Commitment of Healthcare Professionals and Trainees During Crisis

Overview

This section will discuss the responsibility of clinicians to patients, and by extension, the responsibility of medical trainees to patients, during this pandemic. In addition to clinical responsibilities, we discuss the importance of maintaining individual patient rights and humanity and any responsibilities toward broader advocacy efforts.

Duty of Clinicians to Treat Patients Despite Personal Risk

The COVID-19 outbreak poses a very real ethical dilemma: what is a physician’s responsibility to serve patients despite personal risk? Responses during the 2003 SARS epidemic and previous influenza pandemics raise complex and conflicting issues that can guide our present thinking.

In addition to the principles of beneficence and altruism, there are several arguments in favor of the duty to care for patients. First, healthcare professionals have a unique expertise and ability to serve. We have a monopoly on the right to practice medicine, and this right comes with a moral obligation to practice in emergencies when society needs us the most. Second, some might argue that we freely choose a profession that assumes a level of risk. Third, if a physician refuses to work because of personal risk, some might argue that the risk will be passed onto a colleague, and the already significant burden on the healthcare system will increase. The AMA Code of Ethics states that a physician’s responsibility to provide urgent care during disaster situations holds “even in the face of greater than usual risk to the physicians’ own safety, health or life.”

However, is there a certain level of acceptable risk beyond which this duty no longer holds? Some physicians might have comorbidities themselves or live with elderly or immunocompromised individuals, where the consequence of transmitting COVID-19 would be serious. In addition to a duty to their COVID-19 patients, clinicians have a duty to themselves, their loved ones, and their non-COVID-19 patients, both present and future. The duty to serve typically implies reciprocity from the hospital system, including adequate training, support, and PPE to minimize risk of harm, which is not holding true in this pandemic in some areas. In fact, a Seattle ED physician was recently fired, presumably in retaliation for speaking out about lack of PPE and infection control practices in his hospital. Overall, it is important to acknowledge that physicians and other healthcare workers are quite vulnerable to coercion during this pandemic. In a culture that expects selflessness and heroism from physicians, anyone who is hesitant to continue working based on personal risk might worry about openly expressing their opinion for fear of damaging their professional reputation, risking their job, and appearing selfish.

In addition to providing PPE, there are ongoing discussions regarding ways to support healthcare workers during this time. The current stance of the Accreditation Council for Graduate Medical Education (ACGME) is to maintain normal work hour restrictions for residents and fellows, although there are growing concerns that this might not hold true as the number of patients rises. Breaking work hours would increase the number of available staff, although, per the ACGME, likely at the cost of more medical errors and lapses in infection control, which would adversely affect residents, fellows, and patients. Recently, some hospitals have started to consider universal do-not-resuscitate (DNR) orders for COVID-19 patients in the setting of limited PPE and significant risk of exposing multiple healthcare workers during a code. If infected, these healthcare workers would be unable to care for other patients. While instituting a universal DNR for COVID-19 patients would be consistent with the utilitarian approach of placing the needs of many over the needs of an individual patient, it violates a patient’s autonomy when he or she is most vulnerable. Finally, there are online petitions to provide hazard pay for frontline healthcare workers at increased risk of exposure, but it is unclear whether these will lead to change within hospital systems. A case could be made that the high salaries physicians enjoy at baseline are pre-payment for taking on risk when needed, but that is not the case for residents, fellows, nurses, and other hospital staff.

Ultimately, it is important to acknowledge that we have a professional obligation as healthcare workers to put our patients first, but we are also human beings with legitimate concerns about our own safety and that of our loved ones. In return, we expect our hospital systems to value our expertise, time, and lives, and adequately train, support, and protect us. These conflicting priorities are well summarized in the words of an Ohio intern who describes her work in the current pandemic as “a terrifying privilege.”

Thought Questions:

• Are the standards set by the AMA Code of Ethics too much to ask of clinicians when there is insufficient PPE and support? How should healthcare workers combat feelings of guilt or shame if they find themselves unable or hesitant to fulfill this professional obligation?

• If a critical care physician’s child has recently had organ transplantation and is immunocompromised, is it acceptable for this physician to not come to work during this pandemic, or should he/she be held to the same standards as everyone else?

• How can we ensure that hospital administration holds up their end of this social contract? How do we protect healthcare workers, who often are intrinsically altruistic, from administrative exploitation during a pandemic?

Role of Healthcare Workers in Supporting Patients’ Individual Rights and Humanity in a Crisis

One of the foundational ethical principles of doctoring involves balancing respect for patients’ wishes with concern for their welfare. Most of the time, when patients seek care from healthcare professionals, their wishes are aligned with what would be in the best interest for their welfare. However, we now face a pandemic where patients with COVID-19 could infect others and pose a risk to public health. Even people who are asymptomatic may be possible vectors for disease. Autonomy can be overridden in circumstances such as these in the interests of protecting the health of the community. Many hospitals are, therefore, enforcing strict visitor policy guidelines for greater infection control. At Brigham and Women’s Hospital in Boston MA, for example, routine visitors are currently being restricted. Other visitors must be screened for risk of COVID-19 and are only allowed in during special circumstances outlined in their policy, such as a partner to a mother in labor or a parent of a child under 18.

These policies protect the safety of patients and our communities, but they come at a serious cost. Researchers have found many positive patient outcomes related to having visitors in the hospital, including faster recovery times, reduced length of stay, and decreased anxiety and delirium in the ICU. Families serve as key advocates for their loved ones and can help with transitions between care teams and reduce medical errors. The power of emotional support from loved ones is incredibly healing and important in supporting a patient’s sense of humanity. With healthcare workers pressed for time and adhering to strict infection control guidelines, there is little time to spend with patients. The difficult choices we make during this outbreak go against our desire to deliver compassionate, patient-centered care. Are there other alternatives? Perhaps we can imagine an informed consent process so that visitors to dying patients acknowledge the risk and then self-quarantine afterwards.

Thought Questions:

• How do we maintain a patient’s humanity during pandemics? When should we consider policies that protect the health of the population but might sacrifice the individual healing and dignity of patients?

• What is the role of a physician during an overwhelming pandemic with limited resources and time?

• Is what it means to deliver "empathetic care" redefined under the current circumstances, and, if so, what does that look like?

Role of Medical Students

In response to the COVID-19 crisis, American hospitals and medical schools have opted to temporarily halt student clinical involvement. As per guidelines of the Association of American Medical Colleges (AAMC), this suspension has been deemed necessary to allow medical schools “a window of opportunity” to educate students on safety precautions for return to the wards and to also reserve PPE for licensed hospital staff. Given previous cases of medical student exposure to COVID-19, these restrictions also help limit risk of infection and spread to students. With their clinical education and training set to pause, students are left questioning their roles and responsibilities during the pandemic.

Many students are mobilizing efforts to participate in non-clinical ways, including spreading COVID-19 information (such as this curriculum), supporting healthcare workers with non- clinical work, and helping community organizations. As students continue to remain outside of the clinical arena, however, it becomes necessary to consider the consequences of lost educational experiences in the clinic on the quality of medical training for future physicians versus the risk of infection for students and necessary PPE conservation. As hospital staff struggle with increasing patient cases, should medical students be re-introduced to the hospitals to offset some of the workload? Medical schools in Massachusetts and New York City have responded and graduated fourth year students early to immediately increase the pool of healthcare workers. European medical schools have taken similar measures. Historical examples exist from the 1918 Spanish Flu, during which volunteer medical students in Spain were sent to villages with limited oversight.

Thought Questions:

• At what point would it truly be ethically appropriate to allow medical students to practice medicine independently with limited oversight?

• What if early graduation and starting on a COVID-19 floor during the peak of the epidemic was mandatory? What are the ethical implications of such a change?

Responsibilities of Physicians in Broader Advocacy Efforts

With the current surge of COVID-19 cases and need for care, the chief of staff for MassHealth catalyzed policy changes in telemedicine to triage COVID-19 cases. At the same time, a dermatologist noted a 50% follow-up absentee rate in her clinic and advocated for expansion of telehealth to include specialists, allowing many physicians to continue monitoring patients with chronic conditions. If she had not advocated for expanded telehealth coverage during these extenuating circumstances, specialty care likely would have been compromised.

Physicians have begun to collaborate to advocate for policy changes in the wake of this pandemic. States have been encouraged to waive the Medicare telemedicine requirement that a provider be licensed in the state where care is delivered. In doing so, physicians can enhance national telehealth triage efforts to identify COVID-19 cases and refer for testing. The obligation of healthcare workers to not only educate their patient population, but also share information with one another on best practices, is critical for tackling this crisis. If healthcare workers are given access to multimedia resources to share learned practices, such as how to efficiently arrange COVID-19 wards, adopt alternate staffing models, and facilitate screening, we can help save lives. With additional multimedia resources, however, we need to adopt policy changes to maintain patient privacy.

While the virtual world evolves to meet emerging healthcare demands, the physical needs of hospital facilities continue to grow, necessitating policy change. Physicians have pointed out that establishing remote facilities, such as drive-through testing centers and temporary COVID-19-specific wards, would help mitigate the burden on hospitals, especially when capacity is reached. Licensure for such facilities, however, is a lengthy process, and triaging of COVID-19 patients who present to the ED with mild symptoms may be considered an EMTALA violation.

One way in which healthcare workers are responding to the national shortage of PPE is by advocating for and engaging in its acquisition. #GetUsPPE is a grassroots movement initiated by leaders in the healthcare field to organize and distribute donated PPE to those on the front lines. The organization is also pioneering 3D printed mask designs to help meet high demand.

Thought Questions:

• Do we, as healthcare workers, have an ethical obligation to advocate for policy changes on behalf of our patients? What policies might you advocate for?

• Within the limitations of federal policies and national shortages of human and material resources, what is the most efficient and ethical way to triage and treat such patients?