therapeutic reassurance of a clinician’s touch.¹¹ A hand on the shoulder and careful physical attention to the source of his symptoms would be a salient expression of healing. Additionally, eliciting a nuanced history and assessing a possible biological cause of his withdrawn behavior would be more effective at the bedside, particularly when he is already frustrated by technology.

Could this intervention harm my patient? There is a small theoretical risk of exposing the immunosuppressed patient to a nosocomial infection, but overall the intervention poses minimal risk.

Could this intervention harm or help others? The ethical concept of distributive justice contextualizes an individual’s care within the greater needs of society. In this sense, the major possible harms include propagation of SARS-CoV-2 and misuse of personal protective equipment (PPE). Minimizing the risk of transmission to staff is the animating spirit of the Choosing Wisely recommendation to “avoid in-person evaluations in favor of virtual communication unless necessary.”¹ Although the body of evidence is evolving, healthcare workers in environments with adequate PPE do not appear to have discordant rates of infection compared to the general population,^12,13 and a study of 420 healthcare workers directly taking care of COVID-19 patients reported no evidence of viral transmission based on nucleic acid serologic testing.¹⁴ From these data, it is reasonable to suspect that a single patient encounter does not meaningfully increase the likelihood of a healthcare worker contracting COVID-19. Furthermore, in an environment of readily available PPE with functioning supply chains, using a resource for its intended purpose does not clearly harm society.

The benefits to the patient are supported by evidence¹¹ and bolstered by the historical wisdom that a clinician’s presence and touch have incomparable therapeutic value.¹⁵ The major risk arises from concern of SARS-CoV-2 transmission not born out by evidence. Assuming an environment of adequate PPE, a clinician who elects to enter RF’s room would defy the recommendation to “avoid in-person evaluations” but would be justified via deliberate ethical reasoning in pursuing this patient-centered strategy.

Case two

MH is a 23-year-old woman hospitalized for three days with fever, non-productive cough, and respiratory failure with hypoxemia. Labs are notable for lymphopenia, elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), negative sputum cultures, negative blood cultures, negative influenza/respiratory virus NAAT assays from nasopharyngeal specimens, and two negative COVID-19 assays from nasopharyngeal specimens. CT chest shows bibasilar ground-glass opacities. She is clinically stable on dexamethasone and ceftriaxone after completing a course of azithromycin. The pulmonology team recommends pursuing bronchoscopy with bronchoalveolar lavage (BAL) to obtain a lower respiratory tract specimen.

Will this intervention help my patient? There is modest evidence demonstrating BAL is the most sensitive and specific test for detection of SARS-CoV-2 RNA,¹⁶ and World Health Organization (WHO) and Infectious Diseases Society of America (IDSA) guidelines support reserving lower respiratory testing for patients like MH with high pre-test probability and negative upper respiratory assays. A positive result would benefit the patient by eliminating unnecessary broad-spectrum therapy and associated risk of adverse effects. A confirmed diagnosis would likely bring a sense of closure to the patient and her family. A positive test may increase the likelihood of meeting inclusion criteria for experimental trials. A positive test would not change her access to standard therapy for COVID-19, which she is already receiving.

Could this intervention harm my patient? The risks of bronchoscopy are well-described with larger studies indicating an approximate one-percent risk of complication.¹⁷ There is a wide range of the severity of complications, but her young age and lack of co-morbidities are mitigating factors.

Could this intervention harm or help others? A negative lower respiratory sample would benefit the hospital community by discontinuing contact precautions and preserving PPE, but the procedure also poses risk of broader harm. Bronchoscopy is an aerosol-generating procedure that increases the risk of viral transmission to healthcare workers, a risk magnified by logistical steps of cleaning equipment and transporting samples. Of the limited data addressing risk of nosocomial COVID-19 infection associated with performing bronchoscopy, a single-center study reported an infection rate of one-third of operating clinicians.¹⁸

In this case, the ethical framework illustrates tension between potential small benefits to the patient and measurable risks to the patient, hospital community, and by extension, the broader community in which the hospital resides. The benefits are unlikely to change the main treatment MH receives and thus unlikely to affect major outcomes of morbidity, mortality, and length of hospitalization. The primary team, by virtue of ethical reasoning, could forgo bronchoscopy and continue empiric treatment of COVID-19 if aligned with MH’s wishes.

Conclusion

Two starkly different interventions illustrated above demonstrate the spectrum of inpatient care subject to ethical uncertainty in the era of COVID-19. Although clinicians subconsciously integrate ethical principles into daily risk-benefit calculus, a deliberate “ethical pause” is a cognitive technique that could bring clarity to ethical dilemmas and promote high-value care in the same manner system two reasoning combats bias in the formulation of differential diagnoses.¹⁹ Additionally, clinical scenarios that prompt excessive discussion could alert providers to the potential need for a formal consultation to bioethicists. Further investigation may bear out whether provider stress and patient outcomes are affected by the mindful approach of bringing ethical considerations to the surface of clinical decision-making.

Footnotes

Authors’ contribution

All authors contributed to and approved the final draft of the manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Andrew S Parsons

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