Mapping the Moral Dimensions of an Outbreak Dr. William Harper, - - PowerPoint PPT Presentation

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Mapping the Moral Dimensions of an Outbreak Dr. William Harper, - - PowerPoint PPT Presentation

Mar 29, 2023 312 likes •714 views

Coronavirus and Ethics: Mapping the Moral Dimensions of an Outbreak Dr. William Harper, Internal Medicine Dr. Simon Oczkowski, Critical Care Dr. Julija Kelecevic, Regional Ethicist Dr. Andrea Frolic, Director, Office of Clinical &

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Coronavirus and Ethics: Mapping the Moral Dimensions of an Outbreak

  • Dr. William Harper, Internal Medicine
  • Dr. Simon Oczkowski, Critical Care
  • Dr. Julija Kelecevic, Regional Ethicist
  • Dr. Andrea Frolic, Director, Office of Clinical & Organizational Ethics
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Take a Breath…

How is your body feeling? Can you release tension? Can you focus on the present? How can you take care of yourself now? What is your intention?

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► Map some of the major ethical issues arising in outbreaks and pandemics ► Articulate the values that inform ethical decision-making in situations of ambiguity, uncertainty and overwhelm ► Discuss policies that can support social solidarity, protection of the vulnerable and wise resource allocation ► Describe practical resilience strategies to support yourself and your community

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Objectives

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Substantive and Procedural Values

Ethical Issues in Pandemic Response

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Nation Province Region My Organization My Team Me

Action is being taken at all levels of the healthcare system

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► How to reduce rate of spread, balancing social/economic disruption with public health needs? ► How to protect the most vulnerable? ► How to balance individual liberty and communal good? ► How to support and protect front-line workers? ► How to allocate scarce resources (medicine, ventilators, vaccines)? ► How to support fair, evidence-based, practical decision-making in situations of overwhelm?

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Ethical Issues in Pandemic Response

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http://jcb.utoronto.ca/news/covid-19.shtml

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Substantive Values: ► Social Solidarity ► Fairness and Equity ► Protection of the public from harm ► Proportionality ► Duty to provide care and protect others ► Reciprocity ► Trust ► Stewardship of resources ► Individual Liberty Procedural Values: ► Reasonable ► Open & Transparent ► Inclusive ► Responsive ► Accountable

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Ethical Values

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Protecting the Vulnerable and the Healthcare System

COVID-19 and Precautionary Principles

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Coronavirus disease 2019 (COVID-19)

  • Virus: Severe Acute Respiratory Syndrome

Coronavirus 2 (SARS-CoV-2)

  • Outbreak epicenter: Huanan Wholesale

Market December 2019 (bats, pangolins?)

  • Spread respiratory droplets from coughing or

sneezing with R0 2-3 (influenza R0 1.3)

  • Incubation period range 1-14d, median 5-6d

– Asymptomatic infectious phase 1-2d?

  • Diagnosis: rt-PCR nasal swab or sputum,

serology

  • Treatment: supportive, glucocorticoids if

ARDS

– Experimental: remdesivir, choloroquine?

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Putting Procedural Values and Evidence into Practice

Critical Care Resource Allocation

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tri·​age | \ trē-ˈäzh a: the sorting of and allocation of treatment to patients and especially battle and disaster victims according to a system of priorities designed to maximize the number of survivors b: the sorting of patients (as in an emergency room) according to the urgency of their need for care

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Triage is a process which already happens every day, with every stay … in a pandemic, the focus shifts from individual ➝ societal interests

Triage should be

reasonable, inclusive, transparent, responsive, and accountable

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1. Clinical need & benefit

  • need for respiratory support (ventilators) and

hemodynamic support (vasopressors and inotropes)

  • is the patient sick enough to benefit or too sick to

benefit? (initial and ongoing assessment, using standardized criteria, eg. SOFA)

  • does the patient have a condition which limits

survivability?

  • is there evidence this patient is more likely to

survive and function than others? 2. Supplementary factors????

  • multiplier effect — is the patient an essential service

whose survival will help care for future patients?

  • workplace exposure — did they contact the disease

while working in essential services?

  • caregivers — is the individual a caregiver for whom

survival could impact the care of their dependents?

  • fair-innings/life-cycle: are they at an earlier stage in

their life cycle than others requiring care now?

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Note:

  • repeated patient assessment
  • provision for deliberation and transparent

lottery process

  • ongoing committee review to ensure

quality

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Example: Ontario MoHLTC 2008 NOTE: Requires adjustment of standard of care, including consent requirements for withdrawing/withholding treatment to maximize benefit for greatest number.

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  • exhaustion
  • personal (& family) risk
  • moral injury
  • depersonalization
  • decision fatigue

Clinicians are at serious risk when these conditions are sustained under pandemic conditions We need to support and protect our team:

  • shared decision-making
  • transparent, fair process
  • clear documentation
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#inthistogether

On Solidarity in Crisis

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“Collective forethought and a board consensus would go far in helping to tackle the unique moral and ethical dilemmas that will arise when a catastrophic event occurs” (Iserson and Pesik, 2003)

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Solidarity (from “Ethical Framework for Resource Allocation During the Drug Supply Shortage”)

  • Build, preserve and strengthen inter-professional, inter-

institutional, inter-sectoral, and where appropriate, inter- provincial/territorial collaborations and partnerships by:

  • Embracing a shared commitment to the well-being of

patients regardless of care setting or geographic location

  • Establishing, encouraging, and enabling open lines of

communication and coordination amongst health professionals, health institutions, and health sectors

  • Encouraging sharing of resources across health sectors,

health institutions, and, where appropriate, provinces/territories

  • Supporting each other’s allocation decisions consistent with

the ethical framework

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Solidarity

  • as a substantive value
  • as a readjustment in “WE-OTHERS” concept
  • as an intentional practice of cooperation
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Be the Vector of Care

Resilience Protective Equipment (RPE)

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What is Resilience?

  • The strength and speed of one’s

positive adaptation to adversity and the capacity to persevere.

  • Requires a conscious choice to

cope, find meaning and hope and to do one’s best.

  • An internal growth process and

the ability to make meaning, become stronger or burn brighter than before.

  • RESILIENCE IS CATCHING!!
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► Physical preparation: sleep, hydration, nourishment, play, exercise ► Practical preparation: Do you have food and supplies for self- isolation for 14 days (including a functional thermometer!)? Can you log-in from your home computer to support your team at a distance? ► Social preparation: Arrangements for child care, elder care, travel, social gatherings. How to stay connected while apart? ► Mental and emotional preparation: Who are my support people? How can I activate my self-care practices?

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Personal Resources and Preparedness

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#vectorsofcare

I am contagious…in my fears, moods, intentions, actions… * What are the values relevant to this situation? * What do I want my legacy to be in this situation? * How can I be a vector

  • f…solidarity, calm,

compassion, care, wisdom? For my family For my team For my community

Be a Vector of Care!

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Calm your nervous system so you make good decisions for yourself and others! ► Be Aware: How are you? Where has your mind gone? Can you come back to this moment? This is the moment you can make a difference! ► Ground yourself: Connect with breath. Feet on the floor. Release tension. Hand on heart. ► Set intention: What values do I want to embody now? ► Practice Gratitude: small pleasures, moments of joy, working together, spring! ► Connect from the heart: Think about the people you

  • love. Reach out to connect with

eyes, smiles, words, gestures. ► Self-compassion: “This is tough, but I have been through tough things before. I am not

  • alone. May I be well. May we

be well together.”

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RPE: Resilience Protective Equipment!

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#ResilienceProtectiveEquipment #InThisTogether #VectorofCare

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Resources on Novel Coronavirus

  • Joint Centre for Bioethics: http://jcb.utoronto.ca/news/covid-19.shtml
  • Public health Ontario: https://www.publichealthontario.ca/en/diseases-and-

conditions/infectious-diseases/respiratory-diseases/novel-coronavirus

  • Public Health Agency of Canada: https://www.canada.ca/en/public-

health.html

  • HHS hub: https://hub.hhsc.ca/
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www.hamiltonhealthsciences.ca www.hamiltonhealthsciences.ca