Posted on April 7, 2020 at 3:41 PM
by Craig Klugman, Ph.D.
A regular flurry of articles demonstrate the high cost that health care providers pay for their work during the time of COVID: Health care workers are being infected with COVID after caring for patients. In New York City, the current epicenter, doctors are being “redeployed” meaning assigned to work in areas outside of their specialty doing procedures they may not have done since med school or may never have done. Some of the most dangerous specialties right now are pulmonology, respiratory therapy, and anesthesia where you basically are getting close to people’s mouths while performing procedures that dislodge the rich fluids in which COVID thrives. At the same time that we rely on these people to “save lives” there is an international shortage of personal protective equipment (PPE), the gear that they rely upon to keep them safe from infection.
As controversial as this will be, I propose that not only can a health care provider without adequate PPE not give treatment to a patient who poses a risk to their health, but that they should not perform risky procedures without proper protection to such patients.
As a society, we would never send a soldier into battle without a weapon, ammunition, and flak jacket. We would never send a firefighter into a blaze without fire resistant jacket, hard hat, axe, and water. Yet, we are asking health care providers to go into battle in nothing more than scrubs. Many of them are willing to wage war with no defenses and no protection. We must consider that beyond a shortage of PPE, and ventilators, and beds, there is also a shortage of trained health care personnel to deliver care. To conserve PPE, health care providers are given a single mask for an entire day, or sometimes for a whole week. To preserve ventilators, bioethicists and hospitals are drafting triage and reallocation policies, while doctors are connecting up to four patients on a machine made to support one. So why would we not do everything to protect health care providers? Protecting these resources is our most important task.
Physicians, the story goes, have an obligation to help and protect their patients, even if that requires putting themselves at risk. This is one reason that PPE is so important, many doctors do not consider their own well-being when someone else is need; they just help. Other health professionals are obligated to care for themselves as well as their patients: Emergency medical service professionals are ethically obligated to not put themselves in harm’s way. Nurses are required to avoid becoming infected with anything they could pass to others, though all HCPs often put themselves at risk to care for others.
Why do doctors allegedly have a limitless obligation to help? Do health care providers have an obligation to work knowing that conditions are unsafe? Must the health care provider risk their life and health to care for others? History offers a mixed answer to this question: During epidemics sometimes physicians have stayed and risked their own health, and sometimes they have fled the scourge. In 1990, Walter Friedlander wrote about the duty to treat HIV patients, that the AMA Code requires physicians to treat the infected but that they also have the right to choose who to treat: How do you reconcile these two competing ideas? Of course, for some of those early AIDS years, we did not know how the virus was transmitted nor how to protect people. “Universal precautions” became well known and practiced but that also required having adequate PPE. However, with COVID we have a good idea of how it’s spread and how to protect people from it. That knowledge is a key difference.
Literature also provides a mixed message. Bocaccio’s The Decameron portrays doctors as fairly useless, and fleeing to protect themselves (which historically is not what happened). In Albert Camus’ The Plague, doctors stayed in the city during an outbreak. We learn that some of the doctors had nothing useful to do but wanted to be seen as leaders; while Dr. Rieux had good scientific knowledge and willingly toiled long hours, at his own risk, to help. Rieux rarely stops to think about what he is doing and why, he simply does. Geraldine Brooks’ new book, Year of Wonders is about a town self-sacrificing during an outbreak to protect others, but the doctor runs away. In Jose Saramago’s Blindness, the physician treats patients until he succumbs to the plague of blindness himself, when he becomes a burden to everyone else. This is something we often do not consider, the health care provider without protective equipment who works to treat others, will soon need to be treated. The helper becomes the burden.
Neither history nor literature offers a definitive answer. But, they do provide some guidelines:
- Are there times where a health care provider should definitely not be seeing patients (especially when there is insufficient PPE)? Yes. If a health care provider is at particular risk (immunocompromised for example), then they should not be seeing COVID or suspected COVID patients. On bioethics.net, we posted a piece from physician’s assistant Nicki Reno-Walt who is staying away from the frontline because she is immunocompromised and thus COVID presents an extra danger to her. Like Doctor in Blindness, this person is more likely to quickly become one more person in need.
- If actions that can pose a risk to a health care provider is required (and there is PPE available), then people can volunteer to take on these activities. In their non-HCP roles, a person may be taking care of children, or an elderly relative or an immunocompromised spouse. These ancillary people did not take an oath to have their lives threatened. The HCP may be worried and reticent to take part in certain riskier activities because the HCP could become a vector to others in their lives. The nurse may not have the luxury of being able to live in a hotel (who takes care of the kids then?). Rather than forcing someone who is breadwinner or caretaker to have to choose between treating patients over caring for their family, the first step might be asking for volunteers: Who is able and willing to treat COVID patients? Unlike in the AIDS epidemic, health care providers are volunteering in large numbers to be on the front line. Add that many are willingly working grueling, long hours to care for patients suggests that a volunteer corps would work. Those who want to help can, and those who feel they have competing duties could step away.
- If there is a lack of PPE, then no one should be conducting high risk procedures. In the case of COVID, this includes intubation and CPR. According to the state of Colorado Crisis Standards of Care (CSC) guidelines (2020), “Under current circumstances, no CPR or intubation should take place without use of adequate personal protective equipment (PPE), as these are high-risk activities for exposure; this holds true even if donning PPE will delay the initiation of CPR”. No PPE, no ventilation or resuscitation. This might be akin to the “unilateral DNR” concept that has received a great deal of criticism: “This institution does not do resuscitation unless it is safe for everyone involved”. Without PPE, it is simply not safe for the limited resource that cannot easily be replaced and for which we have no workarounds—the health care providers. Such a policy should be transparent and stated to families and patients. If PPE appears later, then a blanket policy against resuscitation for COVID patients could be altered.
- Some might argue that this approach would leave patients without care, but that is not true. All patients would be given supportive, comfort care. They would all be made as comfortable as possible while their bodies fight the virus, or lose to the virus. After all, most aggressive interventions being done now are simply supporting the patient’s own immune system.
These COVID deaths are tragic, but even more tragic would be the loss of even more health care providers because there isn’t enough reliable PPE. While the President can order companies to build more vents, and football franchises can send planes to China to purchase masks, we can’t create new health care providers in short order. At the minimum, even with allowing fourth year med students to graduate early, we are one year from the next medical student cohort being able to help out (and given that they are not allowed in clinical areas now, will they actually be ready to practice at this point in a year?). No code, oath, or standard can change that simple fact.
The most limited resource we have is the health care provider and it is the one we must protect the most. If we don’t have the tools to protect them while they work, then they should not do risky procedures. And if hospitals won’t protect their greatest asset, then the health care providers must say no.
With special thanks to Patricia Mayer, MD, MS, HEC-C for kicking the tires around on this one with me.