COVID-19 - Ethical Guidance in a Pandemic
|Publication: 01/04/2020 --|
|Last review: 01/01/1900|
|Next review: 27/08/2020|
|Approved By: Clinical Advisory Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2020|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
COVID-19 - Ethical Guidance in a Pandemic
- Flowchart -
- Guidance and Support
- Ethical Guidance on Decision-Making in Patients with COVID-19
The COVID-19 pandemic is considered to be the largest international public health challenge in living memory. The challenges to healthcare systems are international, national and local but also individual and deeply personal. The stark reality of constrained resources system-wide is played out in individual decisions between healthcare professionals and patients, determining who will receive which advanced treatments and who will not. The personal toll this takes on healthcare professionals previously used to determining individual best interests with far less attention to resource constraints, has been well documented. This is known as moral distress or discomfort.
Decision-making in a pandemic is complex and involves many aspects of care: whether or not a patient should receive intensive care treatments is one of many possible treatment decisions facing healthcare professionals.
Most healthcare professionals use an individualised patient-centred decision-making approach, bounded by clinical ethics and emphasizing the importance of patient autonomy as per the Mental Capacity Act 2005. Complex decision-making is often based on experience and pattern recognition otherwise known as heuristics or “gut feeling”. This is usually a result of experiential learning and deeply internalised knowledge but is likely to be less flexible to changes in both patient information and the context and is vulnerable to internal biases.
In a pandemic situation, it is not only recommended but ethically necessary for clinicians to make the switch from a mainly individualised autonomy-based approach to a mainly society or community-centred approach, guided by public health ethics. Public health ethics is necessarily more utilitarian in its principles; ensuring fair use of limited resources and emphasising prudent decision-making to optimise overall health and minimise mortality.
It is vital that clinicians apply these principles in a consistent and individualised way. There are several key principles to ensuring that decision-making is ethically defensible:
- Respectful of Individuals, Minimising Harm:
- Allowing the opportunity for individuals (where possible), or those nearest to them, to express their views on treatment options. Taking these views into consideration in order to respect autonomy
- Minimising harm, both individual and societal –
- Individually using evidence-based decisions to consider where medical interventions are likely to involve high treatment burden with minimal prospect of benefit.
- Societally ensuring treatments are most available for those most likely to benefit from them in terms of meaningful survival at a level valued by the individual.
- Transparent and Justifiable:
- Using a consistent framework which may be national or local
- Helps difficult decisions to be defensible
- Aids communication to patients and families
- Reasonable and Evidence-Based:
- As far as practicable in a situation where evidence is emerging, decisions should be based on experience, expertise and evidence
- Fair and Equitable:
- Any decision support tools should not unfairly disadvantage any group disproportionately
- Access to advanced treatments should be equitable for patients with COVID-19 and those suffering from other conditions
- Simple rules such as an age “cut-off” for treatments are unlikely to be fair, equitable or defensible
- Individual decisions may change based on the changing situation
- Treatment may be withdrawn from one patient and offered to another who has a better chance of meaningful survival. Treatments should therefore be framed as “a trial of x treatment”
- In some cases, treatment options previously not offered, may be revisited if appropriate
- New information about the disease should guide revision of any decision frameworks or tools
- Individual decisions may change based on the changing situation
- As the pandemic progresses, ethical decision-making should be sustained
- Especially challenging cases should be supported by an Ethics Advisory Group
- Staff will need support and a safe space to express their moral distress in challenging times
A decision support tool has been developed by Respiratory Medicine and Critical Care. This will take the above principles into account by encompassing a number of clinical considerations which confer a higher risk of poor outcome and combining them with senior clinical opinion to provide a guide to treatment considerations. More complex or unusual situations will need further discussion with a senior clinician in order to ensure flexibility and accountability.
Most clinicians are familiar with Beauchamp and Childress’ 4 ethical principles of medical ethics (autonomy, beneficence, non-maleficence and justice) and may wish to utilise an ethical framework based on these principles. One especially practical ethical framework is the MORAL balance framework (see link in guidance below).
Some decisions may be especially burdensome for individual clinicians or teams. In these instances, support should be sought from the Ethics Advisory Group:
- When clinical teams are unable to reach an agreement
- When a patient or carer expresses significant concern at the decision
- When two individuals with a very similar chance of benefiting require the same resource-limited treatment
As the pandemic progresses, it may be necessary to take account of other factors when determining which individuals receive resource-limited treatments. Clinical and prognostic factors must always take priority, however factors suggested elsewhere to be considered lower down the decision-tree hierarchy include:
- Number/vulnerability of the patient’s dependents - this would be problematic and very difficult to ascertain. The ethical basis for this is in instrumental value, maximising benefit and minimising harm i.e. utilitarian public health ethics in the context of a global pandemic.
- Occupation of the patient - i.e. key workers, especially those who are likely to have acquired COVID-19 through their work. The ethical basis for this is two-fold; maximising future benefit to others and justice considerations i.e. ensuring the risk of a pandemic is equitably distributed in society. This is also problematic and could lead to charges of self-interest and conferring privilege on already privileged individuals.
- Favouring those individuals who are deemed “worse off” either socio-economically or otherwise in order to “even-up” advantages and disadvantages - this is known as prioritarianism. The main problem with this is the chance that the number of individuals benefiting from treatment may be less than other options.
- Offering an equal opportunity to treatments by determining recipients of treatments randomly or by lottery - this is an egalitarian approach to allocating resource-limited treatments. This approach can threaten people’s view of ordinary justice if, for example, a random allocation denied treatment to an individual deemed very likely to benefit from it.
All of these considerations involve explicit value judgements with an associated difficulty in reaching agreement between healthcare professionals.
Decision making in a global pandemic such as COVID-19 is hugely challenging to systems and individuals. Treatment decisions should be individualised, flexible and equitable. Appropriate clinical decision tools can be utilised but must be transparent and justifiable. Where decisions are more problematic, an ethical framework such as the MORAL balance framework is suggested. Any ethical framework employed should be completed adhering to the above principles.
Disagreement, patient or carer concern and true ethical dilemmas where multiple patients have very similar chance of benefitting from a resource limited treatment, should be referred to the Ethics Advisory Group for assistance.
Clinical and ethical guidance for clinicians is being released by local, national and international bodies daily as the clinical picture changes.
Some local support available is listed below:
- https://www.leedsth.nhs.uk/assets/975a812bcc/QSM-Bulletin-ReSPECT-COVID-19-26-03-20.pdf - updated ReSPECT guidance
- https://leedspalliativecare.org.uk/professionals/covid-19-support-for-professionals - includes guidance on communicating difficult conversations by phone, symptom management and other support available to professionals
- https://www.leedsth.nhs.uk/covid19/staff-wellbeing/ - staff well-being support
Useful ethical guidance is listed below:
- https://portal.e-lfh.org.uk/Component/Details/606701 - e-learning module on Decision Making Surrounding Escalation of Critical Care: COVID-19
- Harvey DJR & Gardiner D. ‘MORAL Balance’ decision-making in critical care. BJA Education, 19(3): 68-73 (2019)
- https://www.nice.org.uk/guidance/ng159 - NICE guideline NG159. COVID-19 rapid guideline: critical care in adults
- https://www.rcplondon.ac.uk/news/ethical-guidance-published-frontline-staff-dealing-pandemic - RCP document: Ethical Dimensions of COVID-19 for frontline staff
- https://www.bma.org.uk/advice-and-support/covid-19/ethics/covid-19-ethical-issues - BMA COVID-19 Ethics Guidance
- http://www.ukcen.net/covid-19/article/COVID-19_Resources - UKCEN statement of principles in decision making
Other useful resources and reading:
- https://www.thehastingscenter.org/ethicalframeworkcovid19/ - Hastings Center for Bioethics Ethical Framework for COVID-19
- https://www.nejm.org/doi/full/10.1056/NEJMsb2005114 – Emanuel EJ, Persad G et al. Fair Allocation of Scarce Medical Resources in the Time of COVID-19. NEJM. 23rd March 2020.
- https://www.nejm.org/doi/full/10.1056/NEJMp2005492 – Rosenbaum L. Facing COVID-19 in Italy – Ethics, Logistics and Therapeutics on the Epidemic’s Front Line. NEJM. 18th March 2020.
- https://www.nejm.org/doi/full/10.1056/NEJMp2005689 – Truog RD, Mitchell C & Daley GQ. The Toughest Triage – Allocating Ventilators in a Pandemic. NEJM. 23rd March 2020.
- https://mspgh.unimelb.edu.au/centres-institutes/centre-for-health-equity/news-and-events/planning-for-and-managing-covid-19-ethical-decision-making-tool - University of Melbourne COVID-19 decision making tool
- https://www.gov.uk/guidance/pandemic-flu#ethical-framework - 2017 UK Government guidance on management of a possible influenza pandemic
|Target patient group:|
|Target professional group(s):||Secondary Care Doctors
Secondary Care Nurses
Clinical Advisory Group
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