Ethics and Perspectives

Background

• Since the COVID-19 pandemic, hospitals and clinics in the United States have reduced nonemergency clinical operations.

• Delays in cancer screenings may cause excess deaths that are secondary to the pandemic.

• The present study aims to investigate the decline and recovery of monthly breast, colorectal, and prostate cancer screenings during the pandemic.

Study Design

• This retrospective cohort study utilized data from the HealthCore Integrated Research Database (HIRDD) from January- July of 2018, 2019, and 2020. Participants with a history of cancer prior to the analytical index month were excluded.

Results

• Screenings for all 3 cancers sharply declined in March-May of 2020 when compared to 2019. The absolute deficit in screenings during the pandemic was approximately 9.4 million.

• There was a near complete recovery in breast and prostate cancer screenings by July 2020, however, colorectal screening remained behind.

• The most dramatic decline in screenings was observed in the Northeast region of the United States and in individuals of the highest SES index.

• Telehealth use was associated with an increase in cancer screenings.

Conclusion

• Geographical disparities may be due to the differential timing of pandemic (New York and Northeastern states reported the earliest surges in cases).

• Screening deficits were largest for colorectal and breast cancer, which require procedures. In contrast, prostate cancer requires blood test (prostate specific antigen testing).

• The use of telemedicine seems promising during the pandemic- it allowed for continuation of nonemergency clinical care.

• Ultimately- public health efforts are needed to help bridge the deficits in cancer screenings, as well as explore alternative modalities to screenings that do not require a procedure (such as a colonoscopy for colorectal cancer screening).

Background

• Several COVID-19 vaccines are currently in clinical trials, and over 100 are in preclinical development; many therapeutics are also in preclinical and clinical development

• Without a system to distribute these COVID-19 countermeasures equitably, wealthy nations may purchase most supplies, leaving low- and middle-income countries (LMICs) with limited access to these products (such as occurred with the 2009 Influenza A(H1N1) pandemic)

• COVID-19 has already resulted in medical supply shortages, caused significant disease worldwide, and damaged the global economy

• An effective response requires equitable worldwide distribution of COVID-19 countermeasures

An Opportunity for Equitable Distribution

• Now is the time to plan for equitable financing and distribution of countermeasures

• LMICs may not be willing to share COVID-19 data/samples if they fear the benefits will not be fairly distributed, such as Indonesia’s refusal to share Influenza A(H5N1) data and samples in 2007, citing this concern

• Governments currently have incentive to collaborate while uncertainty remains regarding who will develop effective countermeasures; cooperation must continue once effective countermeasures established

Framework for Distribution

Flexible, Trusted Governance

• Leveraging well-established international forums favored over establishing a new organization

• The G7 negotiated an advance market commitment (AMC) for development, manufacturing, and delivery of pneumococcal vaccines with the World Bank and Gavi Alliance; these efforts yielded 3 vaccines with an estimated 150 million children vaccinated in 60 countries and an estimated 700,000 lives saved

• European Commission-backed Access to COVID-19 Tools Accelerator is a step in the right direction, with over a dozen countries and philanthropies pledging financial support, but support from the US, India, and China is needed

• WHO must play a central role in planning and coordinating this framework’s implementation; their planning strategy must involve entities that develop vaccines, treatments, and diagnostics and support pooled procurement in LMICs

Adequate, Predictable Financing

• LMICs require a financing mechanism for research, development, and distribution of countermeasures, such as advanced purchase commitments (APCs) for products distributed under WHO guidelines

• Terms of commitments must be clear, predictable, and multi-year; commitments must involve a transparent regulatory pathway for countermeasures that is agreed upon by all countries involved; funding could come from country and philanthropic contributions, leveraged to raise additional funds on capital markets, with subsidized or free LMIC participation

• The World Bank could act as a host of the financing mechanism with the Gavi alliance on vaccines and the Global Fund on therapeutics

Open Collaboration and Evidence-Based, Health-Driven Allocation

• Global allocation should be guided by data regarding size, distribution, and risk profiles of affected populations, abilities to implement immunization campaigns, and health surveillance data

• Countries who participate should commit to open scientific collaboration, transparency, and data sharing, and governments should forgo export restrictions on countermeasures

• Governments should set clear guidelines for equitable distribution of countermeasures for their own populations and must ensure that products are affordable and equitably accessible by vulnerable groups

Background

• The COVID-19 pandemic has drastically changed healthcare delivery and continues to have a significant impact on patient care.

• Palliative care specialists, like many other providers, are facing new challenges in meeting the needs of their patients while minimizing SARS-CoV-2 exposure and risks.

• Palliative care patients are especially vulnerable, and the authors of this viewpoint aim to provide insight into addressing palliative care challenges when caring for patients in the COVID-19 era.

Study Design

• JAMA Oncology Viewpoint by Drs. Ambereen K. Mehta, MD, MPH, and Thomas J. Smith, MD of UCLA and Johns Hopkins Medicine

Key Points

• The authors provide a table with challenges and potential solutions (use article link) when caring for patients during the current pandemic.

o Example:

§ Challenge: difficulty establishing rapport with telehealth for new patients

§ Potential solution: be present and patient; validate/respond to emotions and uncertainty

o Example:

§ Challenge: high fears and anticipatory grief from potential COVID-19

§ Potential solution: discuss goals of care specific to COVID-19; support safe inpatient discharge as soon as possible

• Telemedicine is a potential strategy for talking with patients about goals of care, and the US DEA has approved opioid prescribing via video-conferencing with the provider. A unique advantage of telemedicine is being able to assess patients’ home environments.

• Telemedicine can also be used in the inpatient setting to communicate with patients when PPE is limited.

• Interdisciplinary palliative care teams are uniquely suited to help patients and their families with psychosocial support during the pandemic.

• Palliative care providers are specialized in symptom management including dyspnea and delirium and can help patients suffering from COVID-19 which still has no known cure.

• Palliative care experts are also equipped to emotionally support colleagues in the healthcare field—including physicians, nurses, chaplains, social workers—who are afraid and overworked.

Conclusion

• Palliative care experts are uniquely equipped to help patients and coworkers during the current COVID-19 pandemic.

• As the authors conclude: “palliative care is not a luxury; it is a necessity”.

The Bronx, a borough of New York City, has the highest rate of COVID-19 diagnosis and deaths in New York City’s boroughs. In this community, increased chronic disease and chronic stress with decreased access to preventative health services have increased risk of COVID-19. Immigrant families are particularly affected. Many immigrant families live in close quarters with other families, making it impossible to isolate. In addition, lack of translated information about the virus makes it difficult for immigrants to decide if they should go to the hospital for symptoms. There is also a fear of immigrant-related consequences of going to the hospital that is a barrier to care.

In the hospital, communication with immigrants with limited healthcare proficiency is already difficult. The required PPE makes communication even more difficult and scary for immigrant patients. All the problems outlined above prevent immigrants from accessing care and reveal the failure of our healthcare system to provide for vulnerable groups. COVID-19 testing and treatment should be available to all patients in communications in their own language.

Data from Wisconsin and Michigan have demonstrated that percentages of black people affected by COVID-19 are twice as high as the proportion of black people in the overall population. Recently, reporting on this data has sparked a national conversation about racial disparities exposed by the pandemic. The authors warn against three potential dangers of citing statistics without their proper context.

1. Data without context can create biological explanations for racial health disparities. For example, research has shown medical professionals assume there is a biological difference between respiratory organs of black and white people.

2. Date without context can give rise to explanations using racial stereotypes about behavioral patterns. For example, during the tuberculosis outbreak in the 1900s in the South, reports described black people with tuberculosis as “incorrigible”, suggesting they had behaved in a way that increased their risk of contracting the disease.

3. Geographical data can suggest resource-deprived neighborhoods only have residents who behave deviantly.

These three dangers can create a perception that the pandemic is somehow “racial”. One way to combat this include analyzing COVID-19 data by looking at socioeconomic and controlling for it. Another way is to analyze the geographical distribution of healthcare services in relation to the COVID-19 outbreak in the area.

Background

• Older adults are especially vulnerable during the current Covid-19 pandemic.

• There is a current need to develop a Covid-19 vaccine, yet there are challenges in creating an effective vaccine for older adults.

Study Design

• Perspective written by Wayne C. Koff, Ph.D., and Michelle A. Williams, Sc.D.

Key Points

• Studies have shown that vaccine efficacy decreases significantly with age.

• There is a need to better understand the impact of aging on the immune system in order to effectively develop new strategies for disease prevention and control in older populations.

• The recent developments in biomedical and computer science provide new opportunities to work toward decoding the human immune system and elucidating mechanisms behind some individuals’ ability to respond to vaccines or mount appropriate immune responses while others do not.

• There is a need for more longitudinal studies on the immune system and aging including vaccine response.

• With advancements such as artificial intelligence and cutting-edge biomedical tools, scientists ought to collaborate across disciplines in order to identify novel biomarkers for effective immunity in older adults.

Conclusion

• The new research agenda proposed by these authors is one that will “shift from investing primarily in disease-specific research to simultaneously targeting sufficient resources toward decoding the human immune system, particularly for the world’s most vulnerable populations.”

• With the increase in older populations worldwide, it is important to develop vaccines and immunotherapies aimed at protecting older adults and improving healthspans.

An editorial written by Italian pathologists surveying their priorities and considerations during COVID-19:

• To maintain their duty of routine diagnostic activity - diagnoses such as cancer do not get put on hold during a pandemic.

• Utilize protocols in specimen collection which reduce infectivity risks, while maintaining the integrity of the specimens.

• In regards to autopsies, consider every corpse as potentially infectious. Conduct autopsies in Airborne Infection Isolation Rooms and utilize percutaneous core biopsy sampling if a tissue specimen is needed, particularly for a patient with a confirmed COVID-19 diagnosis.

• Collect post-mortem histopathological specimens to produce a tissue and data collection for the nation to utilize in better understanding the pathophysiology of SARS-CoV-2.

Background

• The Covid-19 pandemic has affected millions of individuals, the healthcare system, the world. While a lot of the current literature discusses the impact of Covid-19 on patients with the virus, Dr. Rosenbaum’s article examines the effects on patients without the virus.

Study Design

• Medicine and Society section article by Dr. Lisa Rosenbaum, M.D, national correspondent for NEJM and cardiologist at Brigham and Women’s Hospital

Key Points

• The Covid-19 pandemic has radically transformed our healthcare system and there will be detrimental effects as the strain to the system hinders the ability to provide high quality care.

• There is a significant impact on patients without Covid-19, especially cardiac and oncology patients; interventional cardiologist, Zoran Lasic suggests that “the toll on non-Covid patients will be much greater than Covid deaths.”

• Significant changes in the healthcare system include modifications of protocols and elective surgery cancellations, and these changes are often a difficult trade-off between the patient’s need for procedures and hospital capacity.

• Transparency in decision-making helps patients feel reassured and cared for as one physician describes it is important for his patients “to know that he has personally reviewed their cases and postponed only those he has deemed nonurgent.”

Conclusion

• The Covid-19 pandemic has radically changed the healthcare system and ability to deliver care, and patients without Covid-19 are facing unprecedented challenges.

• It is important for all patients to know that whether they have Covid-19 or not healthcare workers will do their best to get them the best care they can.

The American College of Obstetricians and Gynecologists (ACOG) issued a statement on March 18, 2020 that they “do not support Covid-19 responses that cancel or delay abortion procedures”. Despite this, governors and politicians from several states including TX, LA, OK have ordered cessation of medication and surgical abortions because they classify the procedure as “elective” and “nonessential”. The classification of “elective” surgery in the medical field means surgeries that are planned ahead, as opposed to emergency surgeries. The word “elective” has been politicized in national rhetoric surrounding abortion to become a moral judgement, to suggest certain women deserve to receive abortions (such as for medical emergencies) while others do not. The governors in some states have cited their desire to preserve PPE as a reason for their decisions. However, when these pregnant women deliver or if they present to the ED from abortion attempts, their physicians will use up PPE.

This is a time when abortion is more crucial than ever. Many women cite financial hardship as a reason for having an abortion and the COVID-19 crisis is already creating a huge financial burden. In addition, under shelter in place, many women have less access to contraceptives and are at increased risk for intimate partner violence, both of which may increase unplanned pregnancies. Now is the time for medical professionals stand in solidarity with ACOG’s stance that abortion is a important, essential procedure.

Movies have historically been a way to depict a shared cultural experience. A IMDB.com search in February and March 2020 of 163 infection related terms yielded 373 films in US theaters. 80 films were selected as the most culturally relevant, defined as earning more than $10 million, winning an Academy Award, or having 1 or more cultural references made to it in another film at least 25 years after release. Common topics included selflessness of medical professionals, fear of alien microbes, environmental destruction and other pandemics like the HIV pandemic. Common themes included depersonalization, such as the infected turning into something unrecognizable (i.e. zombies), failure in leadership, social class disparities and stigmatization of the infected.

Contagion (2011) seems to be the movie most are turning to at this time, judged by its top 10 most-downloaded movie position on Itunes. At the end of that movie, a vaccine is developed. Perhaps its popularity is due to its ultimate message of hope.

At Wake Forest Baptist Medical Center, a hospital medicine medical-surgical unit was converted to a Person Under Investigations (PUI) unit for patients with a suspected diagnosis of COVID-19. This paper was written by the doctors leading the efforts of organizing this unit, and detailing how best to best minimize healthcare worker (HCW) exposure to COVID-19 while still providing the highest quality of care for patients.

Unit Goals

• Deliver dedicated, comprehensive, and high-quality care to our PUI patients suspected of COVID-19.

• Minimize cross contamination with healthy patients on other hospital units.

• Provide clear and direct communications with our HCWs.

• Educate HCWs on optimal donning and doffing techniques.

• Minimize our HCW exposure risk.

• Efficiently use our personal protective equipment (PPE) supply.

Unit and Team Characteristics

• The unit consisted of a preexisting 24-bed medical-surgical unit

• The team consisted of an attending physician, advanced practice provider, designated care coordinator, pharmacist, respiratory therapist, physical/occupational therapist, speech language pathologist, unit medical director, and nurse manager.

• A daily huddle was held with all team members to keep apprised of the care of all PUI patients

Administrative Leadership

• A COVID-19 task force conducted daily conference calls, to disseminate information and discuss new treatment updates

• The PUI unit medical director and nurse manager relayed what was discussed on these calls to HCWs and in turn provided the feedback of HCWs to the COVID-19 task force

Patient Flow

• Hospital medicine was the default service for treating suspected PUI COVID-19 cases or cases of confirmed COVID-19 for which the patient required hospitalization

• For confirmed or suspected COVID-19 patients in the E.D or from another institution, they were admitted directly to the PUI unit and tested for COVID-19 upon arrival

Mechanisms to Efficiently Utilize PPE and Mitigate HCW Exposure Risk

• Limited personnel exposure to the PUI patient

  • Assigning only one medical provider able to enter the room

  • Limited number of entries to the room (ie. pharmacy called into the room to speak with the patient, coordinating timing of administering medications, eliminating unnecessary labs/procedures/imaging, etc.)

• Medical providers avoided using nebulizer treatments or noninvasive positive pressure ventilation to avoid the potential for aerosolizing the virus

• Infection Prevention taught the correct donning and doffing of PPE to HCWs and thereafter monitored the PPE usage of HCWs daily and provided real-time feedback

Other things to consider for your PUI unit

These were not implemented in this PUI unit, but should be considered.

• The use of elongated IV tubing, such that the IV pole and pump could be monitored and managed outside of the patient’s room.

• Having designated scanners (x-ray, CT, and MRI) for PUI patients to reduce exposure to non-PUI patients.

• Assign HCWs designated scrubs to wear only on their shift in the PUI unit

• Provide HCWs with a designated place to stay, such as a hotel.

• The utilization of more sophisticated audiovisual technology.

By late March, the New York–Presbyterian Weill Cornell Medical Center in New York City was in need of more ICU beds. To meet the demand, they converted their currently rather unused ORs and PACUs to ICUs wherever possible. In doing so, they were able to arrange 60 additional ICU beds, with the first beds from this arrangement available for use in a matter of three days.

The ORs and PACUs to be converted to ICUs were chosen based on their size, location, and available infrastructure (particularly the medical gas lines and power supplies). The use of negative pressure environments in these “OR-ICU” rooms was utilized to reduce exposure risks for staff and conserve PPE. Staff have also been retrained to understand the new flow of the hospital with these “OR-ICU” rooms.

This transformation has effectively increased the hospital’s critical care capacity by 52% and allowed them to support the needs of their surrounding community, by supporting the influx of patients from hospitals in New York City which are experiencing overloading.

Introduction

• Northern Navajo Medical Center is in Shiprock, New Mexico, within Navajo Nation— 27,000 square miles of desert, canyons and red rocks.

• The population density is seven people per square mile, but many people live together under one roof.

Background

• During the COVID-19 pandemic, Navajo Nation has been significantly impacted.

• The national media recently covered the poverty, isolation, and lack of running water in Navajo Nation but did not emphasize what Kovich calls the “diversity of talent and experience, the resourcefulness” that she sees.

• Current measures in place include a curfew issued by the president of the Navajo Nation and the parking-lot Fever Clinic.

• At the time this article was published, the hospital was at a surge level five as the majority of the hospital was filled with patients with confirmed or suspected COVID-19.

Study Design

• Perspective by Dr. Heather Kovich, M.D.

Key Points

• The doctors, therapists and nurses have multiple roles in the community; many are also farmers, artists, ranchers.

• In Navajo Nation, cases are not only increasing but also are clustering in families.

• Family members are impacted in several ways as multiple relatives are affected at once, both young and old. Kovich writes, “the impact of this collective trauma is hard to grasp.”

• Elders in the community are especially revered, and the impact of the virus on older adults is threatening.

Conclusion

• The impact of COVID-19 on the people and community within Navajo Nation is significant.

• This perspective provides insight into the ways in which the pandemic has affected families as well as how the community has utilized resources and ingenuity to confront it.

The global pandemic has put pressure on clinicians and the Food and Drug Administration (FDA) to act swiftly to make medications available to patients. When very limited observational and anecdotal evidence raised the possibility that the antimalarial drugs chloroquine and hydroxychloroquine may be effective against COVID-19, Trump quickly began celebrating the promise of their widespread use and issued an Emergency Use Authorization (EUA) on March 28 that allowed for use of the drugs to treat patients with COVID-19. Serious concerns have been raised about the adequacy of available studies of these drugs.

Widening access to experimental therapy is likely to have unintended consequences:

Benefits are unknown and may be negligible – such as the case of perimavir, the only other EUA drug used against swine flu. Subjecting patients to the well-documented risks of hydroxychloroquine would be unjustifiable in the absence of meaningful clinical benefit. Furthermore widespread off label use can limit access for patients who need them for effective therapy against lupus and rheumatoid arthritis.

Rapid deployment of treatments are not dichotomous with adequate scientific scrutiny - contrary to the public sentiment. Rigorous evaluation of drug’s safety and effectiveness in randomized, controlled trials remains the primary tool for protecting the public from ineffective and unsafe drugs, even in light of the pandemic.

Widespread emotional distress and increased risk of psychiatric illness is undoubtedly associated with COVID-19 due to uncertainties underlying prognosis and unprecedented public health measures of mass-home confinement directives, shortages of resources for testing, treatment, and protection from infection, economic stress, and conflicting messages from authorities. The effects of the pandemic may cause a range of emotional reactions, unhealthy coping behaviors, and noncompliance with health directives.

Psychosocial assessment and monitoring should include queries on:

1. COVID-19 related stressors (loss of loved ones, exposures to infected sources, physical distancing etc)

2. Secondary adversities (economic loss etc)

3. Psychosocial effects (increased substance use, suicidal ideation etc)

4. indicators of vulnerability (people who contracted the disease, high risk individuals– particularly healthcare providers, and people with preexisting medical, psychiatric, and substance use problems)

Health system leaders, first responders, and health care professionals should work together to identify, develop, and disseminate evidence based resources related to disaster mental health, mental heath triage, referral, anticipate needs of special populations, and bereavement care. In addition to providing medical care, health care providers have an important role in monitoring psychosocial needs and delivering psychosocial support to their patients, colleagues, and the general public.

Along with coronavirus shrouding everyone with fear, racism and xenophobia has also become something worrisome in the US. There have been many slanders regarding the Chinese being responsible for the virus, and this has led to Asian Americans and Pacific Islanders being harassed in public spaces.

Here is a four-step process to speak against these biases:

Interrupt to help pause the conversation to address the issue (ie. a racist joke).

Question to better understand why the person said that – essentially see where they’re coming from.

Educate them in regards to the racism surrounding the virus and how this is subjecting certain groups to be in harm’s way.

Echo someone when they speak up. This means supporting someone when they speak up against this racism. It fosters an environment in which more people would be willing to speak up again and help others in practicing tolerance.

During the COVID-19, hospital capacity is being stretched to the limit, and being able to predict the limit a hospital can tolerate before it happens would be of great value to the health care system. The University of Pennsylvania Health system developed the COVID-19 Hospital Impact Model for Epidemics (CHIME) to accomplish this task.

Study Design

• CHIME was designed as a susceptible, infected, removed (SIR) model that could be used by clinical operations leaders. Design began with projections of bed and ventilator demand for COVID-19 patients in three hospitals in the Philadelphia area.

• Researchers tested their model using existing pandemic data from the Philadelphia area as well as using data from case series published from China.

• Cross-validation was performed with other models of COVID-19 forecasting.

Results

• Across the three hospitals in the system, the model predicted peak hospitalization of 4467 patients with COVID-19 with 487 needing ICU beds and 170 ventilators.

Discussion

• Short-term predictions on hospital capacity strain were able to be produced with input from both clinical and operation teams in the system.

• While the predictions were in the extreme, the system was able to make changes early regarding logistics and surge planning.

• Limitations include not being able to account for the complicated transmission networks, using data from other populations, only predicting COVID-19 hospital demand, and not distinguishing those who have recovered and those who had died from COVID-19. Further work will be needed to validate this model.

Model accessible at https://penn-chime.phl.io/

The COVID-19 pandemic has had much impact on society and how it views the public health and the healthcare system. Older adults and those with chronic disease are at higher risk of complications with infections, and they are also at risk for poor health literacy. To assess how this population perceives the pandemic and the response to it, a cross-sectional survey was performed.

Study Design

• The Chicago COVID-19 Comorbidities Survey was administered in March 2020 to 733 patients, with 630 responding, who were enrolled in existing studies at one of five academic centers or two federal health centers in the greater Chicago area.

• The patients were enrolled in different studies that each had differing inclusion criteria, although they generally enrolled older patients with comorbidities.

Results

• The threat of the pandemic was rated more serious by those >70 years old and by women. Those with >3 chronic conditions rated the pandemic less serious.

• Respondents believed that 14.2% of those infected with COVID-19 would die. Most of the respondents were able to identify three symptoms and three ways to prevent infection.

• 20.8% of respondents believed that they were “very prepared” for a widespread outbreak. Those who live in poverty, unmarried, retired, black or Hispanic were more likely to say they were not well prepared.

Discussion

• This study revealed gaps of knowledge and preparation that were expected among those with lower health literacy and chronic medical conditions. These gaps also fell along racial and economic lines where existing health disparities exist.

• Primary care physicians need to understand the importance of patient education and helping patients prepare for this unpredictable time.

During this time of COVID-19, we have been hit with quite a bit of uncertainty, particularly in the field of medicine. As the task force that is at the frontlines of fighting this pandemic, the healthcare community has also been at the forefront of having to adapt to all of the uncertainty surrounding this situation – particularly that of the Personal Protective Equipment (PPE), ventilator, and numerous other medical supply shortages. This of course has led hospitals to scramble to make adjustments to cope with this burden. One of those adjustments has been limiting the surgeries that are occurring during this time. Elective surgeries have been stopped, and only urgent and emergent cases are being taken back into the Operating Rooms. Someone who has profuse internal bleeding after a high-speed motor vehicle collision, an emergent Cesarean section needing to be performed, or a cancer that needs to be immediately resected –are among surgeries that will be performed right away. But an interesting discussion taking place has been, what about transplant surgeries?

I had the privilege of being on the Transplant Service for one week before the COVID-19 pandemic hit the U.S. full force and we proceeded to have an online clinical curriculum for our third year. On my fourth day of the service, it was announced that all elective surgeries would be canceled soon. I was sitting in the General Surgery Residents lounge, and everyone had mixed opinions when it came to transplants:

“Of course it’s not elective, patients on the transplant list are on there because they are dying of their End Stage Renal Disease. Transplants prolong their lives.”

“But they can be put on dialysis, and have a machine do the work for their kidneys for a while, as they’ve probably been doing while waiting on the transplant list.”

Upon speaking with my transplant surgeon attending, Dr. Rogers, and being able to sit in on some discussions regarding the topic, it turned out to be a much more ambiguous situation. The talk of transplantation for a particular person was very much dependent on that person’s situation. If it’s a live donor kidney transplant (such as the patient’s wife is donating the kidney to them), that can be done at a later time. It should also be considered that we don’t want to bring an otherwise healthy living donor out of quarantine and into our healthcare facilities and potentially expose them to COVID-19. As for deceased donor kidney transplants, we can’t necessarily delay those cases, however; kidneys are only viable to be transplanted within a short time frame, and especially in light of the solid organ shortage we face, along with the fact that, on average, patients are on the waiting list for 3-5 years before reaching the top of the list and receiving a call about a donor. Then there’s the topic of dialysis, which most patients are on while waiting for their new kidneys, and which one could argue that they could continue to be on until this COVID-19 pandemic has gotten under control. But dialysis is not without its own risks, with patients having a 20-25% mortality rate after one year on dialysis, and a 5-year survival rate of 35%.¹ For reference, the mortality rate after 5 years for patients who receive a transplant is a lower rate of 3%.¹ A big factor of transplantation is whether the patient wants to undergo that process, once they do have a viable donor kidney. During this time, patients will have to consider if they’d want to put themselves through this big operation at the present time. Everything from employment to travel to food security has been affected by COVID-19, and patients and their caregivers need to evaluate if they are able to meet the demands of being a transplant patient in this time. Especially for the first 6 weeks following their transplantation, patients need to make regular visits to the transplant clinic to ensure that all is going well; this of course could put them at a higher risk of contracting the very virus that we are all trying our best to quarantine from. Furthermore, transplant patients also take an ICU bed for the couple of days following their transplantation, which potentially could have gone to a complicated COVID-19 case – something of great importance to think about as we are approaching the time when many hospitals in our nation are facing hospital overload due to this highly transmissible virus. Yet of course, we circle back to and have to think of our transplant patients: kidney failures do not magically cease during this pandemic (nor do heart attacks Cesarean sections, or strokes, for that matter).

This is not a comprehensive list of considerations that I have laid out, but I did want to provide you with a picture of what it has been like for transplant surgeons, thinking of the logistics of how to adjust to this virus. And of course, it goes without saying, that this is a microcosm of what physicians across the board have been dealing with in their specialties. There are a myriad of adjustments being made by both patients and their transplant surgeons. It’s still too early to tell what the exact implications will be not only for transplant teams and their patients, but also for all health care systems in America. We can only practice good social-distancing and wait for this to pass.

Introduction

• In the context of the current COVID-19 pandemic there is a potential need for rationing health care.

• Due to the potential of scarce resources and potential of limited capacity to provide care it is important to examine ethical considerations regarding advanced care planning and do-not-resuscitate (DNR) orders

Study Design

• JAMA Viewpoint article written by three physicians at the University of Washington and University of Vermont specializing in Pulmonary Critical Care and Palliative Care

Key Points

• The importance of “providing goal-concordant care is now heightened”

• Physicians should avoid intensive life-sustaining treatments unwanted by the patient.

  • It is important to avoid nonbeneficial or unwanted high-intensity care especially when there is stress on health care capacity.

• Nonbeneficial or unwanted high-intensity care unnecessarily increases transmission risk and strains available resources

  • Multiple health care workers are needed for effective ACLS

  • PPE and mechanical ventilators are limited resources

• Assessing overall goals of care before code status leads to more effective discussions even in the current pandemic setting.

• Telemedicine is a way to have effective conversations with patients and their family members as nonessential medical visits are limited

• The authors suggest informed assent as an alternative model to medical futility when approaching code status discussions with patients.

  • In this approach, the clinician asks the patient or family member to allow the clinicians themselves to assume responsibility

  • To view the authors’ proposed guide for an approach to having an informed assent discussion please use the link to access the original article

Conclusion

• Understanding and proactively assessing patients’ goals of care and code status are especially important in the context of the current pandemic in the context of increasing stresses to the healthcare system and limited resources.

• The authors suggest that approaching goals of care and code status with an informed assent model would allow clinicians to assume more responsibility in determining appropriate actions in line with the patient’s goals.

Summary

Two antimalarial agents, chloroquine (CQ) and hydroxychloroquine (HCQ) have been trusted treatments for rheumatic diseases, particularly in systemic lupus erythematosus (SLE) and autoimmune disorders in pregnancy. With the intense media attention during the COVID-19 pandemic, rheumatologists may face an ethical dilemma in the event that these drugs may be allocated away from routine rheumatology clinical care. The article concludes that rheumatology patients with life-threatening illnesses and pregnant patients with autoimmune conditions must be a priority to continue treatment. All other decisions to halt HCQ treatment in rheumatology patients must include empathetic discussion and consideration of medical implications on an individual basis.

Background

• Both CQ and HCQ are identified as disease modifying anti-rheumatic drugs (DMARDs). HCQ remains a mainstay of treatment for an array of autoimmune diseases, most importantly SLE. In a drug discontinuation study, stopping HCQ in patients with stable SLE resulted in over twice the risk of having a disease flare. An important advantage of HCQ is its safety in pregnancy and is mainstay in controlling numerous immune conditions in pregnancy without fetal risk.

CQ and HCQ in COVID-19

• In vitro studies have hinted that CQ and HCQ function both at the viral entry and post-entry stages of infection to interfere with SARS-CoV-2. One clinical trial of ~100 patients hinted CQ was superior to placebo in reducing pneumonia exacerbation, duration of illness, and duration of clearance of virus. Another non-randomized study of 36 patients combined HCQ with azithromycin and found supporting evidence to be weak and limited.

Ethical Dilemmas and Recommendations

• • Who should get HCQ treatment? Rheumatologists must advocate strongly for continued access to HCQ for valid clinical indications (ex. SLE, palindromic rheumatism, Sjogren’s syndrome, rheumatoid arthritis). Patients with well-controlled disease should not be denied continued treatment.

  • How should we allocate HCQ amongst COVID-19 patients in event of a limited supply? Any use of HCQ to treat COVID-19 patients must be limited to the hospital and/or intensive care unit settings within the context of a formal research protocol. Off-label use outside protocol should be prohibited.

  • Should HCQ be used as COVID-19 prophylaxis? There is no evidence that HCQ can be used to prevent COVID-19 infection. The public should be informed not to seek or self-medicate.

  • How can rheumatologists choose which patients remain on HCQ? Rheumatic disease patients with life-threatening illnesses or pregnant patients must have priority to continue treatment.

Brief Summary

The University of Pittsburgh recently released a document outlining a framework to determine who receives ICU care and ventilation to be enacted if their capacity is overwhelmed and a regional authority has declared a public health emergency. The goals of the framework is to maximize “the greatest good for the greatest number”. They propose the creation of triage teams consisting of an acute care physician, nurse and administrator who will use the allocation criteria to maximize saving lives and life-years to assign patients a score from 1-8 scale (lower score = higher benefit for care) which will determine if the patient is high, intermediate, or low priority for care. The category of priority will determine the order patients receive critical care score. The team would periodically reassess all patients to determine if critical care services should be continued. Unlike other frameworks, there are no strict exclusion criteria like age, disabilities or comorbidities that exclude people from being assessed for receiving care.

Creating the triage team

• Triage officers should have experience with critically ill patients, leadership skills, good communication skills and good conflict resolution skills.

• Officers will be nominated by chairs or directors of departments that care for critically ill patients. They will be approved by the Chief Medical Officer and the responsible party for emergency management.

• The triage officer should be supported by an acute care nurse and an administrative staff member who will do data-gathering and documentation.

• Shifts for a triage team should not last more than 13 hours with proper handoffs on each end.

• The triage officer should first tell the attending physician of the decision. The officer and attending physician should work together to find the best way to inform the family.

• It is possible for patients, families, or clinicians to challenge and appeal the triage decisions. A procedure should be created to begin the appeals process. A Triage Review Committee should be created to review appeals, made up of the Chief Medical Officer, Chief Nursing Officer, Legal Counsel, a hospital Ethics Committee member, members of ethics faculty and/or an off duty triage officer. They will operate by majority vote.

Allocation process

• The allocation process should calculate a patient’s score to categorize into priority groups and how many days each group will receive access to critical care interventions.

  • The Sequential Organ Failure Assessment (SOFA) score will be used to determine the patient’s prognosis after hospitalization. More details are provided in the article for score calculation.

  • Higher priority should be given to people who are necessary for the public health response including clinicians and other key personnel.

  • Separate age groups and prioritize those who have had the least chance to live through life’s stages.

• Determining the days the groups will receive the resource: Hospital leaders and triage officers should assess determinations at least two times per day depending on current resource availability and demand.

• Details are in the article on choosing between patients who have the same score.

Reassessment

• Patients should be given an adequate trial period to determine if the given resource is benefiting them. The duration should be determined by data based off of the clinical course of the disease.

• The triage committee should do periodic assessments on patients receiving care that takes into account the patients’ current condition.

• If patients are not receiving critical care, they should be receiving intensive symptom management and psychosocial support.

Problem

• Interventions to address health disparities in correctional settings are often challenging due to resource limitations and policy constraints. No comprehensive response exists that straddle both correctional facilities and the surrounding communities.

Importance

• Controlling infectious diseases in correctional settings can have positive effects both in these settings and on surrounding communities.

Background

• As of 2016, there were nearly 2.2 million people in U.S. prisons and jails. Populations in the criminal justice system have an increased prevalence of infectious diseases such as HIV, hepatitis C, and tuberculosis. People entering jails are among the most vulnerable in our society, and during incarceration, that vulnerability is exacerbated by restricted movement, confined spaces, and limited medical care.

Relevance to COVID

• People caught up in the U.S. justice system have already been affected by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and improved preparation is essential to minimizing the impact of this pandemic on incarcerated persons, correctional staff, and surrounding communities.

Current Actions

• • Suspend visitation by community members

  • Limit visits by legal representatives

  • Reduce facility transfers for incarcerated persons

  • Teleconferencing services for personal and legal visits

Proposed Actions

• • “Decarcerating,” or releasing, as many people as possible.

  • Urging police and courts to immediately suspend arresting and sentencing people for low-level crimes and misdemeanors.

  • Isolating and separating incarcerated persons who are infected and those who are under investigation for possible infection from the general prison population.

  • Hospitalizing those who are seriously ill.

  • Identifying correctional staff and health care providers who became infected early and have recovered since they may have some degree of immunity and severe staff shortages are likely.

A Kaiser Foundation study surveyed 1226 adults across the country from March 25-30th. The researchers aimed to gather data on public opinion and shed light on what is currently troubling Americans.

Impact on life

• 59% of participants are worried their investments will be negatively impacted for a long time, 52% of participants are worried they will lose their jobs, and 45% of participants are worried about a decrease in work hours. 39% of participants report already having lost their job, lost income, or had hours reduced due to the virus outbreak.

• 80% of participants think U.S. policy should be focused on slowing the virus rather than focusing on the economy.

• 85% of participants are worried local businesses will close permanently due to loss of revenue during the outbreak and 79% of participants are worried the US economy will head into a recession.

• 53% of participants are worried they or a family member will become sick from the virus.

74% of participants think the worst of the outbreak is “yet to come”.

Review by Michelle Qiu on 4/2/20.

The Italian College of Anesthesia, Analgesia, Resuscitation, and Intensive Care (SIARRTI) released clinical guidelines on March 16, 2020 for managing the limited resources in the ICU during the COVID outbreak. Using principles from the field of disaster medicine, the authors recommend treating those with greater chances of therapeutic success and favoring those with the greatest life expectancy. The authors additionally outline more specific recommendations, some of which are summarized below.

1. Criteria for ICU admission must be locally adapted to projected ICU admissions numbers and availability of resources.

2. Eventually set an age limit for ICU admissions, operating under the principles of maximizing benefits for the largest number of people. Limited resources should be for people with the greatest probability of survival.

3. Consider comorbidities and functional status of ICU patients when allocating resources. A patient with many comorbidities may have a more “resource-consuming” course compared to a young healthy patient.

4. Recommend advance care planning and advanced healthcare directives to patients and share with all healthcare staff involved with the patient.

5. ICU admission criteria should be discussed with patients as early as possible. Daily assessment of patients’ clinical course and wishes should be made. Decisions to withhold or withdraw care must always be discussed in a timely manner.

6. Appropriate palliative care must always be provided.

Ultimately, the principle of distributive justice allows for denying access to some patients due to the exceptional circumstances and lack of resources.

Review by Michelle Qiu on 4/2/20.

Being a patient in the hospital can be scary, lonely, and nerve-wracking to say the least, but many patients are able to find solace in having their loved ones present to support them through that time. But the COVID-19 pandemic and its highly infectious nature has prompted hospitals all over the nation to implement strict visitor visitations, which while necessary during this time, impede that very source of solace for patients in hospitals.

To help ease this burden on our patients and their loved ones, healthcare workers have turned to the thing the whole world has been leaning on during this pandemic: technology. But it really is up to the discretion and empathy of each healthcare worker.

A particularly heart-wrenching story that I came across was that of 86 year-old Steve Kaminski, who due to COVID-related complications, passed away at Mt. Sinai before being able to see his family again. But before he passed away, a nurse set up a group call with his family to say their goodbyes. While he was on a ventilator and unable to speak, the nurse told the family that he visibly lit-up as they spoke to him. See this article from CNN for the full commentary on Mr. Kaminski’s story: https://www.cnn.com/2020/03/29/world/funerals-dying-alone-coronavirus/index.html.

Suggestions for healthcare workers regarding Visitor Restrictions during COVID-19:

• Be aware of the important people in the patient’s life – write a note in their charts with their contact information

• Help patients set up a video chat or group call with their loved ones, particularly if they are unable

• Be cognizant of when the best time for the above would be, especially if a patient’s health is deteriorating rapidly

• Think of each patient you care for as your own family member – you will remember the importance of making that call

• Be willing to step in and be the source of comfort for that patient

Written by Shaleen Thakur, MS3 on 3/29/20.