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COVID-19 Intelligence Report: Ethics

May 11, 2020

Title: CPR in the COVID-19 Era — An Ethical Framework

Publisher: NEJM

Publication Date: 06 May 2020

URL: https://www.nejm.org/doi/full/10.1056/NEJMp2010758

Key Takeaways: The authors feel that it is important that clinicians acknowledge resource constraints when discussing goals of care and DNR status with patients.  It may be appropriate to withhold CPR in certain circumstances: 1) if ventilators or critical care beds are not available or patient is not eligible to them due to fair triage process or 2) if the patient’s condition is deteriorating significantly despite provision of critical care, or 3) the institution determines that staffing shortages are so severe that the deployment of a typical code team would jeopardize outcomes for other patients.

May 4, 2020

Ventilator Rationing Literature:

Title: Crisis Standard of Care Recommendations for Triaging Critical Resources During the COVID-19 Pandemic

Publisher: Society of Critical Care Medicine

Publication Date: Not provided

URL:  https://www.sccm.org/COVID19RapidResources/Resources/Triaging-Critical-Resources

Key Takeaway: The Society of Critical Care Medicine proposes recommendations for allocatoin of resources during Covid-19 pandemic at three levels of institutional capacity; conventional, contingency and crisis. 

 

Title: Universal Do-Not-Resuscitate Orders, Social Worth, and Life-Years: Opposing Discriminatory Approaches to the Allocation of Resources During the COVID-19 Pandemic and Other Health System Catastrophes

Publisher: American College of Physicians

Publication Date: April 24, 2020

URLhttps://annals.org/aim/fullarticle/2765363/universal-do-resuscitate-orders-social-worth-life-years-opposing-discriminatory

Key Takeaway: This article reviews several proposed approaches for decision-making during a time of limited resources and applies standards of ethical decision-making. No guidelines given.

 

Title: Ventilator Allocation Guidelines

Publisher: New York State Department of Health

Publication Date: November 2015

URLhttps://www.health.ny.gov/regulations/task_force/reports_publications/docs/ventilator_guidelines.pdf

Key Takeaway: This 2015 document is an update of a 2005 New York State guidance on use of ventilators if/when shortages occur. This was developed for the H1N1 Pandemic Influenza. 

 

Title: Too Many Patients…A Framework to Guide Statewide Allocation of Scarce Mechanical Ventilation During Disasters

Publisher: Chest

Publication Date: April 2019

URLhttps://journal.chestnet.org/article/S0012-3692(18)32565-0/fulltext 

Key Takeaway: The authors propose a strategy for ventilator allocation in epidemics of novel respiratory pathogens that uses a scoring system comprised of 4 elements: 1) likelihood of short-term survival based on a sequential organ failure assessment (SOFA) score and 2) likelihood of long-term survival (based on presence of comorbid conditions).

 

April 27, 2020

Title: COVID-19 Ethics Resource Center  

Publisher: American Medical Association Journal of Ethics 

Publication: Continuously updated   

URL: https://journalofethics.ama-assn.org/covid-19-ethics-resource-center 

Key Takeaway: 

● A collection of AMA resources and writings meant to promote ethical reflection around challenges including rationing of limited health care resources, restriction of individual movement and liberties, and the professional duty to treat in the face of personal danger.  

April 20, 2020

Title:  Ethics in the Time of Coronavirus: Recommendations in the COVID-19 Pandemic

Publication: Journal of the American College of Surgeons, April 1, 2020

URL: https://www.journalacs.org/article/S1072-7515(20)30309-4/pdf

Key Takeaway: Recommendations for several of the most pressing ethical challenges of the novel coronavirus (COVID-19) pandemic:

  • Professional responsibility vs risk to health care workers
  • Patient confidentiality
  • Who should be screened and tested
  • Allocation of scare resources
  • Ethical concerns created by relaxing FDA research rules and relaxing crieteria for certification into the medical field
  • End of life care issues

 

Title: Too many patients…A framework to guide statewide allocation of scarce mechanical ventilation during disasters.

Publication: Chest, April, 2019

URL: https://www.ncbi.nlm.nih.gov/pubmed/30316913

Key Takeaway: How to ration ventilators: This is a multi-year Johns Hopkins study (following Katrina) involving doctors and laymen to create a scoring system using Sequential Organ Failure Assessment (SOFA), severity of comorbidities, and age to determine who gets a ventilator.

National Academies Rapid Expert Consultation on the Crisis Standards of Care

  • A rapid primer on the principles and guidelines on the rationing of healthcare resources during an overwhelming crisis, also known as the Crisis Standards of Care.  

March 31, 2020

Advance Care Planning and DNR

  • JAMA Viewpoint: Advance Care Planning and DRN in patients with Covid-19
  • Curtis JR, Kross EK, Stapleton RD. The Importance of Addressing Advance Care Planning and Decisions About Do-Not-Resuscitate Orders During Novel Coronavirus 2019 (COVID-19). JAMA. Published online March 27, 2020. doi:10.1001/jama.2020.4894 
  • Note from submitter: JAMA Viewpoint: Advance Care Planning and DNR in patients with Covid-19.

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