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Each face-to-face interaction between a COVID-19 patient and a health-care worker requires a fresh set of personal protective equipment. The speed at which hospitals consume items such as masks, gloves and gowns is referred to as the burn rate.
A robot operated by medical teams helps treat patients suffering from COVID-19 in the Circolo hospital in Varese, Italy.
The 1922 version of the Canadian Medical Association’s code of ethics was blunt and unequivocal. “When pestilence prevails, it is their (physicians’) duty to face the danger, and to continue their labours for the alleviation of suffering, even at the jeopardy of their own lives.”
The “even at risk of death” demand was dropped by the time the next revision was released four years later. The COVID-19 pestilence is raising the question: How much mortal risk should we be asking doctors and other health-care providers to take?
In New York City “doctors are getting sick everywhere,” William P. Jaquis , president of the American College of Emergency Physicians told the New York Times. Two New York nurses have already died. In Italy, where hospital systems are on the verge of total collapse, 4,824 health-care workers had been infected with the virus as of March 22; 61 doctors have died, 40 of them in Lombardy, Italy’s worst hit region.
How much mortal risk should we be asking doctors and other health-care providers to take?
As intensive care units here begin to fill, doctors have begun isolating themselves to avoid bringing COVID-19 home to their families. There is a current of low-level anxiety as doctors and nurses confront the two most pressing worries facing the system now: the prospect of having to severely ration personal protective equipment (PPE) and mechanical ventilators.
“There are places that have shortfalls, there are decisions being made because we don’t have the supply, period. Nobody at the moment has an understanding, a full Canadian understanding of how much PPE is in stock at each facility,” said Dr. Andrew Morris, an infectious diseases specialist at Sinai Health System and the University Health Network in Toronto.
Staff are already using cellphones and baby monitors to communicate with unventilated COVID-19 patients in order to limit face-to-face contact and slow the “burn rate” — the amount of PPE they’re burning through every time they gown, glove or mask up to speak to a patient.
“For every one patient who is on a ventilator, for every single day, you’re talking somewhere in the order of hundreds of pieces of PPE when you add up the gowns, the gloves, the masks,” Morris said.
“When the Prime Minister says they have all this supply coming, how is it going to be distributed? How are they going to figure out where the need is? They have no idea, because nobody has done that work,” Morris said. “We’ve started that work here; we’re working on that frantically to figure that out.”
The federal government has placed orders from different companies for 157 million surgical masks, 60 million N95 masks and 1,570 ventilators, and is looking at ordering another 4,000, according to Public Services and Procurement Minister Anita Anand.
For now, everywhere people are trying to balance the need to protect health-care workers with the need to protect supply. But some doctors, likewise nurses, are asking, do they have an obligation, a duty to care, if faced with a nightmare shortage of supplies and equipment?
According to the Canadian Medical Protective Association, the powerful body that provides legal defence to the nation’s doctors: “Physicians may be permitted in exceptional circumstances to refuse to practice if they reasonably believe that the work environment creates a legitimate unacceptable hazard that is not inherent to their ordinary work.”
While a refusal to work due to inadequate gear could put a doctor at risk of a hospital or licensing college complaint, hospitals generally have an obligation to provide a safe work environment, the CMPA said.
Doctors are also worried about legal or ethical issues around decisions they’re very likely to soon confront, such as who gets treatment and who is left to die if ventilators and ICU beds become seriously strained. “As always, members should document their rationale for decisions under crisis situations to assist in the event of medical-legal difficulties,” the CMPA’s guidance stated.
When someone’s breathing deteriorates to the point they need be tethered to a ventilator, there’s a brief window “during which they can be saved,” reads an article published this week in the New England Journal of Medicine. Withdraw the ventilator, and the person usually dies within minutes. “Unlike decisions regarding other forms of life-sustaining treatment, the decision about initiating or terminating mechanical ventilation is often truly a life-or-death choice.”
Ontario and other provinces are working out criteria for ICU rationing — how do we save the most lives? Should the young leapfrog the old? How much time should people be given to show signs of recovery before life support is removed? Three days? Seven? Reports from Italy describe doctors weeping in hallways. “The angst that clinicians may experience when asked to withdraw ventilators for reasons not related to the welfare of their patients should not be underestimated — it may lead to debilitating and disabling distress for some clinicians,” the authors of the NEJM perspective article wrote.
In Canada, the more immediate concern is dwindling supplies of protective gear. “(Doctors) have questions about the reuse of protective gear, questions about what’s appropriate with respect to the use of homemade gear,” said Dr. Todd Watkins, the CMPA’s associate executive director.
Doctors could refuse to work should they reasonably believe the environment creates an unacceptable risk, much the same way a firefighter wouldn’t be expected to run into a burning building without safety gear.
“Physicians can’t refuse to see patients who are ill or who have an infection, but there would be some expectation that they would have the appropriate gear to be able to complete their task,” Watkins said.
“And so that’s what we’re telling physicians, but that doesn’t necessarily go far enough. Because at the end of the day, the building is still burning, patients are still sick and they need to be cared for and physicians feel that tremendous obligation to care for them.
“So it’s really putting the doctors in a very difficult position, because they’re concerned about their patients, they’re concerned for their own health. They’re concerned about transmitting the infection back to their family. And they’re concerned about asymptomatic spread.”
The medical-legal issues around rationing care, Watkins said, are secondary. “I think what they’re really concerned about is, ‘do I have the guidelines to make proper decisions and do I have the support structure to make an unthinkable rationing decision of two patients, and one ventilator.’
“What they’re looking for now is really some guidance, some standards on how to make those decisions should they be forced to do so.”
There is angst among some U.S. doctors around duty to care without adequate protective gear. “My friends in Italy and Spain didn’t seem to wrestle with it as much,” said Dr. Anand Kumar, a Winnipeg critical care doctor. In Canada, “we’re a little less focused on the individual well being here and more supportive of the social contract where we look out for each other,” Kumar said. “I just think Canadian doctors will be less likely to consider staying home if help is needed on the frontlines of this battle.”
When SARS hit in 2003, doctors and other health-care workers were confronted with, like now, a mysterious coronavirus of unknown origin for which there was no known treatment or cure. In Toronto, two nurses and one doctor died. While health workers generally showed “heroism and altruism,” according to a 2005 report by the University of Toronto Joint Centre for Bioethics, some resisted caring for the infected; others refused to show up for work. But how much risk should they have been asked to take? “There is currently a vacuum in this field,” Dr. Ross Upshur and his co-authors wrote.
“Duty of care was an issue in SARS,” said Upshur, who also chaired a World Health Organization working group on duty to care in a pandemic and has published extensively on the topic. “The question of whether you should be willing to provide care only if you have access to personal protective equipment is an interesting one,” Upshur said.
For millennia doctors provided care without any PPE, he said. COVID-19 is a global pandemic, “and the sad fact of the matter is that in most health systems around the world, physicians, nurses, health-care providers have limited to no access to personal protective equipment,” Upshur said. Many health centres around the world don’t have running water or soap.
“Our colleagues in low and middle-income countries and in very poorly developed health-care systems do not have the protections we are afforded in high-income countries, and they show up for work.”
But the physician workforce isn’t unlimited, he said. What happens if large numbers of doctors get sick and end up in quarantine? Canada is already 1,000 emergency doctors short.
And doctors know what they signed up for, Upshur said. “If you are entering the health-care profession, at any level, and you are not aware or do not know that you may be exposed to infectious diseases we have not done our job in preparing people to enter the professions.” There have been three major viral outbreaks in Canada alone since 2003 — SARS, H1N1 in 2009 and now, COVID-19 — “all of which posed particular risk to health-care providers,” Upshur said.
I think all health-care professionals are going to have to look in the mirror and ask themselves some very hard questions
“Health-care professionals do face risks from infectious diseases. It’s part and parcel of one’s job.” However, society also has a reciprocal obligation to provide as much protection as possible, he said.
“But what we’re seeing now, and facing now, are the ideas that we do not have limitless resources. And that scarcity then really makes the ethical issues that much more important for us to sort out. But we should have sorted them out before this happened.”
“I think all health-care professionals are going to have to look in the mirror and ask themselves some very hard questions about why it is they became physicians and what they see as their obligations to the patients that they serve.”
Doctors are running towards the crisis, not away, said Dr. Sohail Gandhi, president of the Ontario Medical Association. Doctors have been volunteering for COVID-19 assessment centres and frontline work. “The primary concern is, ‘am I doing the right thing for my patients? None of us think of legal concerns first.'”
“We’re all on edge,” added Morris. “This feels like the Viking ships are on their way, we don’t know how many ships there are, we know that when they arrive they’re going to pillage, destroy. We don’t know how much we’re going to be able to fend them off.
“We’re just hoping they’re just sending one ship, and we’ve got enough people to battle them. We just don’t know.”
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