Pretend you’re an ER physician in the Covid-19 pandemic. Mrs. Johnson, a 50-year-old otherwise healthy female, is gasping for air. There is fear in her eyes. Unless you place a breathing tube into her windpipe and use a ventilator to fill her lungs with oxygen, her heart will stop. But there are no ventilators and no ICU beds.
Then emergency medical services (EMS) rushes in Mr. Gass from a nursing home known to have many patients testing positive for Covid-19. They’re doing CPR. His heart stopped beating. He suffers from severe heart failure, lung disease that requires chronic oxygen, and multiple other medical problems. His prognosis is poor. His advanced directive says he wants everything done.
Under normal circumstances, you would not question those directives and the patient’s request would be honored. But your experience amid Covid burdens you with the knowledge that more patients will be coming, resources are limited, and that this patient’s prognosis for recovery may be much lower than that of the next patient.
What do you do?
Covid-19 has challenged the clinical skills of healthcare providers and rattled some of medicine’s operating assumptions, beliefs, and norms. The ground shifted beneath our feet. Part of the process of preparing for the new normal that lies ahead is re-evaluating the integrity of the houses that have stood the test of time.
“Do No Harm” is one of those houses. It is a bedrock precept of medicine that dates back over 2500 years to Hippocrates. Of course, the commitment to do not harm is not always possible. The practice of medicine is the practice of modulating benefits and harms. Many of medicine’s life-saving advances, such as chemotherapy, surgery, and antibiotics, are not without various degrees of risk and potential harm.
An additional problem is that different people interpret “harm” differently. For example, “Do no harm” in Mrs. Johnson’s situation is to intubate her and support her breathing with a ventilator. Considering Mr. Gass’s dismal prognosis, some physicians and surrogate decision-makers might consider “treatment” the harm. The “life-saving” interventions won’t save his life and instead become sources of burden and pain. Although some people will disagree with that logic.
During the Covid-19 pandemic, hospitals were faced with the stark possibility that there wouldn't be enough life-saving resources such as ventilators, ICU beds, and drugs for those who would need them. The practice of triage, prioritizing which patients need attention first, is part of everyday practice in emergency medicine. The ethical rules of care focus on saving the sickest people. But the rules shift in the face of scarcity. Resources are allocated to benefit the greatest number of patients. These triage decisions are both necessary and a source of discomfort. When Covid-19 challenged hospital capacities, states, professional organizations, and hospitals crafted documents—crisis standards of care (CSC)—to ensure that decisions promote transparency, trust, fairness, and equality.
Model CSC protocols are designed so that patients are evaluated using the same, validated criteria, often offloading allocation decisions to a neutral triage team not involved in the patient’s care. This strategy supports thoughtful and objective deliberation but isn’t always feasible for the time-sensitive situations facing emergency providers. The ER physicians caring for Mrs. Johnson and Mr. Gass are confronted with tough, unprecedented, and emotionally wrenching decisions and equally difficult conversations with patients and their families. And what if your CSC documents, despite their eloquence and detail, function more impressively as ideas on a page than practical guidance for providers?
Being prepared demands probing the very idea of preparedness. Assuming that we are prepared can lead to a complacency that rocks our foundations when faced with destabilizing new conditions. We have a responsibility to continually reevaluate and plan for the worst. How does emergency care as a practice achieve this?
Patients have been the primary subject when assessing risks and benefits. What are their preferences? What are their desires and fears? But during Covid-19, the operating conditions became more complex. Frontline health workers cared for patients with insufficient or inadequate personal protective equipment (PPE). Their safety entered into the calculus of “Do no harm.”
Personal risk isn’t new to ER physicians and nurses. Physical and verbal violence against healthcare workers was increasing before the Covid-19 pandemic. Despite the baseline tolerance to ER workplace violence, the risk due to Covid-19 is different. Fulfilling our duty on the frontlines carries a statistically increased risk to self and family members, due to the contagious nature of Covid. There is a difference between risk assumed and risk imposed. Healthcare workers are used to accepting a measure of personal risk, but might draw the line on imposed risk to themselves or their families.
When it comes to cardiac arrest, most healthcare workers are hard-wired to respond to patients without considering risk. Look no further than the California nurse who rushed to the bedside of a coding Covid-19 patient without adequate PPE, only to die two weeks later from Covid-19. The code team responding to Mr. Gass includes physicians, nurses, ER techs, and respiratory therapists. It requires procedures that expose multiple people to a potentially deadly virus and PPE that is in short supply. How do we factor in healthcare worker harm and levels of PPE scarcity when caring for patients?
In the new Covid-19 world, “Do no harm,” serves as both a moral guidepost and a portal of entry for discussing the many clinical challenges of emergency care. In a time of Covid-19, when a patient is in cardiac arrest, can healthcare providers take the precious minutes to don the appropriate PPE when time is critical to patient survival and outcomes? Should intubation and resuscitation be offered if a patient in cardiac arrest has a poor chance of survival? (And if not, what emergency measures should follow to assure timely and compassionate alternatives care pathways?) And what do you do with Mrs. Johnson? A chorus of insistent voices scream “Intubate her!” But these voices change their tone when they realize that the only way for Mrs. Johnson to get a ventilator is to remove someone who has a worst prognosis. For many caring physicians (and patients and communities) removing a patient from a life support machine because someone else with a better prognosis based on clinical indicators is more than distressful, it’s repugnant. It marks a sharp departure from existing medical norms.
In the examples cited, “Do no harm” for one person may be perceived by another as medical-legal negligence. During the height of the pandemic, states statutes offered protections for clinicians. These protections were rolled back as the crisis conditions eased, though some statutes remain in place regarding patients with known Covid-19 patients. Unfortunately, emergency medicine is a practice of uncertainty. We might not know whether a patient has Covid-19 when making clinical decisions and assessing risk.
These aren’t esoteric concerns. The physician and poet William Carlos Williams wrote, there are “no ideas but in things.” Mrs. Johnson and Mr. Grass aren’t real patients, but they serve as reminders that pandemic preparedness should never lose sight of how and why real people are impacted, including how people of color are disproportionately affected
While some states are experiencing a pandemic pause, many others face rising numbers of Covid-19 cases. People aren’t wearing masks. A second-wave looms on the horizon. In addition to the infectious threat, there’s a pandemic of mistrust as a nation rages against years of police violence and systemic racism. And come the fall, hospitals must brace for seasonal influenza, and with that, possible hospital and ER crowding. How do we use “Do no harm” when social distancing and cooperation is vital to minimize transmission of the Covid-19 and large numbers of patients fill the waiting rooms? How do we function if the spaces in which we provide care present risk to patients and providers alike?
Emergency medicine is a practice of uncertainty. When providers don’t know whether a patient is infected with SARS-CoV-2, how should they assess personal risk when making clinical decisions? If inadequate PPE continues to plague frontline providers, what constitutes acceptable risks, and what are the options when that threshold isn’t met? People’s fear and anxiety about Covid-19 has kept many from going to hospitals for much needed medical treatment. How is it possible to do no harm in an environment where people are afraid to seek help? How can ERs overcome this narrative and create spaces and clinical practices to reassure patients that seeking care will not put their health at added risk?
The ground has shifted and we must test the integrity of all the foundations of our moral and clinical beliefs and practices. Design presents pathways forward. It is a critical and logical partner for shaping our understanding of these moral spaces. Design is a practice, the actual application, or use of an idea, belief, or methods. Ethics shares the same root for ethos, the Greek word for character. For the Greeks, character is a function of the choices we make and the actions that emanate from those choices. Design and ethics share practical applications. It’s been my experience that artists are more comfortable working with uncertainty and probing discomfort. Their inquiry has roots in the messy particulars of the world. The Covid-19 pandemic is a reminder that medicine can’t examine our cherished houses from above. We need to inspect the integrity of the rooms as the ground shifts, and how well they’re serving everyone who lives there.
Jay Baruch - MD, Associate Professor Alpert School of Medicine, Brown University; Director of the Medical Humanities and Bioethics Scholarly Concentration
Being prepared demands probing the very idea of preparedness. Assuming that we are prepared can lead to a complacency that rocks our foundations when faced with destabilizing new conditions.
The ground has shifted and we must test the integrity of all the foundations of our moral and clinical beliefs and practices. Design presents pathways forward. It is a critical and logical partner for shaping our understanding of these moral spaces.