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

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 Additionally, eliciting a nuanced history and assessing a possible biological cause of his withdrawn behavior would be more effective at the bedside, particularly when he is already frustrated by technology.

The benefits to the patient are supported by evidence ¹¹ 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.

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.