SCCM Resource Library-Team Ethical Considerations

Video Transcription

Hello, everyone. My name is John Greenwood, and I'm both an emergency physician as well as an  intensivist at the University of Pennsylvania in Philadelphia, Pennsylvania in the United States.  And what I'm going to talk about today is a really important topic. It's team ethical  considerations. And this is particularly related to the track that we're in right now, the COVID-19  modified clinical emergency processes. And this is really aimed at looking at how we work  during these crazy times of the pandemic. I really wish we were in person to have face-to-face discussion, but understand that we can't. So if any of you have any questions  whatsoever, my email address is down at the bottom, as well as my Twitter handle. Please feel free to reach out. I always love talking about resuscitation topics. So  I'd love to hear from each and every one of you, if I could. So let's get started. And when we're  talking about ethical considerations, I really wanted to divide this in two main buckets,  if you will. I think it's, what are the ethical obligations we have towards our patients? And  we're going to specifically focus in on out of hospital cardiac arrest care during a pandemic.  And then the flip side of that is what are the ethical obligations we have towards each other?  And so we're going to focus on that in the second half of this talk. But I think the first question  is really an important one. This was kind of a lightning rod discussion, particularly at the  beginning of the pandemic, because it really tested us as clinicians, right? Like I think  all of us, when we think about ethics, we think about kind of the moral principles that help  guide our behaviors. And most of us got into medicine to do one thing, it's to help people  and save lives. And when it comes to cardiac arrest care, there's nothing more quintessential  in terms of saving someone's life than resuscitating someone from out of hospital cardiac arrest.  But during this time in the early pandemic, there were a lot of questions about whether or not we  should do that. And I was very fortunate at Penn to have an institution that stood by us and thought  about this in a really intense way. And our university came up with a policy that gave us as clinicians some latitude during this period of a lot of unknowns of safety and efficacy,  and basically told us that if you think it's going to be helpful, by all means, do your normal clinical practice. But if not, then maybe you don't have to. But certainly,  I think a lot of us, this didn't feel right. This was something that we were used to doing on a almost daily basis at times, taking care of patients with cardiac arrest who were  critically ill. And to say, no, we're not going to care for you right off the bat, that was really  a bitter pill to swallow. So something I think a lot of us struggled with. But I don't think  it was just us at University of Pennsylvania. This was across the country and across the world.  There were doctors that were being told, don't perform cardiac arrest care. Don't perform CPR.  This was published in the British Medical Journal. And it even made its way to the lay press where  the discussion of whether or not hospitals should just consider universal DNR orders  for patients with COVID-19. And certainly, it was focused on this concept of team risk, healthcare worker risk versus patient benefit. But we saw a big dip in survival to discharge.  In fact, almost 20% of patients that were likely to survive, there was a decrease in our usual  survival rates during this period. So this really hit home and I think affected a lot of us.  Well, what is the literature said? Over the past two years, there's been certainly a number of  publications that has helped guide our decisions of where we stand today. This was probably the  first one. This was published in Critical Care Medicine in 2020 by Dr. Shah, colleagues at  Downand Hospital in Georgia. This was a single health system, retrospective cohort study of about 63 patients. And they all had COVID-19 or sorry, were diagnosed with COVID positive  and experienced in-hospital cardiac arrest. Now, this was early on in the pandemic, so March to August of 2020, they weren't chronically ill, but they were all severely  hypoxic. So they had PF ratios less than 200 in a majority of these patients. So the presumed cause  was likely respiratory. And in addition to that, over 90% of these patients had non-shockable  rhythms. Now, the care they provided, it seemed like they were right on top of it. So ACLS was  initiated within one to two minutes and they were able to achieve ROSC in about 30% of their  patients. But over 50% of those 30% that did achieve ROSC re-arrested within two hours. And  unfortunately not a single one survived. And this was pretty shocking. When we're talking about  efficacy, should we do ACLS in patients with COVID, a 0% survival really moves the needle potentially about whether or not care is futile. And I think concerned a lot of us in the  resuscitation community, but followed to that in 2021, Oscar Mitchell published in resuscitation,  his multicenter study, this included 11 sites in the Northeast, as well as the state of Washington, a much larger sample. So 260 patients, again, early in the pandemic with COVID,  90% non-shockable rhythm, they achieved ROSC in again, about 20% of patients with a 30 day  survival of 12%. But not only that, over a third of that 12% had a CPC score greater than three,  which means not only were patients surviving, but they had good neurologic outcome.  So now comes into the question, maybe this first study where there are hospital policies that were directing clinicians to stop CPR early. Was there something else driving that 0%  survival? Because in the Mitchell study, clearly the outcomes were not as futile as one might take  away from that first study. But that's in hospital cardiac arrest. And we all know out of hospital  cardiac arrest is much more challenging and the outcomes are always poor because the duration of  time out of clinical care, then when it's, the cardiac arrest is seen right when it happens.  Well, this article was published in 2021 by Dr. Squisato. This was a meta-analysis of 10 studies  that included over 1300 patients with out of hospital cardiac arrest with COVID or presumed  COVID. And again, early on in 2020, February through July, 93% non-shockable rhythm. So very  similar to the patients we just discussed in the previous two studies. And they found that ROSC  again, about 22% was achievable, but there was a, only a 2% survival. Now, you know, I think this  2% is probably more consistent with what we're seeing nationally in the United States of that  usual two to 5% survival for out of hospital cardiac arrest. So, you know, I think my takeaway  from this is really that maybe cardiac arrest care isn't futile. That certainly there are patients  who will survive, but we just have to make sure we're doing it the right way. And so what does  that mean? What is doing cardiac arrest care, ACLS the right way mean during a pandemic? Well,  the AHA published their interim guidance in July of 2021, which gave us basically some ground rules  for cardiac arrest care. So they basically said we should be performing ACLS, but we should be  doing it safely. Okay. That's helpful. But what does that mean? It means make sure you're wearing  PPE. So that means I wear masks and gowns. If you get past that five, first five minutes and need to  place an invasive airway, make sure you're using viral filters to prevent viral transmission or  aerosolization. Transmission risk does seem to be low with hands-only CPR. But certainly, you know,  be aware that in certain communities, you know, certain patients might be more affected by the  access to emergency care. So we should really be paying attention to this. But certainly, ACLS can be given to patients with COVID or presumed COVID during a pandemic era.  Okay. So now the next question I think is, how do we ethically take care of each other? This has been a really trying time, I think, for all of us, both clinically, emotionally,  physically, this has been one of the, I think, the most trying times in our United States healthcare  system, our international healthcare system. But we need to be careful about how we're taking care  of each other. And we, I think we do have some ethical obligations to take care of each other,  because we've seen over the past two years, a number of things that have contributed to  decreases in mental health, right? So we've had increased workloads, longer shifts,  shifts have been more intense. There's a lack of physical psychological safety  related to some of these events. And certainly, we just talked about the moral conflicts and  just simple things like perceptions about job security. Certainly, all of these things have  played a part in increasing a number of stressors that have impacted our mental health. Now, this was published in 2021. There was a basically the incidence of depression,  we're about 25% in healthcare workers during this time, anxiety, changes in our sleep patterns,  there are patients who felt PTSD, all about 25% incidence in these things. And I think the most  concerning thing was related to the general public, healthcare workers had a 50% increase  in thoughts of suicide or self harm. So we're normally might be around five to 6%. Healthcare  workers were up to 11 to 12% of these thoughts. And so what this tells me is that we need to figure out ways that we can take care of each other during these really stressful times.  New England Journal had this published, they talked about five key elements that we can make  a high priority to protect our well-being. And the first one being wellness officer integration. So  taking someone and making them accountable for our well-being is important at the organizational  level, making sure that we're talking about this and also supporting current programs that are  already in place locally, this is really valuable to ensure that our healthcare workers are taken  care of. And on a national level, certainly we need to fund this topic more and not only study  it, but report the outcomes. Now at Penn, we have an initiative called the Cobalt program that  it's a digital platform that we can basically on the spot access to mental health resources,  as well as clinicians. Hopefully you have access to that or something similar at your institution.  If not, please reach out. I'm happy to connect you on how we can kind of build this type of support network outside of our university. But these types of things are really important  and invaluable to making sure that the people who are caring for people are getting cared for.  Now, one clinical intervention I think is probably helpful in terms of supporting healthcare worker well-being is this idea of a hot debrief. And this is something that we,  we do at Penn particularly related to cardiac arrest care should, you know, really distressful decisions being made, but this was incorporated during  the COVID-19 pandemic, particularly where we basically had a four element  intervention to create a discussion around how a cardiac arrest went. And this was designed to  happen in a very short period of time. This happened in five minutes post-resuscitation  after the outcome, whatever it was, was achieved and has five key elements. I'll talk about that.  Really the first element is going around the room and asking what people's reaction was,  how did it feel? Was there anything that was concerning to individuals about the resuscitation?  If we stopped early, should we have stopped earlier or later? What are the thoughts? And  then come up with a key description of the event. So what were the main issues that we had to  address? The analysis part was really important because this gave everybody a real voice.  It allowed team members to identify performance gaps, to express things that were appreciated,  things that were concerning or uncomfortable, and then allowed people just to speak up about  their individual perspective. I think this is really critical, particularly in these distressing types of periods. And then lastly, there were some team-based solutions. You know,  how can we close some of the performance gaps that we identified? You know, these types of things can  really be impactful and there's a pretty decent evidence base that they increase staff well-being.  So something you can definitely take back to your institution or at least consider in whether or  not it's all resuscitations or certain ones that seem to be more distressful than others.  You know, I think at the end of the day, this pandemic has been really stressful, not only on families, patients, but on all of us. And it's important when we talk about ethics,  that we talk about not only our ethics to clinical care to the patients, but ethics towards taking care of each other. You know, it's been an absolute pleasure reviewing  this topic, discussing it. And again, like I said, if any of you have any questions at all, please don't hesitate to reach out. It's been an absolute pleasure to take part in this,  in this track and to be the virtual moderator as well. So thank you very much.

Video Summary

In this video, Dr. John Greenwood discusses the ethical considerations related to out-of-hospital cardiac arrest care during the COVID-19 pandemic. He talks about the initial debate among clinicians about whether or not to perform resuscitation due to safety concerns and the impact it had on survival rates. He then presents various studies that provide insights into the outcomes of cardiac arrest care during the pandemic. Dr. Greenwood also emphasizes the ethical obligations healthcare professionals have towards each other in terms of mental health and well-being. He suggests interventions like hot debriefs and the integration of wellness officers to support healthcare workers during these challenging times.

Asset Subtitle

Ethics End of Life, Quality and Patient Safety, 2022

Asset Caption

Clinician safety and adequacy of personal protective equipment, communication challenges, and hospital/system-level process modifications have left permanent changes after the COVID-19 pandemic. Fostering continued vigilance of team performance, measuring system latent threats, and data vigilance are challenging. Speakers discuss methods to maintain the resuscitation team and system excellence.

Meta Tag

Content Type Presentation

Knowledge Area Ethics End of Life

Knowledge Area Quality and Patient Safety

Knowledge Level Foundational

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Education

Tag Quality and Patient Safety

Year 2022

Keywords

ethical considerations

out-of-hospital cardiac arrest care

COVID-19 pandemic

resuscitation

survival rates

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