Discussion Questions

JOURNAL OF HOSPITAL ETHICS

THE JOHN J. LYNCH, MD CENTER FOR ETHICS

Volume 7

Number 2

Spring 2021

Features

______________________________________________ Organizational Ethics Support for Health Care Leaders During the COVID-19

Pandemic and Beyond

Tim Lahey, MD, MMSc; Susan Reeves, EdD, RN; Isabelle Desjardins, MD;

and William Nelson, PhD, MDiv

Ethical Distribution of COVID-19 Vaccines to Health Care Workers: One Hospital

System’s Attempt at a Moral Allocation Algorithm Joseph M. Dunne, PhD; Karen L. Smith, PhD, HEC-C; Matthew J. Haugh, MA;

Rebecca E. Washburn, MHA, RN; Wan-Ting K. Su, PhD; and Alexander Plum, MPH, CHES

Increased Ethical Burden in Surrogate Decision-Making During COVID-19

Adrienne D. Mishkin, MD MPH; Nicole Allen, MD; Adira Hulkower, JD, MS;

and Lauren Flicker JD, MBE

The Ethical Allocation of Remdesivir Within Hospitals

Amber R. Comer, PhD, JD

Delirium Assessment in COVID-19: What a Difference a Little Change Can Make Evan DeRenzo, PhD; Catherine Bledowski, MD; Jozef Bledowski, MD; and Chee Chan, MD

In Practice

______________________________________________

Shared Decision-Making in The Presence of COVID-19 and The Absence of Families

Lynette Cederquist, MD; Biren Kamdar, MD; Alex Quan; and The Editorial Group

of the Lynch Center for Ethics

When Extracorporeal Mechanical Oxygenation (ECMO) Needs to be Turned-Off

The Editorial Group of the Lynch Center for Ethics

Inpatient Psychiatry in a Pandemic: The Organization and The Individual Christian Carrozzo, PhD (c)

C O

V ID

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EDITORIAL GROUP

EDITOR-IN-CHIEF

Evan G. DeRenzo, PhD

SENIOR EDITOR

Christian Carrozzo, PhD (c)

MEDICAL EDITORS

Jack A. Sava, MD

Michael Pottash, MD

CONTENT EDITORS

Jory Barone, MLS

Fred King, MSLS

S. Layla Heimlich, MSLIS

ADMINISTRATIVE ASSISTANT

Nikki Glover

INTERIM EXECUTIVE DIRECTOR

Ben Krohmal, JD, HEC-C

EDITORIAL ADVISORY Amanda Anderson, RN, BSN, CCRN

Fellow in Clinical Scholars, Robert Wood Johnson Foundation

Chee M. Chan, MD, MPH

Medical Director, Intermediate Care Unit, MedStar Washington Hospi-

tal Center

Zacharia Cherian, MD

Chair of Neonatology, MedStar Washington Hospital Center

O. Mary Dwyer, JD, MA

Clinical Assistant Professor, Department of Bioethics Case Western

Reserve, School of Medicine

J. Hunter Groninger, MD

Director, Section of Palliative Care, MedStar Washington Hospital Center

Laura K. Guidry-Grimes, PhD, HEC-C

Assistant Professor of Medical Humanities and Bioethics, University of

Arkansas for Medical Sciences

Josh Hyatt, DSH (c), MHL, CPHRM

Adjunct Professor, Massachusetts College of Pharmacy & Health Sci- ences

Jack Kilcullen, MD, JD, MPH

Attending Physician, Medical Critical Care Service, INOVA

Eran Klein, MD, PhD

Assistant Professor, Department of Neurology, Oregon Health & Sci-

ences University

Jason Lesandrini, LPEC, HEC-C

Assistant VP of Ethics, WellStar Health System

Barbara M. Mitchell, RN, MSN

Director, Quality Resources & Outcomes, MedStar Washington Hospi-

tal Center

Stephen W. Peterson, MD

Psychiatric Physician, Outpatient Behavioral Health, MedStar Wash- ington Hospital Center

Ira Y. Rabin, MD

VP of Medical Operations, MedStar Washington Hospital Center

Jack Schwartz, JD

Adjunct Professor and Senior Research Associate, University of Mary-

land Carey School of Law

Stephen Selinger, MD

Chief Medical Officer, Anne Arundel Medical Center

Eric A. Singer, MD

Assistant Professor, Section of Urologic Cancer, Rutgers Cancer Insti-

tute of New Jersey, Robert Wood Johnson Medical School

Carol Taylor, RN, MSN, PhD

Senior Research Scholar, Kennedy Institute of Ethics and Professor, School of Nursing & Health Studies, Georgetown University

MISSION

The mission of the Journal of Hospital Eth-

ics is to enhance interdisciplinary bioethics

discourse and assist in the development of

skills associated with recognizing, understand-

ing, and managing moral uncertainties and

ethical complexities in hospital practice.

The mission of the John J. Lynch, MD Cen-

ter for Ethics is to assist hospital profession-

als in meeting a standard of excellence in the

care of patients through education, training,

consultation, policy development, and re-

search in clinical bioethics. Additionally,

when appropriate, we address the ethical con-

cerns of our patients and families, directly.

The MedStar Washington Hospital Center’s

ethics program began in 1982. The John J.

Lynch, MD Center for Ethics, subsequently

established, is involved in over 400 clinical

consultations per year, as well as the develop-

ment of internationally recognized bioethics

conferences, scholarship, and education pro-

gramming.

INSTITUTIONAL ACCESS

Institutional subscribers are able to access the full run of volumes directly from their network: Log-in from your

home institution and go to www.medstarwashington.org, click on ‘Our Hospital’, ‘The John J. Lynch, MD Center

for Ethics’, ‘Journal of Hospital Ethics’ and download any issue as a PDF.

© Copyright 2021 John J. Lynch, MD Center for Ethics. All Rights Reserved. Photo Credit: @iStock Romolo Tavani

JOURNAL OF HOSPITAL ETHICS

THE JOHN J. LYNCH, MD CENTER FOR ETHICS

Volume 7

Number 2

Spring 2021

Rounding with the Editor

55 Hospital Ethics in an Era of Pandemic Evan G. DeRenzo, PhD

Features

______________________________________________

58 Organizational Ethics Support for Health Care Leaders During the COVID-19

Pandemic and Beyond

Tim Lahey, MD, MMSc; Susan Reeves, EdD, RN; Isabelle Desjardins, MD;

and William Nelson, PhD, MDiv

65 Ethical Distribution of COVID-19 Vaccines to Health Care Workers: One Hospital

System’s Attempt at a Moral Allocation Algorithm

Joseph M. Dunne, PhD; Karen L. Smith, PhD, HEC-C; Matthew J. Haugh, MA;

Rebecca E. Washburn, MHA, RN; Wan-Ting K. Su, PhD; and Alexander Plum, MPH, CHES

73 Increased Ethical Burden in Surrogate Decision-Making During COVID-19

Adrienne D. Mishkin, MD, MPH; Nicole Allen, MD; Adira Hulkower JD, MS;

and Lauren Flicker JD, MBE

82 The Ethical Allocation of Remdesivir Within Hospitals

Amber R. Comer, PhD, JD

85 Delirium Assessment in COVID-19: What a Difference a Little Change Can Make Evan DeRenzo, PhD; Catherine Bledowski, MD; Jozef Bledowski, MD; and Chee Chan, MD

In Practice

______________________________________________

90 Shared Decision Making in The Presence of COVID-19 and The Absence of Families

Lynette Cederquist, MD; Biren Kamdar, MD; Alex Quan; and The Editorial Group

of the Lynch Center for Ethics

94 When Extracorporeal Mechanical Oxygenation (ECMO) Needs to be Turned-Off

The Editorial Group of the Lynch Center for Ethics

97 Inpatient Psychiatry in a Pandemic: The Organization and The Individual Christian Carrozzo, PhD (c)

Jo H

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Journal of Hospital Ethics 55

ROUNDING WITH THE EDITOR

Hospital Ethics in an Era of Pandemic Evan G. DeRenzo, PhD

Welcome to the Journal of Hospital Ethics (JoHE), Vol-

ume 7, Number 2. This is our special issue on COVID-

19. For those of you who have been sick with COVID-

19 or who have had a loved one who has been sick with

COVID-19 (or worse, who have had more than one loved

one sick with COVID-19), we hope you are well again.

For those of you who have lingering symptoms, we wish

you well soon. For those who have lost loved ones since

our last JoHE issue, we grieve with you.

With all of the sickness and death this past year has

brought, if there is anything we have learned at the

Lynch Center for Ethics through this pandemic, it is how

important family is for our patients. This is, of course,

not a new lesson. But it is a lesson seared indelibly into

our hearts and minds as a result of the visitation re-

strictions that the SARS-CoV-2 virus has required of

hospitals and other health care organizations.

One can understand the reasons for these restrictive

policies, and families have been tolerant, relatively

speaking. Nonetheless, the restrictions have produced

emotional burdens on top of unspeakable grief. Especial-

ly for our patients who have not been doing well, who

have not turned the corner in the right direction, discus-

sions with families about moving toward plans of care

focused on comfort only have often been fraught with

tensions and conflict.

Mishkin et al make this clear as they state, “…triage

decisions are hospital-specific and the reasoning behind

recommendations for patient care, and who makes those

decisions, may be unclear to surrogates, who find them-

selves attempting to advocate for patients’ wishes despite

realistically having few, if any, options.” These authors

capture the pandemic’s acutely heavy burden on surro-

gates as they note, “…Not only because of the plethora

of sources of information, but because of rapidly chang-

ing medical knowledge during the pandemic, the sense of

uncertainty that surrogates will have in trying to make

decisions for their loved ones is heightened.” Readers

might pay close attention to the recommendations this

article makes, especially related to communications with

families of African and Afro-Caribbean descent.

At our own hospital, for example, we are acutely

aware of the efforts our nurses and physicians make to

provide our families with video visits so they can witness

for themselves their loved one’s decline. Unfortunately,

such efforts have too frequently been insufficient to help

Dear Readers,

56 Journal of Hospital Ethics

families, friends and guardians appreciate how poorly a

patient is doing and how the decline is not likely re-

versible. Death is terrible for everyone. We instinc-

tively avoid, and often overtly fight, its overtaking the

lives of our patients. When death comes to isolated

hospitalized patients, the distance and separation can be

overwhelming for family and friends.

This situation is repeated in hospitals across the

country and around the globe. Our case by Cederquist

et al makes this reality stark. In their case of Mrs. C,

her cardiac arrest is secondary to her COVID-19 infec-

tion. For all intents and purposes, Mrs. C is dying, but

by the initial interpretation of her hospital’s restrictive

visitation policy, she is not unstable enough to have her

family come in and say their good-byes. The family is

caught in the nightmare of not being able to come in

and see her, so the process is protracted with added

misery for family and medical care team.

Pre-pandemic, family and friends could sit with a

dying patient. The closeness of others can bring com-

fort to the dying if that individual is awake and alert

enough to appreciate others’ presence. If not for the

patient’s sake, then at least the nearness is a comfort to

the survivors, even when grief is overwhelming. The

case of Mrs. C is only resolved because of compassion-

ate communications.

With COVID-19, as with past plagues, protection

of the unaffected means dying patients often die alone.

My book club recently read Albert Camus’s The

Plague, copyright 1947. As the only member of the

book club who works in a hospital, and who has

worked physically in the hospital throughout the past

year, the book’s plot was eerily similar to present cir-

cumstances. The protagonist is a physician. The book

follows him during his hospital rounds and watches

him come to his scientific hunches much like we have

watched the scientific understandings and uncertainties

unfurl in COVID-19. Camus writes so beautifully and

frightfully one has to frequently remind oneself that he

is writing in 1947 not 2021.

Finally, another of the marked similarities between

Camus’s The Plague and the present are Camus’s de-

scriptions of the responses of the public to the pandem-

ic. Such description of sheer panic, sometimes bravado

that they will live through it unscathed, results in

swings from portrayals of those who virtually barricade

themselves in their homes to those who continue to

walk the streets in a seemingly devil-may-care mood.

If you haven’t read the book, I recommend it. If

you read it years ago, reading it again now will amaze

you. It is little wonder that Camus was one of the

youngest Nobel Prize Winners in Literature.

Several of this issue’s articles and one of the cases

address organizational considerations presented by the

pandemic. Nelson and Lahey raise an interesting

thought about how best to support hospital leaders.

When this article came in and underwent the initial,

internal review, I realized that one never thinks about

how to support leadership. It is always the other way

around; the discussion is often about how leadership

can support the clinicians. The paper’s authors take a

practical and implementable approach to how to sup-

port leadership. So often administration is a thankless

task, in no small part because a hospital’s clinicians

always need more of this or that. Patient care needs

rightfully take constant attention. But what are the

needs of leadership? How best can they be met? And

how may the need for leadership be expanded and

strengthened during a pandemic? These are fascinating

questions, some of which Nelson and Lahey answer

themselves.

In terms of justice and allocation, we have seen

many arguments arise in the literature as we gathered

more information about the appropriate distribution of

resources within hospitals and communities. Dunne et

al offer a good deal of experience, which they employ

in the development of a moral vaccine allocation algo-

rithm, something well worth contemplating by our

readers for their own hospitals. Comer, too, may pro-

vide insights our readers may usefully integrate into

their own hospital’s utilization strategies for

Remdesivir.

Our own Christian Carrozzo’s case analysis re-

garding the possible moral challenges in creating a spe-

cialized COVID-19 psychiatric unit, is also something

many of us wouldn’t ordinarily consider. This case

illustrates in part the moral tension that can arise be-

tween the realization of a possible good for the organi-

zation (and thus impacting the services it provides), and

the appropriate psychiatric care of an individual. If we

are serious about addressing the ethics of mental health

in a pandemic, it is important that we pay close atten-

tion to the organizational complexities COVID-19 pos-

es for management of a psychiatric unit, where there

exists an elevated challenge to keep patients at safe

distances from each other and adhere to mask man-

dates.

Last among our organizationally focused pieces is

my article with my colleagues from psychiatry and crit-

ical care. With a pandemic that has stretched hospital

resources to the breaking point, now that we have

learned that COVID-19-related delirium (not merely

garden-variety delirium) puts patients at increased risk

of intensive care unit admission and death, we suggest

a slight addition to routine nursing assessments. It is

just possible that delirium assessment performed earlier

and more often than is presently standard of care might

produce big pay offs for patients and hospitals.

Our last piece is the case about ECMO or extracor-

poreal mechanical oxygenation. When it needs to be

Journal of Hospital Ethics 57

turned off how best can that terrible moment be ap-

proached. ECMO is not new technology, although

there still are only select medical centers that have the

resources, including perhaps first and foremost the spe-

cialized and highly trained clinicians capable of compe-

tently using this technology. What is new, of course, is

the application of ECMO to a patient population of

COVID-19 positive patients. Although at the begin-

ning of SARS-CoV-2, there was a cautiousness about

the use of ECMO for patients whose lungs were rav-

aged by the disease. With experience, outcomes for

COVID-19 positive patients has improved. For those

COVID-19 positive patients for whom ECMO does not

improve survival, however, the period during which the

treating team realizes that ECMO should be turned off

is an anguish for all involved. Clinicians who work in

critical care areas (including clinical ethicists) see much

death and know how difficult it is to die in a high tech

hospital today. Under COVID-19 conditions, the mis-

ery is just unimaginable.

Today, there is an expanding group of clinical bio-

ethicists coming together to attempt to produce a con-

sensus statement on ethics guidelines for ECMO in the

era of COVID-19. This group is beginning to congeal,

loosely for the moment, within the Clinical Ethics Con-

sultation Affinity Group (CECAG), one of the affinity

groups of the American Society of Bioethics and Hu-

manities (ASBH). Nobody is quite sure what processes

this project is going to take. Can those who do not be-

long to ASBH join? Will it only include clinical ethi-

cists and interested others in the United States, or ought

the group be international? What sort of research will

be required? What will be the range of societies, associ-

ations and colleges of various medical, nursing and

respiratory therapy that will have to agree to produce a

consensus with any authority?

These are just a few of the questions that will have

to be hammered out before the substance, i.e., the deep

dive, can begin. To be of sufficient merit to warrant the

time and effort this project will take means that this

will be a long slog. But it holds out the promise of im-

portance and utility for clinical ethics and the applica-

tion of ECMO technology.

The other promise at the end of Camus’ The

Plague, also on the horizon in the United States and

world-wide, is the end of this scourge with the advent

of vaccines. We are so close. And, in the meantime,

we hope you find this special COVID-19 issue of JoHE

useful, insightful, and challenging. We would love to

hear your thoughts.

Sincerely,

Evan G. DeRenzo, PhD

Editor-in-Chief

Journal of Hospital Ethics

John J. Lynch, MD Center for Ethics

MedStar Washington Hospital Center

Washington, DC

58 Journal of Hospital Ethics

FEATURES

Organizational Ethics Support for Health Care Lead-

ers during the COVID-19 Pandemic and Beyond Tim Lahey, MD, MMSc; Susan Reeves, EdD, RN; Isabelle Desjardins,

MD; and William Nelson, PhD, MDiv

Organizational ethics can be described as the organiza-

tion’s efforts to define its core values and mission and to

embed both into a health care organization decision-

making and practices. Organizational ethics programs

thus can identify when critical values come into conflict

and help resolve those tensions in fair, transparent, and

consensus-driven ways. As a result, organizational ethics

programs can help address ethical challenges that arise

around institutional resource allocation amid scarcity,

fair balance between patient needs and other institutional

concerns, and thoughtful consideration of all stakehold-

ers, including employees, in making decisions aligned to

organizational mission and values. 1-3

Despite the presence of clinical ethics committees in

today’s health care institutions, their focus tends to be on

the resolution of bedside clinical conflicts and sometimes

assistance with prevention of such issues via engagement

in quality improvement projects.4 This important work

may not, however, address all institutional ethics needs,

leading senior leaders to identify separate and hopefully

complementary organization ethics resources.5 These

may arise from the clinical ethics program foundation 6

or arise entirely separately. Whatever the program’s ori-

gins, the novelty of the role of organizational ethicists

may lead to their underutilization or misutilization.

To help clarify the ways organizational ethicists can

support leaders of health care organizations, we previ-

ously proposed a dashboard for organizational leaders

which emphasized the need for effective organizational

ethics resources and suggested some metrics that leaders

can use to assess the ethical alignment of their organiza-

tion and various organizational decisions and issues that

could benefit.7 The processes through which organiza-

tional ethics – a phrase we use here inclusively to indi-

cate the work of organizational ethicists, organizational

ethics programs and clinical ethicists providing organiza-

tional ethics support – helps achieve these goals in col-

laboration with senior leaders have not been fully ex-

plored in the ethics literature.

In 2020, health care institutions around the world

have scrambled to provide safe, ethical, and financially

feasible care amid the epidemic. Stressors have included

the specter of few mechanical ventilators, limited hospi-

tal capacity and human resources, disrupted personal

protective equipment (PPE) supply, testing and pharma-

ceutical shortages, and the need to balance patient, fami-

Introduction

Abstract

Organizational ethics programs can help senior health care leaders align an institution’s decision-making to its stated mission

and values. The optimal ways organizational ethics can and should support senior leaders, however, are evolving. To inform that

conversation, we discuss how organizational ethics has supported senior leaders in two tertiary hospitals during institutional

responses to the COVID-19 pandemic. This real-time process of organizational ethics program development has helped charac-

terize the types of support organizational ethics can provide to senior leaders and has identified how organizational ethics can be

embedded in leadership processes to ensure the recognition and management of ethical challenges in health care.

Journal of Hospital Ethics 59

ly, and caregiver safety via visitation policies and em-

ployee health monitoring.

From crafting Crisis Standard of Care (CSC)

guidelines for COVID-19 to providing guidance for the

use of scarce personal protective equipment to support-

ing the formulation of visitation policies and beyond,8

we show how organizational ethics resources can and

have helped institutional leaders deliver on their mis-

sion and values during the COVID-19 pandemic. In this

way our pandemic response can illuminate how organi-

zational ethics resources can support leaders of health

care organizations even in ordinary times.

How COVID-19 pandemic helped demonstrate the

value of organizational ethics

As a team of ethicists and senior leaders of two New

England tertiary care centers, in this article we illustrate

how leaders can harness organizational ethics expertise

to align organizational decision-making to mission and

values. We summarize how the COVID-19 pandemic

influenced our institutions and we depict how organiza-

tional ethics helped us make challenging decisions dur-

ing the pandemic, from fair ventilator allocation, PPE

equity, visitation policies, protecting resuscitation team

safety in the event of PPE shortages, management of

patient refusal of masks and testing, addressing staff

moral distress and management of learners. (The contri-

butions of organizational ethics to leadership manage-

ment of these marquee issues in the COVID-19 epi-

demic is depicted on the next page in Figure 1.)

Central to our institutions’ responses to each of

these ethically challenging issues was the need to shift

from a limited clinical ethics approach centered on indi-

vidual patients to a broader focus on ethical decision-

making across the entire system of health care delivery

during a time of crisis. Beyond the specific issues with

which organizational ethics supported senior leaders, in

this paper the following concrete examples illustrate

how organizational ethics supported senior leaders in

hopes that enables future implementation of such sys-

tems of support even in ordinary times.

Fair, transparent and community response alloca-

tion of mechanical ventilators

Many states already had crisis standards of care on file

to address shortages of mechanical ventilators and other

medical resources during an influenza pandemic, or

other public health crises, while others had none. For

those that had crisis standards, they were often dusted

off and revised during COVID-19, including in Ver-

mont where one of our institutions are located. Key

challenges of developing guidelines for insufficient

mechanical ventilator supply include need to allocate

limited resources fairly and transparently using prag-

matic ranking systems that are usable and aligned to

existing systems of bed allocation, the duty to insulate

staff who are making such heartbreaking decisions

from moral distress, and our desire to respond to valid

concerns from the disability community as well as ad-

vocates for people of color who rightly feared such

policies could perpetuate historical health care inequi-

ties.

Organizational ethics support for development of

these guidelines illustrated key ways organizational

ethics can support leaders of health care organizations

in general. Examples include synthesizing the ethics

literature regarding wise resource allocation, framing

the plan-making process around values at play such as

moral equity and fairness, solicitation of input from

diverse stakeholders, and contributions to public mes-

saging about guidelines including to state officials, re-

porters, and representatives of interested communities

such as advocates for disability rights and people of

color.

As an example of how organizational ethics sup-

ported senior leaders through the resource allocation

policy development process, in both Vermont and New

Hampshire, disability advocates were concerned that

patients with congenital neurological impairments,

cystic fibrosis and other preexisting medical conditions

would be disproportionately disadvantaged by the

guidelines. We engaged with advocates, incorporated

language they suggested in evolving guidelines and

reassured them with concrete factual information that

their concerns were valid and more fully addressed in

updated guidelines. This helped promote not only im-

provements to our institutional resource allocation

guidelines but also, we hope, fostered more trusting

relationships between the institution and the communi-

ties it serves.

Fair and equitable allocation of personal protective

equipment (PPE)

As scientific data regarding optimal health care worker

protection from COVID-19 evolved, there was natural

variation in PPE usage. Some clinicians used PPE more

aggressively without regard to the degree of exposure

risk. Others were more targeted in their PPE use,

choosing the most protective equipment only for high

risk exposures. Nationwide PPE shortages then

emerged, forcing the question not only of fair allocation

of a scarce medical resource but also regarding how a

single complex health care organization can assure fair

access across potentially competing departments that

typically have complete discretion regarding PPE utili-

zation. This dynamic was complicated by disparate

recommendations of national guidelines released by

bodies representing different procedural fields. 9, 10 In-

fection control departments took the lead in such nego-

tiations, providing scientific evidence for a unified ap-

proach to PPE utilization and conservation. Senior lead-

ership nonetheless had to balance competing values

such as departmental independence and wise network-

wide utilization of a shared resource amid evolving

60 Journal of Hospital Ethics

Figure 1. The contribution of organizational ethics

to leadership responses to the COVID-19 pandemic.

data. To support senior leadership, organizational ethics

contributed by framing the dilemma at hand in terms of

shared but potentially conflicting values, conducting

outreach to departmental leaders with misgivings, help-

ing frame communications about network-wide deci-

sion-making around values such as fairness, teamwork

and encouraging the development of accountability

systems based on PPE run rates in order to inform next

steps in leadership oversight of policy implementation.

The organizational ethics perspective thus helped in-

form conversations about when evidence was sufficient

for safe reuse of N95 masks and use of procedure

masks for lower risk procedures as part of institutional

PPE conservation strategies. Consistent with the obser-

vation that organizational ethics thinking can amelio-

rate costly organizational conflicts,11 the conversations

that allowed implementation of network-wide policies

regarding PPE utilization and conservation helped pro-

mote enhanced leadership connections across the net-

work at a time in the formation of a relatively young

network of hospitals when individual affiliate autono-

my and sense of connection to the larger network were

still being built.

Visitation policy development

Visitation of hospitalized patients by loved ones is cru-

cial to recovery and to the concept of patient- and fami-

ly-centered care. Visitation can also risk transmission

of SARS-CoV-2 to employees and other patients. It

complicates significantly the space engineering chal-

lenges inherent to waiting rooms, inpatient rooms with

more than one bed, cafeterias and all social distancing

and disinfection requirements; and as such visitation

restrictions have been a major component of infection

control and social distancing in health care institutions

during the COVID-19 epidemic. The management of

visitation restrictions amid COVID-19 as local epide-

miology changed also made consistent communications

a challenge, especially as inevitable edge cases arise.

Should visitation restrictions be loosened for loved

ones wanting to visit a dying patient or children or the

birth of a child? Making exceptions on one hospital unit

can risk perceptions of unfair application of rules on

other units. Are any who call themselves health care

workers considered visitors, e.g. interpreters, doulas,

and clergy or should the hospital define who does and

who does not qualify as a member of the health care

team?

Organizational ethics can help define foundational

principles that justify visitation restriction policies as

well as exceptions to them. It has helped leaders of

specific institutional units like labor and delivery and

pediatrics develop fair and consistent local rules that

can be explained elsewhere by an organizational ethi-

cist conducting shuttlecock diplomacy. Organizational

ethics can help reassure staff who feel guilty about

denying visitation in a particular instance by helping

them understand that such challenging decisions are

justified by other potentially more preeminent values in

the moment such as the protection of safety of other

patients. Inevitably decision-making and institutional

communications about visitation can identify break-

downs in the institutional system of accountability and

in turn yield system improvements if pointed out by

organizational ethics. For instance, if a given depart-

ment is violating institutional visitation policies without

coordination with senior leadership, organizational eth-

ics can catalyze connections between departmental and

organizational leadership that yield a shared resolution

that in turn can lead to concrete improvements in insti-

tutional culture. This aligns to previous findings that

organizational ethics involvement can support staff

sense of institutional morals and likelihood of retention. 12, 13

Balancing staff safety from COVID-19 with obliga-

tion to provide the standard of care

Health care workers experience elevated risk of

COVID-19.14 Naturally, then, staff safety can come

Journal of Hospital Ethics 61

into tension with other values such as the provision of

the standard of care.

There is no single solution to this balancing of val-

ues, and after developing generalizable guidelines, insti-

tutions can partner with employees to develop individu-

ally appropriate plans.15 For instance, the infection con-

trol team can develop expectations of PPE that apply to

everyone while human resources may work with older

or immunocompromised staff who are at higher risk of

developing severe COVID-19 to consider reassignment

if desired.

Nowhere is the tension between staff safety and the

standard of care as evident as in the moments before

cardiopulmonary resuscitation. If adequate PPE are not

available when the cardiopulmonary resuscitation team

arrives at the door of a COVID-19 patient’s room,

should they risk their own safety to save a life or risk

the patient’s wellbeing while awaiting PPE? Grappling

with this question – which has innumerable permuta-

tions from the conduct of elective procedures on

COVID-19 patients to decisions to undertake high risk

thoracic procedures on COVID-19 patients amid PPE

shortages – can pit individual clinicians’ sense of pro-

fessional obligation against leadership’s mandate to

assure a safe workplace. If individual clinicians opt to

resuscitate, others may feel coerced to do the same, thus

making policy development influential on local team

culture.

Organizational ethics can help identify the emerg-

ing literature regarding deferral of cardiopulmonary

resuscitation in COVID-19 patients until adequate PPE

are available, can help clinicians with different intuitive

resolutions of the tension in values to reach consensus

and can identify preventive approaches to avoid the

ethical tension in the first place such as avoiding such

harrowing decisions via creative investments in ade-

quate PPE for all cardiopulmonary resuscitations.16, 17

Ultimately, we guided clinicians to ensure adequate PPE

were present to assure staff safety before attempting

resuscitation in accordance with subsequently published

national and international guidance. Fortunately, organi-

zational ethicists were able to reassure clinicians that

with adequate PPE available the risk of contracting

COVID-19 was extremely low.

Management of patient refusal of masks and asymp-

tomatic testing

Some patients or visitors will refuse to comply with

hospital COVID-19 infection control policies, such as

screening for symptoms and temperature, mask man-

dates, physical distancing rules and pre-procedural test-

ing for COVID-19, which in turn can require caregivers

to make potentially unaccustomed decisions about

whether to discontinue care in order to enforce those

rules vs. accept personal risk in order to deliver care.

These decisions involve similar ethical tensions as

those regarding cardiopulmonary resuscitation with in-

adequate PPE but with a new overlay of patient duty to

engage productively in their own health care. In addi-

tion, to justify mandatory testing, the benefits of manda-

tory testing must outweigh any downsides in terms of

loss of patient autonomy or access to care, with that

balance of risks and benefits highly dependent on the

pretest probability that the COVID-19 test will be posi-

tive.18 Here organizational ethics can help by framing

the problem not only in terms of which institutional

values are in tension but also outlining factors that influ-

ence this risk-benefit calculus and contributing to com-

munications to community members about the new test-

ing policy. This ultimately has an impact on the patient

experience so is of relevance to the institution’s chief

experience officer as well, bringing the organizational

ethicist into collaboration with a wide array of senior

leaders.

Addressing staff moral distress

The provision of clinical care in extremely stressful

circumstances under conditions of scarce resources can

foster moral distress, a major contributor to health care

worker burnout, depression, and potentially PTSD relat-

ed moral injury.19 The COVID-19 pandemic, therefore,

is likely to be followed by a new epidemic of health

care worker moral distress.13, 20, 21, 22

Organizational ethics can ameliorate the risk of

moral distress amid the COVID-19 pandemic in two

ways: (1) by ensuring the difficult moral decisions made

by health care workers responding to COVID-19 are

part of a coherent, transparent, palpable institutional

moral culture that includes a defensible organizational

ethics decision-making process 13 and (2) by supporting

healing conversations with caregivers who have con-

fronted such situations.23, 24 For example, senior

leaders and ethicists met with frontline clinicians re-

sponding in Vermont to a nursing home outbreak in part

to ensure adequate provision of health care resources,

reinforce the need to utilize surge team replacements,

and importantly to provide a forum for discussion of

emotional reactions to the experience and any moral

misgivings that arose during the course of care. In New

Hampshire, the group formed to develop crisis standards

of care embedded written guidance within the standards

regarding the need to address moral distress in the clini-

cian workforce. Using the clinical ethics committee as

subject matter experts to articulate the potential roots of

moral distress that were anticipated, this group then

used the consultative arm of their committee as a mech-

anism to detect, via rounding on inpatient units, any

developing moral distress in the clinicians and intervene

when necessary. The clinical ethics committee devel-

oped additional resources for the workforce including

62 Journal of Hospital Ethics

information on how to access employee assistance,

chaplaincy, and other clinician supports.

Balancing learner safety with their educational in-

terests

The incorporation of learners in the clinical environ-

ment during the COVID-19 pandemic has been contro-

versial.25 In some cases, learners may be dispensable to

the provision of clinical care yet have the potential to

increase the bandwidth of an already overtaxed clinical

workforce. Furthermore, learner safety might be endan-

gered by participation in clinical care, particularly for

patients with COVID-19.

In response, some hospitals excluded learners from

the clinical environment in order to protect learner safe-

ty and conserve scarce PPE. Other institutions felt stu-

dent participation in COVID-19 and other care were

critical to future education regarding the sustainability

of the health professions and included them despite

downsides. Each institution may need to strike its own

balance in collaboration with its educational affiliates

in light of local epidemiology. In Vermont and New

Hampshire, organizational ethics ameliorated the

COVID-19 risk to learners and faculty by converting

all large group preclinical learning from in-person to

virtual, enforced strict mask-wearing policies for small

group in-person learning, and included learners in the

clinical environment only once PPE supplies were as-

sured. Neither facility allowed medical students to par-

ticipate in hands-on care of patients with COVID-19. In

both New Hampshire and Vermont, senior leaders ap-

preciated the opportunity to address a surge in COVID-

19 cases with expanded clinical bandwidth accom-

plished in a fashion that was nonetheless safe for learn-

ers and appropriate to their level of training.

The issues addressed in relation to balancing learn-

er safety with educational and clinical needs included

ensuring that learners such as residents who remained

on clinical duty always practiced within the scope of

their license, asking medical students who were re-

lieved from ordinary clinical duties to volunteer in oth-

er contexts that were appropriate to their level of skill

while still educational.

Beyond COVID-19: Toward durable organizational

ethics support for senior leaders

Organizational ethics requires adequate institutional

support in order to support senior leaders in the fash-

ions outlined above. This institutional support can take

many forms depending on the structure of the organiza-

tional ethics team and its reporting relationships to sen-

ior leaders. Whatever the local approach, key compo-

nents of adequate organizational ethics support pertain.

These have been partly identified and clarified by our

organizations during the COVID-19 response.

People working in organizational ethics need ade-

quate protected time to join meetings, draft policy state-

ments, and meet with stakeholders. The amount of pro-

tected time required for that work likely varies substan-

tially from organization to organization and may

change in response to evolving engagement of organi-

zational ethics expertise. For instance, some organiza-

tions may employ a solo organizational ethicist who

joins senior leadership meetings, others may form or-

ganizational ethics committees that are either integrated

with clinical ethics committees or separate from them. 5,6,7 To ensure engagement with senior leadership deci-

sions organizational ethicists should report to specified

senior leaders such as the chief medical officer or chief

executive officer and have key accountabilities such as

policy ownership, committee oversight, or success met-

rics that are reviewed regularly.

Incorporation into leadership processes is also

needed to assure organizational ethics has the oppor-

tunity to engage issues with ethical ramifications

whether or not senior leaders identify those ramifica-

tions up front. People doing organizational ethics work

can be consulted on an as needed basis to engage some

leadership decisions while other meetings (such as

COVID-19 incident command groups) likely benefit

from standing ethics expertise. We recently clarified

how organizational ethics programs can grow from

programs that formerly focused solely on clinical ethics 6, 26 and which organizational issues may benefit from

organizational ethics involvement. 7

In Vermont, we embedded an organizational ethi-

cist in our COVID-19 operational organizational re-

sponse and in both states clinical and organizational

ethicists participated in subgroup meetings focused on

Crisis Standards of Care development. In both settings,

organizational ethics had a fundamental impact, helping

to readily anchor the conversation in explicit discussion

of how to balance the good of individual patients with

the good of the whole population during a pandemic.

Having organizational ethics present to name and reaf-

firm the balance of fundamental ethical values comple-

mented input from clinicians and operational subject

matter experts in conversations about crisis standards of

care, PPE use, visitation and testing policies and be-

yond and helped bring clarity and supported quick,

reliable and coherent decision-making. Organizational

ethics thus served as our “true north” and helped allevi-

ate staff moral distress about difficult decisions that had

to be made very rapidly during the institution’s COVID

-19 response.

To be effective at supporting senior leaders, people

doing organizational ethics work may require training

outside of typical clinical ethics expertise including in

health care financing, health care delivery science, pop-

ulation-wide communications and familiarity with how

Journal of Hospital Ethics 63

health care is delivered beyond what most clinical ethi-

cists may be familiar with from direct clinical ethics

consultation. This training can be obtained with men-

torship from senior leaders as well as through comple-

mentary roles held by the same individual, such as the

practicing clinician leader who is also a health care

ethicist. Graduate level training in health care delivery

science also can enable the acquisition of such skills. 27

Conclusion

Organizational ethics can support senior health care

leaders in the alignment of institutional decision-

making to organizational ethical values. Organizational

ethics support for senior leaders during the COVID-19

pandemic has helped encode and integrate the types of

support organizational ethics can provide to senior

leaders as well as how organizational ethics can be po-

sitioned to provide that support most effectively. AUTHORS

Tim Lahey, MD, MMSc is an infectious diseases physician

and director of ethics at the University of Vermont Medical

Center as well as professor of medicine at University of Ver-

mont Larner College of Medicine.

Susan Reeves, EdD, RN is the Executive Vice President for

Dartmouth-Hitchcock Medical Center as well as clinical pro-

fessor of community and family medicine at Geisel School of

Medicine at Dartmouth.

Isabelle Desjardins, MD serves as Chief Medical Officer of

the University of Vermont Medical Center, the only Academ-

ic Medical Center in Vermont. She is a physician, Associate

Professor of Psychiatry at the University of Vermont Larner

College of Medicine and founding partner of WISER Systems

LLC, an information technology software company.

William Nelson, PhD, MDiv is a health care ethicist, director

of the Ethics and Human Values Program, and a professor in

the Dartmouth Institute for Health Policy and Clinical Prac-

tice at the Geisel School of Medicine at Dartmouth

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Journal of Hospital Ethics 65

Ethical Distribution of COVID-19 Vaccines to Health

Care Workers: One Hospital System’s Attempt at a

Moral Allocation Algorithm Joseph M. Dunne, PhD; Karen L. Smith, PhD, HEC-C; Matthew J.

Haugh, MA; Rebecca E. Washburn, MHA, RN; Wan-Ting K. Su, PhD;

and Alexander Plum, MPH, CHES

Early in the coronavirus disease 2019 (COVID-19) pan-

demic, the National Academies of Sciences, Engineering,

and Mathematics’ (NASEM) “Framework for Equitable

Allocation of COVID-19 Vaccine” provided initial guid-

ance for distributing COVID-19 vaccines once they were

released for public use.1 Their proposed framework in-

volved a phased distribution hierarchy with high-risk

health workers and first responders receiving Phase 1a

distributions, and people of all ages with comorbid and

underlying conditions that put them at significantly high-

er risk and older adults living in congregate or over-

crowded settings receiving Phase 1b distributions. Our

best predictions, however, suggested that initial distribu-

tions of COVID-19 vaccines would be so scarce that

large health systems would likely be unable to vaccinate

all their high-risk health workers and first responders

with initial allotments. This short piece addresses our

system’s efforts to operationalize and further specify the

NASEM framework in order to best identify those health

care workers at highest risk of COVID-19 infection and

provide an ethically justifiable distribution process of

vaccines until they are no longer scarce.

Our health system is a six-hospital health care sys-

tem in the greater Detroit metropolitan areas employing

over 33,000 persons and serving a diverse population in

inner-city, suburban, and rural areas.

Threats and Vulnerabilities

Our Vaccine Allocation Committee (VAC) was com-

prised of clinicians, ethicists, operational leaders, epide-

miologists, and others from our health care system who

met diligently for several weeks in order to carefully de-

velop a vaccine allocation program for our employees.

With a focus on safety, quality, and high reliability, we

were committed to protecting those at the highest risk for

exposure and those who were most vulnerable to the ef-

fects of COVID-19. The central aim was to develop an

allocation algorithm for ethically distributing scarce

COVID-19 vaccines as soon as they were received by

our health system. We agreed that the formula should

sort individuals in an evidence-based, just, and fair way.

Our hope was to create a formula that was automatable,

able to capitalize on the data we already had (i.e., avoid-

ed surveying), avoided any possible violations of em-

ployee privacy or confidentiality (e.g., did not include

Introduction

Abstract Early in the coronavirus disease 2019 (COVID-19) pandemic, guidelines providing initial recommendations for ethical distribu-

tion of COVID-19 vaccines were released for public use before vaccines were available. Almost all these initial guidelines

placed high-risk health workers in the first tier of distributions. But as the COVID-19 vaccines inched closer to distribution, it

became increasingly clear that there would not be enough vaccines for all high-risk health workers in the initial distributions –

raising the question of how health care systems should tier and distribute scarce vaccines to their high-risk health workers specif-

ically. This article overviews our Health System’s efforts to appropriately identify and stage our health care workers at highest

risk of COVID-19 in order to provide an ethically justifiable allocation process for vaccines until they were no longer scarce.

Our allocation algorithm aimed to capitalize on the data we already possessed, avoid violations of employee privacy or confiden-

tiality, remain objective and unbiased, and be automatable. Moreover, our allocation algorithm importantly reflected Centers for

Disease Control and Prevention (CDC) guidelines to include Social Vulnerability Indexing factors by including some personal

features of our health care workers – such as gender, race-ethnicity, age, and postal code.

66 Journal of Hospital Ethics

sensitive data on employee health comorbidities) and

was as objective and unbiased (i.e., removed as many

subjective factors) as possible.

Building upon the guidance of NASEM, our VAC

decided to create a staged distribution hierarchy for

scarce vaccine allocation. To appropriately stage our

employees, the proposed algorithm considered the

threats that an employee faced - understood as the fac-

tors that impacted the likelihood of exposure - in addi-

tion to the vulnerabilities that an employee faced - un-

derstood as the factors that increased the likelihood of

illness due to exposure. While the initial identified

threats included location of job and time spent at job,

the VAC decided to not to utilize time spent at job be-

cause of the difficulties and ambiguities associated with

this category. For example, it is not clear how we

would unambiguously assign different values to the

average number of employee hours worked per week,

such data does not tell us anything about whether the

employee works from home, is in our buildings, or is

bedside with patients, and average number of employee

hours does not necessarily increase the likelihood of

exposure for employees already working in places of

increased likelihood of exposure.

The VAC expanded the location of job category to

include those places where the threat of COVID-19

exposure was the highest as well as those procedures

that most threatened exposure to COVID-19. These

locations and procedures were selected based on CDC

data indicating that certain locations and procedures

present a greater likelihood of exposure.2 In particular,

the VAC identified those places where aerosol generat-

ing procedures (AGP) take place and the personnel who

perform AGPs as the most threatened given that

COVID spreads primarily through respiratory droplets

or small particles, such as those in aerosols, produced

when an infected person coughs, sneezes, sings, talks,

or breathes.3 Stage 1 distributions of vaccines, for ex-

ample, were limited to the pool of inpatient employees

belonging to cost centers that captured the places where

AGPs take place (e.g., emergency departments and

intensive care unit) and the personnel who perform

AGPs (e.g., respiratory therapists, physicians, and nurs-

es). These cost centers were vetted and selected by

VAC team members from human resources and quality

from our corporate suite to ensure that no relevant

groups were excluded.

The personal vulnerabilities identified were gen-

der, race-ethnicity, age, and postal code based on CDC

documentation. Gender was identified as a factor that

increases the likelihood of illness when exposed given

CDC data indicating that men who contract COVID are

more likely to die than women.4 Accordingly, the VAC

decided that a male gender should be given more

weight than a female gender in the algorithm. Similar-

ly, race-ethnicity was also identified as a vulnerability

given CDC data indicating that certain race-ethnicity

groups faced higher risks of hospitalizations and death

when compared to White, non-Hispanic persons.5

Blacks and Hispanic/Latinos – but not Asians, who

were weighted the same as Caucasians – were given

more weight than their Caucasian counterparts in the

algorithm. Age was also identified as a vulnerability

given CDC data indicating that older individuals faced

much higher risks of hospitalization and death than

younger individuals.6 Thus, the older the individual, the

more corresponding weight they were given in our al-

gorithm as well. The category of age carried the highest

numerical weights in our formula since age was deter-

mined to be the greatest personal risk indicator for

those dying from COVID-19.

The VAC also included postal code as a relevant

vulnerability to serve as a proxy for capturing social

determinants of health.7 Food, transportation, and hous-

ing insecurities are key examples of social determinants

of health that studies have suggested account for some

80% of a person’s whole health and wellness.8 In order

to incorporate social determinants of health vulnerabili-

ties into our COVID-19 vaccine allocation algorithm,

our VAC looked to the CDC’s Social Vulnerability

Index (SVI).9 The SVI, which is updated every year,

uses 15 variables from the census to grant a value be-

tween 1 and 0 (where 1 signifies the most vulnerable)

to four domains of vulnerability: (1) Socioeconomic

Status; (2) Housing Composition and Disability; (3)

Minority Status and Language; and (4) Housing and

Transportation. These rankings are originally applied to

census tracts – a unit of geography too discrete for op-

erationalization – which required us to crosswalk and

convert into United States Postal Service zip and Cana-

dian postal codes. Employees who live in a zip/postal

code in the 95th or higher percentile of social vulnera-

bility were classified as “socially vulnerable,” and

weighted accordingly, based on a regression model

conducted by members from our system’s Analytics

team. Also, it is also worth noting that the SVI draws

on the same data source as Health Resources and Ser-

vices Administration’s Area Deprivation Index, and

was tailor-made to discrete census tracts, while the Ar-

ea Deprivation Index aims at the broader county level.

Our system’s Analytics and Population Health teams

collaborated to incorporate SVI rankings at the zip code

level into Population Health’s risk stratification and

predictive analytics tool.

Because our system employees come from all over

southeastern Michigan and Canada, the VAC sought to

uncover the most socially vulnerable postal codes in

adjacent Canadian locations as well as in Wayne, Jack-

son, Macomb, Monroe, Washtenaw, and St. Clair coun-

ties. Forty-three postal codes in southeastern Michigan

Journal of Hospital Ethics 67

and three in Canada were ultimately demarcated as

socially vulnerable postal codes that were given extra

weight in the algorithm when compared to other, less

socially vulnerable postal codes. Finally, the VAC ini-

tially decided that an employee with a confirmed

COVID+ test on record would be excluded from the

algorithm given the likely presence of relevant COVID-

19 antibodies per initial CDC recommendations.10 The

group agreed that it would be morally appropriate to

offer them a COVID-19 vaccine once scarcity was no

longer an issue.

Risk Points Overview

Our system’s Analytics team assigned a stratification of

Risk Points per vulnerability category based on the

relative weights (coefficients) from the logistic regres-

sion model. The model was developed using previous

COVID-19 encounter data (patients with COVID-19

tests) gathered during the COVID-19 pandemic, i.e.,

the age, race-ethnicity, gender, and health outcome for

COVID-19+ individuals within our system. Health out-

comes were demarcated with a binary flag as either

hospitalized/intubated/admitted to an intensive care unit

or else deceased. Some categories, such as race-

ethnicity, also incorporated national data when our in-

ternal data was insufficient, and we added postal codes

to help approximate SVI as well. The stratification of

Risk Points per vulnerability was as follows (max 22

points.):

Age: 18-29 (0); 30-39 (3); 40-49 (5); 50-64 (9); and

65+ (16) years old

Gender: Female (0) and Male (2)

Race-Ethnicity: Other (0); Non-Hispanic Asian/

Pacific Islander (1); Non-Hispanic White (1); Hispanic/

Latino (2); and Black (3)

Postal Code: Not from 43 Socially Vulnerable United

States Zip Codes or 3 Socially Vulnerable Canadian

Postal Codes (0); and Yes (1)

Risk Index = RPAge + RPGender + RPRace-

Ethnicity + RPPostal Code

Statistical Modeling for Creating Risk Index For-

mula: Subjects

Demographic data from 17,490 patients were included

in this study. Data were collected using Epic electronic

medical records (Epic Systems Corporation, Verona,

WI) in a custom table designed for patients with

COVID-19 tests from March 1, 2020 through October

31, 2020. The average age of patients included in this

study was 52.76 years old. Patients under 18 years old

were excluded from this study. 55% of patients identi-

fied as female while 45% identified as male. The race-

ethnicity distributions for non-Hispanic White, Black,

Hispanic/Latino, non-Hispanic Asian/Pacific Islander,

and Other/Unknown were 45%, 38%, 4.2%, 2%, and

11%, respectively.

Outcome

To establish a clear outcome variable, our Analytics

team created a binary flag for COVID-19 related health

outcomes as noted above where ‘1’ meant the patient

had the outcome, while ‘0’ meant the patient did not

have the outcome. The COVID-19 outcome was de-

fined as one of the following: ED admission, hospitali-

zation, intensive care unit admission, ventilator use, or

death. Their data contained 5155 (29%) records of the

COVID-19 outcomes.

Statistical Analysis

To develop the index, our Analytics team split their

data into a training and test group. The training data

contained 75% of the data while the remaining 25%

was left for validation given that validation sets are

typically set somewhere between 10% and 33% of the

data. The training data were used to develop a logistic

regression model with negative COVID-19 outcomes

as the dependent variable and all other demographics as

the independent variables. After validating the training

model, the final points were assigned using all available

data. (The stratification of each demographic variable

can be found in Table 1 on page 68.)

To determine the number of points each level

should be assigned, each coefficient was divided by the

lowest coefficient in the model and rounded to the near-

est integer.11 For example, a male gender had a coeffi-

cient of 0.32 and the lowest coefficient of 0.15 was

assigned to a non-Hispanic White race-ethnicity. By

dividing 0.32/0.15, we get 2.133, which rounds off to 2,

resulting in a final point allocation of 2 for a male gen-

der. (Table 2 on page 69 shows each coefficient and

the resultant points assigned to them.)

Although the analysis performed by our Analytics

team did not show statistically significant results for the

non-Hispanic Asian/Pacific Islander race-ethnicity,

they were nevertheless comfortable referencing CDC

data to assign a single point (based on the coefficient

0.17) to this group.

Performance

To assess performance, the model built using training

data was assigned to the test set and a confusion matrix

was generated. The area under the curve of the model

on their test set was 0.7211. The sensitivity was 0.3756

and specificity was 0.8525. The confusion matrix for

this model – along with other relevant performance

68 Journal of Hospital Ethics

Vulnerability Categories N N (%)

Age Group

17,49

0

18-29 2,389 (14%)

30-39 2,403 (14%)

40-49 2,458 (14%)

50-64 4,713 (27%)

> 65 5,527 (32%)

Gender

17,49

0

Female 9,682 (55%)

Male 7,808 (45%)

Race/Ethnicity

17,49

0

Other/Unknown 1,940 (11%)

Asian/Pacific Islander 352 (2.0%)

Hispanic/Latino 730 (4.2%)

Black 6,563 (38%)

White 7,905 (45%)

Zip hotspot

17,49

0

5,258 (30%)

COVID-19 outcome: Yes

17,49

0

5,155 (29%)

metrics – can be found in Table 3 on page 70.)

Overall, the performance seemed reasonable given the limited data points available and how well it aligned with

the values reported by the CDC.

TABLE 1: Descriptive Statistics

Distribution Stages

The four stages of distributions for our system employees were as follows:

Stage 1: Inpatient employees belonging to cost centers that captured both the places where AGPs take place and

the personnel who perform them, e.g., critical care attending physicians, ED staff, most fellows and residents, res-

piratory therapy, intensive care unit staff, catheterization laboratory, etc.

Stage 2: All other inpatient hospital employees not otherwise immunized, e.g., physical and occupational therapy,

housekeeping, general medical units’ staff, security, hospice, cancer care, ancillary services, etc.

Journal of Hospital Ethics 69

Stage 3: Outpatient employees belonging to cost centers that captured both the places where AGPs take place and

the personnel who perform them, e.g., walk-in and urgent care facilities, pulmonary rehabilitation, pediatrics, pri-

mary care clinics, etc.

Stage 4: All other inpatient/outpatient/off-site employees not otherwise immunized, e.g., billing, information tech-

nology, administrators, clinical documentation, etc.

TABLE 2: Model Coefficients

The VAC agreed that all the above stages were subject to change and readjustment pending changes in circum-

stances or relevant facts. Also, in larger departments like environmental services or pharmacy where employees

might perform their tasks in different locations, the VAC agreed that managers should be contacted to clarify em-

ployee roles and exposure to AGPs in order to more appropriately stratify them among the various stages of distri-

bution. This implies that environmental services health care workers working in the ED, for example, would be

boosted into stage 1 as opposed to their colleagues working in corporate office buildings who would remain in

stage 2.

Allocation Process

All 33,000+ of our employees were initially de-identified and assigned a number by electronic human resources

staff. Those employees with a confirmed COVID-19+ test on record were initially excluded from the pool based

Characteristic Coefficient OR 95% CI p-value RP Pointsa

Age Group

18-29 (Ref) — — — — — 0

30-39 0.51 1.67 1.38-1.99 <0.001 RP1 3

40-49 0.78 2.18 1.83-2.61 <0.001 RP2 5

50-64 1.37 3.94 3.35-4.59 <0.001 RP3 9

> 65 2.4 11.02 9.46-12.87 <0.001 RP4 16

Gender

Female (Ref) — — — — — 0

Male 0.32 1.38 1.28-1.47 <0.001 RP5 2

Race-Ethnicity

Other (Ref) — — — — — 0

Asian/Pacific Islander 0.17 1.19 0.89-1.57 0.25 RP6 1

White 0.15 1.16 1.02-1.33 0.02 RP7 1

Hispanic/Latino 0.33 1.39 1.12-1.72 <0.001 RP8 2

Black 0.48 1.62 1.42-1.85 <0.001 RP9 3

Zip hotspot

No (Ref) — — — — — 0

Yes 0.2 1.22 1.12-1.33 <0.001 RP10 1

70 Journal of Hospital Ethics

TABLE 3: Confusion Matrix

upon expected antibody immunity from past infection. The team of electronic human resources staff then took the

list of de-identified employees (already excluded COVID-19+ employees) and assigned each employee a personal

risk index score (PRIS). As noted above, this score specifies each person according to their vulnerabilities using

the formula, i.e., age, race-ethnicity, gender, and postal code.

The list of de-identified employees with a PRIS was further sorted according to hospital site (i.e., one of our

system’s six hospitals) and according to their threats (i.e., those cost centers corresponding to where AGPs take

place and the personnel who perform them). At this point, every non-COVID-19+ employee had been sorted ac-

cording to their hospital, properly staged according to their cost center, and ranked within their stage according to

their PRIS. Depending on the number of vaccines received, the properly sorted, staged, and scored employees were

then offered a vaccine – starting with those employees in stage 1 with the highest PRIS. Once hospital sites re-

ceived an allotment of vaccines, their non-COVID-19+, stage 1 employees with the highest PRIS scores would be

offered vaccines until they ran out. If there were more employees with identical PRIS scores in some stage than

available vaccines, the VAC agreed that utilizing a randomizing lottery to determine who was eligible for available

vaccines was fair.

For example, if a hospital had enough initial doses to vaccinate their stage 1 employees with a PRIS of 22

down through 11 but had more employees with a PRIS of 10 than available doses, a randomized lottery was rec-

ommended to ethically and fairly distribute those remaining doses to the remaining employees with a PRIS of 10.

Those employees with a PRIS of 10 in this example who were unselected by the lottery would then be contacted

first upon the next delivery of vaccines until the relevant stage was completed. This randomization tool was only

expected to be needed, if ever, in the initial stages of the vaccine allocation process given that additional supplies

of vaccines and multiple kinds of vaccines were expected in early 2021.

All employees – sorted according to hospital, staged, and given a PRIS – were then re-identified by electronic

human resources staff and matched to their employee names. Electronic human resources staff then compiled an

ordered list based on the re-identified data to send to Employee Health in order to contact individuals, offer them a

vaccine, and begin the vaccine administration process. Importantly, this employee list contained names and contact

information only without any further identifying information utilized in the algorithm process to protect employ-

ee’s private information.

Employee Health then contacted those employees listed to them by HR in order to offer the vaccine, schedule

an appointment, or document a declination. Any employee that initially declined but later wished to receive a vac-

cine had to contact Employee Health at a later date to check for availability and schedule an appointment to be

vaccinated. Once Employee Health administered the vaccines to employees, they received a card with the day and

time of their next appointment if their vaccine required 2 doses. This card could be used during the daily screening

process as well if an employee acutely developed symptoms from vaccination. This card would allow them to con-

tinue working given that the development of acute, mild symptoms (e.g., headache, fatigue, low-grade fever, etc.)

after vaccination was expected for at least a small portion of employees. Like most health care systems, our system

Reference/Observed

Outcome 0 1

Predictive outcome 0 2647 773

1 458 465

Accuracy 0.717

Sensitivity 0.376

Specificity 0.853

Positive predictive value 0.504

Negative predictive value 0.774

Prevalence 0.285

Area under the curve 0.721

Journal of Hospital Ethics 71

had health screening protocols that all employees had to

pass through, including temperature checks and ques-

tions about COVID-19 exposure and symptom history

prior to entering the facility.

At first glance, this process may seem quite daunt-

ing or complex, but it was surprisingly accomplished

rather quickly using the powers of data processing and

the ingenuity of our Analytics team. Incidentally, most

of our committee time was spent determining the mor-

ally relevant sorting features, the appropriate steps in

the allocation process, and proper staging. The actual

work of sorting employees and obtaining the relevant

data was the fastest step of the whole process.

A Major Challenge

One of the most significant challenges we faced was

discovering exactly where certain employees work in

our attempt to appropriately identify AGP staff for

stage 1. Perhaps surprisingly, this was most challenging

with respect to providers (physicians, physician assis-

tants, and advance practice providers). As noted above,

most cost centers were initially used to quickly and

easily identify large groups such as respiratory therapy

and nursing. This seemed like the best method for these

employees, but we soon found out that this method

failed to capture all the relevant AGP staff. The seem-

ingly simple process of identification was complicated,

for example, by staff that worked in two different set-

tings, full-time staff in non-clinical settings, and bed-

side staff that were otherwise part-time or contingent.

Moreover, other employee situations presented further

sorting difficulties such as an employee from quality

(e.g., infection control) who sometimes worked in the

ED or a physician who would sometimes round on pa-

tients in the ED but was categorized under an admin-

istration cost center.

The shortcomings of our initial identification pro-

cess were most evident with respect to providers. As an

alternative, we looked at better capturing them in our

algorithm by looking at board certification, privileges,

and other cost centers, but these approaches proved

similarly problematic. The difficulty in trying to appro-

priately identify AGP physicians was only present for

some physician groups and not others, e.g., identifying

anesthesiologists was easy but identifying intensivists

proved more challenging. In the end, we had to look at

each provider individually within those physician

groups that proved difficult to appropriately identify

and manually sort them into their proper stage. Thank-

fully, the medical staff offices ended up sorting through

their physician groups over a weekend before we re-

ceived our first doses of vaccines. To help ameliorate

this and related issues in the future, some members of

the VAC suggested that, institutionally, we could add a

location code to existing position numbers or job de-

scriptions that might help to better define employee

placement that may be unclear from their cost center.

Conclusion

Though we faced a few surmountable complications

along the way, we believe that our efforts at operation-

alizing and further specifying the NASEM framework

in order to best identify those health care workers at

highest risk of COVID-19 infection and provide an

ethically justifiable distribution process for vaccines

was workable and successful. In general, we believe

that this was a positive step forward for seriously con-

sidering the social determinants and personal determi-

nates of health in an ethical way. Part of our hope is

that this piece will inspire further inclusion of these

determinants in future scare resource allocation frame-

works.

AUTHORS

Joseph M. Dunne, PhD is a Clinical Ethics Fellow for the

Henry Ford Healthcare System in southeast Michigan and a

Lecturer in Philosophy at the University of Michigan–

Dearborn. His research areas are in clinical ethics, law and

religion, and moral philosophy more generally. He earned his

doctorate in philosophy from Wayne State University in

2018.

Karen L. Smith, PhD, HEC-C has been a member of hospi-

tal ethics committees for over twenty years. She is currently

the Director of Ethics Integration for Henry Ford Health Sys-

tem. She specializes in death and dying and works to educate

the public on Advance Directives. She has been on the Na-

tional Board for the Funeral Consumers Alliance, a non-profit

organization dedicated to providing public education and

advocacy related to after death needs.

Mathew J. Haugh, MA earned his Master of Arts in Industri-

al Organizational Psychology from Wayne State University.

He is a currently Data Scientist for Henry Ford Health System

where he uses statistical methods to answer operational ques-

tions about patient care. His research interests include model

evaluation, social determinants of health, health care equality,

and discrimination in AI.

Rebecca E. Washburn, MHA, RN works in Accreditation

and Patient Safety with diverse groups to help solve challeng-

ing health care problems in order to make health care safer.

Rev. Alexander Plum, MPH, CHES is Henry Ford Health

System’s Director of Clinical and Social Health Integration, a

role in which he establishes, directs, and evaluates programs

designed to connect care teams with community social ser-

vices with a focus on business sustainability, value-based

care, and return on investment. Alex is a Salzburg Global

Fellow, a former Paul D. Coverdell Fellow, and a Returned

Peace Corps Volunteer. He received his MPH at the Rollins

School of Public Health at Emory University which honored

him that year with the Emory University Humanitarian

72 Journal of Hospital Ethics

Award.

Wan-Ting K. Su, PhD is an Assistant Research Scientist

with the Department of Public Health Sciences at Henry Ford

Health System. Prior, she worked on research in data mining

and risk assessment for intravenous medication harm in the

Regenstrief Center for Healthcare Engineering, Purdue Uni-

versity. Dr. Su's research areas are medical informatics and

EHR data-drive risk predictive modelling of health outcomes.

She has experience in applying statistical analysis to investi-

gate risk factors and their associated impacts on women's

health, cancer survival outcomes, readmission, and adverse

harm events and developing individual risk prediction mod-

els.

REFERENCES

1. National Academies of Sciences, Engineering, and Medi-

cine. 2020. Framework for Equitable Allocation of COVID-

19 Vaccine. Washington, DC: National Academies Press.

2. Hughes, M. M., Groenewold, M. R., Lessem, S. E., Xu, K.,

Ussery, E. N., Wiegand, R. E., X. Qin, et al. 2020. Update:

characteristics of health care personnel with COVID-19 —

United States, February 12–July 16, 2020. MMWR. Morbidi-

ty and Mortality Weekly Report 69: 1364-8.

3. Centers for Disease Control and Prevention. 2020. How

COVID-19 spreads. Accessed March 24, 2021. https://

www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/

how-covid-spreads.html.

4. Griffith, D. M., Sharma, G., Holliday, C. S., Enyia, O. K.,

Valliere, M., Semlow, A. R., Stewart, E. C., and R. S. Blu-

menthal. 2020. Men and COVID-19: a biopsychosocial ap-

proach to understanding sex differences in mortality and rec-

ommendations for practice and policy interventions. Prev

Chronic Dis 2020; 17:200247. DOI: https://doi.org/10.5888/

pcd17.200247

5. Centers for Disease Control and Prevention. 2021. Risk for

COVID-19 infection, hospitalization and death by race/

ethnicity. Accessed March 24, 2021. https://www.cdc.gov/

coronavirus/2019-ncov/covid-data/investigations-discovery/

hospitalization-death-by-race-ethnicity.html.

6. Centers for Disease Control and Prevention. 2021. Risk for

COVID-19 infection, hospitalization and death by age group.

Accessed March 24, 2021. https://www.cdc.gov/

coronavirus/2019-ncov/covid-data/investigations-discovery/

hospitalization-death-by-age.html

7. Centers for Disease Control and Prevention. 2021. Social

determinants of health: know what affects health. Accessed

March 24, 2021. https://www.cdc.gov/socialdeterminants/

index.htm.

8. Institute for Clinical Systems Improvement and Robert

Wood Johnson Foundation. 2014. Going beyond clinical

walls: solving complex problems. Accessed February 1, 2021.

http://www.nrhi.org/uploads/going-beyond-clinical-walls-

solving-complex-problems.pdf.

9. Agency for Toxic Substances and Disease Registry. 2020.

CDC Social Vulnerability Index. Accessed February 1, 2021.

https://www.atsdr.cdc.gov/placeandhealth/svi/index.html.

10. Advisory Committee on Immunization Practices and Cen-

ters for Disease Control and Prevention. 2020. COVID-19

ACIP vaccine recommendations. Accessed February 1, 2021.

https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/

covid-19.html.

11. Lee, S. J., Lindquist, K., Segal, M. R., and K. E. Covin-

sky. 2006. Development and validation of a prognostic index

for 4-year mortality in older adults. JAMA 295: 801-8.

Journal of Hospital Ethics 73

Increased Ethical Burden in Surrogate Decision-

Making During COVID-19 Adrienne D. Mishkin, MD, MPH, Nicole Allen, MD, Adira Hulkower,

JD, MS, and Laura S. Flicker, JD, MBE

The 2020 COVID-19 pandemic has introduced, exposed,

and exacerbated a variety of individual medical condi-

tions and health care system issues. Medically, the great-

est proximate cause of mortality from COVID-19 has

been respiratory failure, including adult respiratory dis-

tress syndrome (ARDS), but COVID-19 has also contrib-

uted to other major health complications such as renal

failure in adults and Kawasaki disease in children.1-3 The

pandemic has revealed many gaps in the health care sys-

tem, including insufficient capacity for testing, ICU beds,

ventilators, dialysis machines, and expertly trained staff

in key areas such as respiratory therapy.1, 3, 4 In this anal-

ysis we explore how surrogate decision making is not

only more difficult and stressful during this time, but in

what ways the ethical challenges surrounding surrogate

decision making have been heightened.

When patients are unconscious or otherwise decisionally

incapacitated, the medical system calls on health care

agents to serve as medical decision makers. These health

care agents can be identified via health care proxies,

health care power of attorneys, by the next of kin availa-

ble at the hospital, and in some states by an algorithm.5

For the purpose of this analysis we will refer to all of

these decision makers as surrogates. Clinical, practical,

and ethical challenges facing surrogates have been well

studied. It is known that surrogates experience high psy-

chological distress during decision making, and for some

this experience triggers chronic anxiety and depression.6-

10 Studies have found that surrogate decisions often do

not reflect the patient’s values and preferences, and in

situations in which patients later recover capacity, surro-

gate-patient concordance is low: sometimes no better

than chance.6, 10-15 Possible reasons for this include inade-

quate communication from the medical team about the

range of medical options and insufficient exploration of

the patient’s values before the patient became incapaci-

tated. Outcomes have included declining treatment the

patient would have wanted, overtreatment, prolonging

the dying process, and contributing to the high cost of

medical care at the end of life, which can in turn nega-

tively affect both the family of the patient and the health

care system.6, 10

Introduction

Abstract Surrogate decision makers are called upon to inform medical teams what unconscious and decisionally incapacitated patients

would have wanted for themselves. This task poses significant challenges for surrogates as they struggle to determine what the

patient they represent would have wanted, which often takes a physical and emotional toll on the surrogate. Surrogates com-

monly voice hesitancy regarding withholding or withdrawing treatments, leading to the provision of potentially non-beneficial

treatments, driving up costs both to the system and to the family, prolonging the dying process, and increasing distress for the

family and the medical team. These ethical issues have been highlighted and exacerbated by the contemporary COVID-19 pan-

demic. Here we explore the unique manifestations of ethical issues surrounding surrogate decision-making in the COVID-19

context, particularly focusing on how triage, communication, time course and isolation impact the ethics of surrogate decision-

making.

74 Journal of Hospital Ethics

Limited Commodities

Patient choices are limited by the general availability of

treatments, what each particular hospital can offer, and

insurance coverage. This is not a new issue: transplant

organs are a chronically limited commodity, quality

acute inpatient physical rehabilitation is often difficult

to access,16 treatments still under study may only be

available to those enrolling in research, and health care

is limited by cost and insurance coverage.17

In the COVID-19 setting, personal protective

equipment, medical personnel, medication, and equip-

ment such as ventilators and dialysis machines have

been in short supply.18 This has required government

bodies, hospital administrations, and medical staff to

navigate optimal distribution of scarce commodities.

General emergency triage literature recommends that

during a disaster, a triage officer or team with an appro-

priate range of expertise should be assigned to make

resource allocation decisions based on evolving evi-

dence of who would benefit most from the particular

intervention.19 In reality, triage decisions are hospital-

specific and the reasoning behind recommendations for

patient care, and who makes those decisions, may be

unclear to surrogates, who find themselves attempting

to advocate for patients’ wishes despite realistically

having few, if any, options. Resource limitations and

subsequent shifting hospital policies mean that in a

pandemic, autonomy may not be prioritized (or per-

ceived to be prioritized) in comparison to other goals,

such as justice in allocation.4 This is in significant con-

trast to the largely autonomy-driven prior experiences

had by physicians, patients, and surrogates.

In some cases, rather than desiring greater autono-

my, surrogates seek authoritative guidance from physi-

cians during medical care.20 Physicians should provide

a comprehensive informed consent process to the surro-

gate, as would be expected if they were speaking to the

patient themselves. Surrogates often seek advice from,

and to share responsibility with, the medical team to

reduce the burden and potential trauma of making deci-

sions alone. Surrogates fear the responsibility and the

risk of making a moral error if they make the “wrong”

decision or if the patient does not survive.21 Surrogates

report appreciating reassurance and validation from

clinicians about their decisions, and state that the physi-

cian agreeing with their decision helps them continue

with their own lives afterwards.6 Surrogates hoping for

greater direction may also experience more stress dur-

ing the pandemic because of the ambiguity of the infor-

mation on which to base decisions. In the pandemic,

information is particularly uncertain, and rapidly

changing. Even the case fatality rate changes frequent-

ly.1, 22 The amplitude of uncertainty and the speed of

change of data exacerbate all of the baseline difficulties

surrogates face when there is medical uncertainty.

Communication

Communication and Medical Uncertainty

Medical uncertainty always poses a challenge when

communicating options and prognosis to patients and

surrogates. Studies of physician communication about

uncertain outcomes in critical illness have found that

physicians fully inform patients about the uncertainty

of outcomes only 16-18% of the time.23 The known

percentage risk of a particular procedure or treatment is

much easier for physicians to understand and communi-

cate effectively to patients and surrogate decision-

makers.24 Most people, including physicians and even

statisticians, have limited ability to mentally turn these

percentages into truly meaningful qualitative infor-

mation.24, 25 Therefore, both for the patient and for the

well-being of the surrogate themselves, it is important

for physicians to communicate complete information as

efficiently and unambiguously as possible, including

information about uncertainty.

A unique aspect of pandemic care is the degree and

modality of media coverage of new and unfolding med-

ical data, including incorrect or sensationalized re-

ports.26, 27 Sources of poor communication and misin-

formation from the media about the COVID-19 pan-

demic include genuinely confusing medical infor-

mation, conspiracy theories, scams and fraud designed

to scare citizens into purchasing protective gear or in-

surance, cyber-scams designed to infiltrate computers,

both domestic and international political agendas, ce-

lebrities speaking out with opinions outside of their

knowledge base, and even mistaken satirical news

sites.28, 29 The United Nations and World Health Organ-

ization have actively fought what they are terming an

“infodemic,” because of misinformation spreading fast-

er than the truth.29 This is deleterious for everyone

watching the news: a meta-analysis of 14 studies and

over 5,000 subjects found that short-term trauma-

related anxiety predicted long-term psychiatric and

medical issues, including decreased life expectancy.30

We can therefore not rule out the possibility that this

type of media information is damaging to viewers

chronically. Information overload contributes to the

stresses of medical decision-making for patients and

surrogates, and incorrect information can obviously

lead a patient or surrogate to make a different decision

from the one they would otherwise have made. The

infodemic may also be eroding trust between the public

and physicians, as people often receive information

from non-medical sources first, which may contradict

what they are later told by medical personnel.

Not only because of the plethora of sources of in-

formation, but because of rapidly changing medical

knowledge during the pandemic, the sense of uncertain-

ty that surrogates will have in trying to make decisions

for their loved ones is heightened. Providers are chal-

Journal of Hospital Ethics 75

llenged to balance providing the known medical data,

honestly communicating the degree of uncertainty

around that data, and ultimately making a recommenda-

tion in spite of these ambiguities. This is in addition to

the general challenges of communication, targeting

information to the listener’s educational level, medical

literacy, preferences and goals. This can often lead to

providers communicating the most possible number of

details and avoiding a clear clinical recommendation.

The significant need for clinicians to be prepared to

have these difficult conversations also requires that the

system allow for time to think, read and process – time

many providers cannot set aside during a pandemic

without directed administrative support. We recom-

mend that hospitals and clinics support providers in this

way and invest in having those who specialize in com-

munication work with high-acuity first-line providers to

support them in efficiently reaching a plan of how to

communicate uncertainty. Extra resources and time

during a pandemic may feel impossible to allocate, but

are nevertheless critical.

Communication and Scarce Resources

The narrowing of choices due to scarce or threatened

resources and the need to triage is another ethical chal-

lenge. Although there are protocols for making triage

decisions, what is lacking are evidence-based practices

for how to communicate choices to families, or how to

engage a surrogate when there is no real choice to

make. A non-profit organization called Vital Talk has

created a guide for communicating common concepts

in the COVID-19, but there is no wide-spread, evidence

-based, or formally adopted system of communication

for this situation.31 If the patient is in respiratory fail-

ure, and does not meet triage criteria for intubation,

implying to a surrogate that there is a choice to be made

is unethical. Contacting family to inform them that their

loved one is deteriorating is vital, but there may be a

tension between complete transparency (that, for exam-

ple, the patient has such a low possibility of recovery

that a ventilator cannot be allocated to them) and avoid-

ing doing harm to the family by informing them of this

in excessive detail. The chronic tension between want-

ing to offer the surrogate options and not being able to

offer care that is not available or will not benefit the

patient, is significantly heightened in the pandemic by

the public health interest of fair and appropriate re-

source distribution.

These conversations are even harder and more

complex when the limited commodity is not concrete,

such as an available ventilator, but instead, are re-

sources like limited expert staffing or personal protec-

tive equipment. Some hospitals have run out of profes-

sional respiratory therapist hours before running out of

equipment, and have thus needed to rely on less trained

providers to care for patients without informing patients

and families of this situation. This is complex in myriad

ways, including for the providers themselves.32 An ethi-

cal issue that specifically impacts surrogate decision-

making is how and whether to disclose this infor-

mation, especially if the surrogate specifically asks

about the members of the medical team. There is again

a need to balance the goal of honesty while avoiding

causing excess psychological trauma to the family. This

again will necessitate that conversations not be rushed,

and that responses are truly thoughtful.

Communication in non-Dominant Languages

A final consideration about communication with surro-

gate decision-makers during the coronavirus epidemic

is to remember the additional practical and ethical bur-

dens on surrogates with Limited English Proficiency

(LEP). Communication with patients who are not fluent

in the dominant language is a known chronic determi-

nant of inequality across medical settings.33 In our clin-

ical experience, the current pandemic has further com-

plicated interpretation. Because currently surrogates,

and sometimes interpreters, are largely not allowed at

bedside, communication between doctors and surro-

gates is often exclusively by phone. Whether phone

interpretation can ever fully replicate an in-person in-

terpretation is unknown. Further, doctors’ time to com-

municate with surrogates during the COVID-19 pan-

demic is even more limited than at baseline. In our clin-

ical experience, discussions utilizing an interpreter re-

quire significant additional time. We are concerned that

this combination of factors may result in decreased

engagement in the lengthier conversations often re-

quired for critically ill patients and their surrogates.

These limitations reduce total communication with the

LEP population, and further exacerbate inequities in

care.

Time Course

Coronavirus can lead to life threatening illness in previ-

ously healthy people in a matter of days.34 Patients who

were previously completely healthy - and who had nev-

er seriously considered their end-of-life preferences -

can quickly become critically ill. One Wuhan study of

over 800 patients found a mean of 12 days from first

symptom to ICU admission.35 Decisions about intuba-

tion may also happen rapidly, compounding the ethical

concerns of surrogate decision-making in a number of

ways.

A short time in which to make a decision has pre-

viously been cited as a major stressor for surrogates.36

Although the hospital and legal systems encourage a

single representative to act as the main decision-maker,

in reality families do - and should - confer at length

before making potentially end-of-life decisions. Family

76 Journal of Hospital Ethics

members after a loss.6 Because of social distancing and

travel limitations, families cannot come together at the

bedside – or sometimes even elsewhere in person - in-

hibiting group communication. Combined with often

rapid clinical decompensation, ensuring that all in-

volved loved ones have the opportunity to contribute to

the plan is further compromised.36 Decreased quality

engagement with the family limits the opportunity to

identify additional information about the patient’s val-

ues and preferences that family members can offer,

reducing the probability that the surrogate will have all

the relevant data before using substituted judgment.

Surrogates who have had the opportunity to dis-

cuss end-of-life preferences with the patient before

having to act as a surrogate reported this as a major

protective factor for feeling comfortable with the deci-

sion.6 Families are unlikely to have had conventional

opportunities to consider the end-of-life preferences of

patients who were young and healthy prior to COVID.

A meta-analysis of 795,909 people across 150 studies

found that only 37% had completed any kind of ad-

vance directive. People under 65 years old had only a

32% rate of having an advanced directive.37 We there-

fore expect that the need to make a quick decision cou-

pled with a reduced probability of having prepared for

the need to do so will increase stress in surrogate deci-

sion-makers, and decrease their confidence that they

are making the decision the patient would have made.

Based on these data, we recommend introducing the

topic of advanced care planning upon admission for

patients with possible COVID-19, even for otherwise

young and healthy patients, because of the possibility

of a precipitous decline.

Distance

The need for physical distance between parties in deci-

sion-making discussions is one of the most unique and

pervasive aspects of the current era. Because of at-

tempts to reduce transmission of coronavirus, physi-

cians are seeing patients less often or via teleconfer-

ence, and meeting with their own teams by phone and

videoconference. Although there are no definitive data

about long-term tele-relationships between providers

and patients, it is thought to be harder to form an initial

therapeutic alliance, but to improve over time.38 This is

not especially helpful for situations of acute critical

illness and regardless, all prior data involve providers

who opted into using telehealth due to their own prefer-

ences, which is unlikely to represent the experiences of

those suddenly forced into the use of telehealth to pre-

vent disease transmission (author ADM is also re-

searching the experiences of such providers).

Visitor restrictions in many hospitals have required

that surrogates make decisions remotely. Having to

make a decision from a distance has been cited as a

factor that makes surrogate decision-making more diffi-

cult.6 Via telephone, the surrogate is unable to see for

himself how sick the patient looks or whether she ap-

pears to be deteriorating or improving. He may not be

able to convince himself by phone whether the patient

is being well taken care of. And most importantly, he

may feel that the distance means he has no possibility

of saying goodbye. Not being able to say goodbye

when a family member is dying is distressing to rela-

tives, and is associated with long-term depression and

post-traumatic stress disorder.39-41 Many families con-

sider the opportunity to have a parting visit with their

loved one to be an essential part of the process. It may

be the case that for some surrogates, their strong moti-

vation to visit the patient at least once would prevent

them from agreeing to a do-not-resuscitate order, even

if they believe it is the right decision, out of a hope that

they will be able to have a final visit if they prolong the

process.

Use of technology, creativity, and flexibility by

providers and systems may mitigate this issue. A will-

ingness of providers to take on the role of assisting with

communication between patients and families has been

a suggested act of humanity that can allow some fami-

lies to experience closure.42 We also suggest that alt-

hough extreme caution and close preservation of per-

sonal protective equipment have been appropriate

measures, that we must be careful not to project the

necessity of all crisis-phase protocols such as restricting

visitors indefinitely into the future. As we learn more

about prevention, transmission, and treatment, hospital

systems must evolve practices, such as carefully allow-

ing bedside visits of limited family members when pa-

tients are unlikely to be discharged alive. It may also at

times be appropriate to consider allowing cautious vis-

itation of surrogate decision-makers in order to allow

them to have a reasonable view of how the patient is

faring prior to asking them to make potentially life and

death decisions.

We also must remember that distance plays not

only a role in the direct medical setting, but in the en-

tire environment of the family and surrogate to whom a

medical team is directing questions. Any social struc-

ture that would normally be part of the surrogate’s own

support system, such as her own work colleagues,

church community, or other associations are likely to

be less available due to social distancing practices. A

known source of comfort to surrogates is the presence

of religious support groups, which are now largely

avoided to prevent the spread of disease.6 To what de-

gree such support can be given over the phone has not

been determined.

Special Populations

Age and Life Stage

Journal of Hospital Ethics 77

At least some patients affected by COVID-19 are sig-

nificantly younger than the life expectancy in the Unit-

ed States. As of December 26, 2020, the CDC data

show in the United States there have been over 18 mil-

lion cases and 330,000 deaths. Very few deaths have

been in children, and most deaths have been in seniors,

but a significant number of deaths have taken place in

previously healthy adults of working age.22 The ethical

aspects of considering age, life expectancy, and quality

of life in medical decision-making have been thorough-

ly explored elsewhere.43, 44 We see surrogate decision-

making for young adult patients as also complicated by

the current pandemic.

As described above, it is rare for younger healthy

patients to have ever documented their end-of-life val-

ues or preferences.37 Younger patients are also signifi-

cantly more likely to be employed, and to have minor

children. Families - including at times the surrogate

decision-maker himself - may be financially or practi-

cally dependent on the patient. Financial stress has been

reported as a barrier to efficient decision-making by

surrogates.6 In some cases, the patient may be the sole

source of income and health insurance for the family,

creating economic instability for the family in the case

of the patient’s death. This is especially concerning

considering that other household members were likely

exposed to the patient prior to their hospitalization, and

the surrogate would be rightfully concerned that addi-

tional family members could become sick with COVID

-19 and require hospitalization themselves. Surrogate

decision-makers who are spouses, partners, or co-

parents therefore could be motivated to prolong the

patient’s death from fear that if they lose their spouse’s

health benefits, they or their children may be left unin-

sured while ill. Although this is understandable and

resources should be committed to help assist families

through these situations, it is also concerning that the

end result might be to prolong an uncomfortable dying

process against what the patient would have wanted

and against their interests.

In some of these cases, the surrogate decision-

maker is also currently infected with COVID-19, has

other medical problems, or has additional sick or dying

family members. He or she may be taking on sole care

of elderly or minor family members as a result of an

identified illness. They may be either newly out of

work, or have much increased work, depending on their

occupations. Competing responsibilities and personal

health problems have both been cited as sources of dif-

ficulty for surrogate decision-makers.6 Given rising

unemployment45 and the high rates of infection of

COVID-19, we anticipate these issues to be particularly

common during the coronavirus pandemic, and that all

of these sources of increased stress on surrogates will at

times translate into decreased ability to exercise substi-

tuted judgment and best decision-making on behalf of

the patient.

Race

In the United States, racially and ethnically based dis-

parities in access to care have been well documented,

including in end-of-life care.46, 47 COVID-19 is known

to have overall disproportionately affected people of

color, particularly people of Latino and African de-

scent.48 A single-center Louisiana study found that of

1382 COVID-19+ patients who were hospitalized,

76.9% were black and 23.1% were white.49 This dis-

crepancy indicates that ethical and psychological issues

related to surrogate decision-making during COVID-19

may be even more widespread in patients and surro-

gates of color.

Surrogate decision-making has been studied in

different racial and ethnic groups prior to COVID-19.

A study of 1447 surrogates across 22 states found that

family members of African American decedents were

less likely than those of white decedents to rate the care

their loved ones received as excellent (OR 0.4) and

were more likely to report that the physician communi-

cation was insufficient.47 African American patients

were also less likely to have documented end-of-life

wishes.47 Of patients surveyed about their desire to doc-

ument end-of-life wishes, significantly fewer African

American patients reported intention to document a

living will.50 Another study also found significantly

more white patients had a durable power of attorney or

a living will than African American patients.15 African

American patients are significantly more likely than

white patients to desire life-sustaining or heroic treat-

ments, regardless of whether they report trusting their

physicians or the healthcare system.15, 50 The underlying

factors in these differences have not been elucidated,

but differences in trust and religious differences have

been explored as potential reasons.50 As some have

defined advanced directives as the presence of having a

do-not-resuscitate order or other instructions for treat-

ments the patient would not want, it would also make

sense that some patients who do wish to be resuscitated

would not see any value in completing an advanced

directive.51 This possibility makes it even more difficult

to interpret the differences in rates of completing ad-

vanced directives, and to determine what racial and

ethnic disparities may be linked to these differences.

Because of actual and perceived limitations of life-

sustaining and heroic treatments during the COVID-19

pandemic–and because it has been considered to order

do-not-resuscitate a standard or even mandatory order

for COVID-19+ patients -- although no United States

jurisdiction has actually done this to our knowledge –

individuals who want all treatments continued indefi-

nitely are less likely to have this value fully honored

78 Journal of Hospital Ethics

than in non-crisis circumstances. Because the African American community has a greater number of people who

do want resuscitation, this group is statistically at higher risk for having their end of life values violated.4, 18 There-

fore, surrogates of African American patients may be at further disadvantage in their attempts to extend the pa-

tient’s autonomy, because of the poor alignment between what our triage system currently is prescribing and the

values and preferences of this community. We recommend that physicians keep these stressors and cultural factors

in mind when communicating with families of African and Afro-Caribbean descent. The figure below is a sum-

mary of our recommendations:

Conclusion

Due to precedented but severely exacerbated issues including limited commodities, challenges posed by medical

uncertainty and communication, the need for speed, distance and isolation, and competing responsibilities, surro-

gate decision-making has been extremely difficult. Where we see the need for medical provider caution, and many

potential ethical pitfalls, we also see opportunities for creativity, flexibility, and kindness if these issues are consid-

ered and included in our mission as thoughtful members of the health care system. By understanding the extra

pressures put on surrogate decision-makers during these challenging times, clinicians and hospitals can begin to

consider how to mitigate these extra stressors. While encouraging patients to talk to family members about values

and preferences has always been important, we must now expand these discussions to all patients regardless of age

or health status. We can also consider pandemic-specific factors such as isolation and speed, and how these stress-

ors particularly impact surrogate decision-makers for patients of certain racial and ethnic groups. Finally, we en-

courage hospitals and clinic systems to provide the necessary time and support to enable clinician sensitivity dur-

ing this difficult time.

Recommendations for Physicians and Medical Teams

Physicians should provide a comprehensive informed consent process to the surrogate, as would be ex- pected if they were speaking to the patient themselves

Physicians should communicate the most total information as efficiently as possible, including infor- mation about uncertainty, and ultimately make a recommendation in spite of these ambiguities

Providers should keep stressors and cultural factors in mind especially when communicating with fami- lies of African and Afro-Caribbean descent

A willingness of providers to take on the role of assisting with communication between patients and families has been a suggested act of humanity that can allow some families to experience closure

Recommendations for Hospitals and Medical Systems

The topic of advanced care planning should routinely be introduced upon admission for patients with possible COVID-19, even for otherwise young and healthy patients, because of the possibility of a precipitous decline

Professional interpretation should always be used for patients and surrogates with LEP, potentially through the use of remote video-conferencing

Hospitals and clinics should allow providers time to think, read, and process during this time to maxim- ize their ability to provide excellent care

Hospitals and clinics should invest in communication specialists, including in-house palliative care and psychiatry teams, to work with first-line providers to help them efficiently reach a plan of how to communicate uncertainty

Journal of Hospital Ethics 79

AUTHORS

Adrienne Mishkin, MD, MPH is an Assistant Professor of

Psychiatry at Columbia University Medical Center in New

York. She completed her residency in psychiatry at St.

Luke's-Roosevelt Hospital and fellowship in consultation

liaison psychiatry at Montefiore. She is the psychiatric liai-

son to the Blood and Marrow Transplantation Program at

New York Presbyterian Hospital.

Nicole Allen, MD is an Assistant Professor of Psychiatry at

Columbia University Medical Center in New York. She com-

pleted her residency in psychiatry at Montefiore Medical

Center and fellowship in consultation liaison psychiatry at

Columbia. She currently works in the Women's Program at

Columbia.

Adira Hulkower, JD, MS is chief of the Bioethics Consulta-

tion Service at Montefiore Medical Center and assistant pro-

fessor of epidemiology and population health, Albert Einstein

College of Medicine. In addition to bioethics consultation,

Ms. Hulkower teaches bioethics to the medical students and

medical residents.

Laura S. Flicker, JD, MBE is the Associate Director of the

Montefiore Einstein Center for Bioethics. Her work focuses

on reproductive ethics, decision making, and ethical issues at

the end of life.

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82 Journal of Hospital Ethics

The Ethical Allocation of Remdesivir Within Hospitals Amber R. Comer, PhD, JD

Consensus in Allocating Remdesivir

Hospital policies and ethics literature has reached con-

sensus that remdesivir requires allocation criteria as the

potential for drug shortage could create a public health

crisis.4 The overarching structure of these policies in-

cludes ethical guiding principles, drug eligibility inclu-

sion and exclusion criteria, and an allocation process.

Guiding principles of ethical allocation has found con-

sensus in not excluding patients based on characteristics

such as age, disability, gender, race, and immigration

status. Allocation criteria have reached consensus on

inclusion criteria for patients who should be considered

for remdesivir which is derived from the FDA Emergen-

cy Use Authorization (EUA) guidelines and includes

clinical data such as laboratory confirmed COVID-19

test and oxygen saturation (SpO2) ≤94% on room air,

requiring supplemental oxygen.5

Consensus in regard to an allocation process is that a

first-come-first-serve process of allocation should not to

be utilized and that some form of lottery should be used

when the number of eligible patients exceeds remdesivir

supply.

Variance in Allocating Remdesivir The greatest variance in ethics policies allocating

remdesivir is found in the exclusion criteria for the drug.

Some policies did not outright exclude patients, while

other policies excluded or reduced the priority of patients

who are imminently and irreversibly dying or who are

terminally ill with life expectancy under six months.6-10

Other policies excluded pregnant patients and children as

they could receive remdesivir through the compassionate

use program.7 An important variation in allocation poli-

cies was the way in which the lottery was structured.

Some polices chose to use a weighted lottery, while other

polices, such as the Veterans Affairs Hospitals chose to

use a random lottery.6-10 Within weighted lottery policies,

variations were found in which patients received greater

priority with some lotteries giving patients such as essen-

tial workers and disadvantaged populations priority.7

Most policies chose to implement a random lottery as

weighted lotteries which give patients priority based on

life style may not be easily implemented and have the

propensity to create complex ethical dilemmas which

may result in judgements that some people have greater

societal value.6-10

Abstract Recent evidence has shown that remdesivir may shorten length of hospital stay and recovery in COVID-19 patients.1-3 Many

hospitals are experiencing shortages of remdesivir and are being forced to determine systems for the ethical allocation of this

drug. Ethical allocation of remdesivir is imperative for upholding principles of justice during public health crisis.2 Currently,

there is no consensus on the ethical distribution of remdesivir to patients within hospitals. This article discusses places of consen-

sus, variance, and limitations of hospital level remdesivir allocation policies throughout the US during the COVID-19 pandemic.

Journal of Hospital Ethics 83

Limitations in Allocation of Remdesivir Policies

There are several major limitations in remdesivir allo-

cation policies that need to be addressed. First, the

EUA guidelines have created a sort of purgatory for

pregnant patients.11 Several hospitals use pregnancy in

their exclusion criteria because these women were able

to use the compassionate use program; however, under

the EUA guidelines, patients are not eligible for com-

passionate use if their hospital has remdesivir. This

issue should be corrected in current hospital policy

exclusion criteria. Another limitation is that many of

these policies do not include an appeals policy in the

event that a patient believes they have had remdesivir

withheld unfairly. This may be because many policies

have developed binomial exclusion and inclusion crite-

ria which does not lend itself to exceptions. Although

this may be the case, patients should have the right to

appeal the decision to ensure just treatment.

The fact that each individual hospital is creating

their own allocation policy is a limitation in-and-of-

itself. Without a community standard for the allocation

of remdesivir several problems may arise: 1) patients

may qualify for remdesivir at one hospital and be ex-

cluded at the hospital across the street; 2) hospitals

have varying supplies of remdesivir and hospitals who

more conservatively allocate the drug may not be open

to sharing their supply with hospitals who run out due

to a more liberal allocation policy.

Conclusions

There are varying ethical approaches to the allocation

of remdesivir being implemented throughout the coun-

try. A community standard for the ethical allocation of

remdesivir should be devised in order to ensure just and

equal access to this drug for all COVID-19 patients. As

a community standard does not yet exist, hospitals

should develop a policy for the ethical allocation of

remdesivir in order to ensure just treatment of all pa-

tients within their institution. Policies should be devel-

oped by an interdisciplinary team. Ethical consensus

among hospital policies suggests the following policy

format: 1) developing patient inclusion and exclusion

criteria for remdesivir eligibility that is based on clini-

cal criteria and is blinded to patient characteristics such

as age, gender, race, disability, and immigration status;

2) distributing remdesivir to all eligible patients until

the number of eligible patients outnumbers the courses

of treatment available; 3) at the point in which the sup-

ply of remdesivir is lower than eligible patients, enter-

ing all eligible patients into a random lottery for distri-

bution; and 4) developing an appeals process for pa-

tients who feel they have been unfairly excluded. Once

a policy is developed, it should be reevaluated as new

evidence emerges.

AUTHOR

Amber R. Comer, PhD, JD is an Assistant Professor of

Health Sciences in the Indiana University School of Health

and Human Sciences. Dr. Comer is a member of the Eskenazi

Hospital Medical Ethics Committee and holds an appoint-

ment at the Regenstrief Institute as an Affiliate Research

Scientist as well as faculty appointments in both the Indiana

University School of Medicine Center for Bioethics and the

Indiana University RESPECT Center. Dr. Comer is currently

a member of the American Academy of Hospice and Pallia-

tive Medicine Public Policy Committee and Chair of the Eth-

ics Committee. Her research interests include medical deci-

sion-making for patients with life threatening illness, neuro-

palliative care, and biomedical ethics.

REFERENCES

1. Gilead. Remdesivir. https://www.remdesivir.com/us/

access/?

gclid=CjwKCAjw1K75BRAEEiwAd41h1O4edfM6LE3B9H

aIJ62Z9OC_GxgtZA5NFJfl3fPyhyd2hYxt4vJH4RoCXLAQ

AvD_BwE&gclsrc=aw.ds. Accessed August 6, 2020.

2. Beigel JH, Tomashek KM, Dodd LE, et al. Remdesivir for

the Treatment of Covid-19 - Final Report. N Engl J Med.

2020;383(19):1813-1826. doi:10.1056/NEJMoa2007764,

10.1056/NEJMoa2007764

3. WHO Solidarity Trial Consortium, Pan H, Peto R, et al.

Repurposed Antiviral Drugs for Covid-19 - Interim WHO

Solidarity Trial Results. N Engl J Med. 2020;. doi:10.1056/

NEJMoa2023184, 10.1056/NEJMoa2023184

4. DeJong, C, Chen AH, Lo B. An Ethical Framework for

Allocating Scare Inpatient Medications for COVID-19 in the

US. JAMA. 2020;323(23):2267-2368.

5. U.S. Food & Drug Administration. EUA Letter of Approv-

al. https://www.fda.gov/media/137564/download. Accessed

January 13, 2021.

6. Pennsylvania Department of Health. Ethical Allocation

Framework for Emerging Treatments of COVID-19.

https://www.health.pa.gov/topics/disease/coronavirus/Pages/

Guidance/Ethical-Allocation-Framework.aspx. Accessed

August 6, 2020.

7. Veterans Affairs Hospital. Remdesivir Emergency Use

Authorization (EUA) Requirements. May 2020. https://

www.va.gov/covidtraining/

docs/20200618_Dynamic_Drugs_in_the_Battle_of_COVID_

19/

Remdesivir_Emergency_Use_Authorization_Requirements.p

df. Accessed August 6, 2020.

8. Lim S, DeBruin DA, Leider JP, et al. Developing an Ethics

Framework for Allocating Remdesivir in the COVID-19 Pan-

demic. Mayo Clin Proc. 2020;95(9):1946-1954. doi:10.1016/

j.mayocp.2020.06.016, 10.1016/j.mayocp.2020.06.016

84 Journal of Hospital Ethics

demic. Mayo Clin Proc. 2020;95(9):1946-1954. doi:10.1016/

j.mayocp.2020.06.016, 10.1016/j.mayocp.2020.06.016

9. Washington Department of Health. Washington State

Remdesivir Distribution Plan. June 3, 2020.

https://cdn.ymaws.com/www.wsparx.org/resource/resmgr/

covid/WA_Remdesivir_Distribution-2.pdf. Accessed August

6, 2020.

10. Black H, Buhr R, Cederquist L, Dastur C, Dicker R,

Doucet J. et. al. Allocation Guidelines for Remdesivir if De-

mand Outstrips Supply. University of California Critical Care

Bioethics Working Group. June 26, 2020. https://

www.ucop.edu/uc-health/reports-resources/uch-coordinating-

committee-guidance/uc-critical-care-bioethics-working-group

-report.pdf. Accessed August 6, 2020.

11. Burwick RM, Yawetz S, Stephenson KE, Collier ARY,

Pritha S, Blackburn BG, et. al. Compassionate use of

remdesivir in pregnant women. Clinical Infectious Diseases.

2020; (ciaa 1466). https://doi.org/10.1093/cid/ciaa1466

Journal of Hospital Ethics 85

Delirium Assessment in COVID-19: What a Difference

a Little Change Can Make Evan G. DeRenzo, PhD; Catherine Bledowski, MD; Jozef Bledowski,

MD; and Chee Chan, MD

Science still has much to learn about how the SARS-CoV

-2 virus, or COVID-19, wreaks havoc on the human

body. One piece of COVID-19’s complexity that is com-

ing into view, however, is the way in which delirium is

part of the COVID-19 picture. Although delirium is often

seen during critical illness, there appears to be something

specific about COVID-19’s effects on the central nervous

system (CNS) that puts patients at increased risk for de-

lirium.1

Even prior to awareness that an individual might be

ill with COVID-19, mental status changes may be an

early warning signal. For the patient who presents at an

acute care hospital’s Emergency Department (ED) with

altered mental status, this is now an alert that the individ-

ual may be infected with COVID-19. Delirium in

COVID-19 patients once they have been hospitalized,

especially if they have been admitted to an Intensive

Care Unit (ICU), is already a predictor of poor outcome.2

Now that we have a better appreciation for the neu-

rologic sequelae associated with COVID-19 to include,

but not limited to, delirium,3, 4 it is time to proactively

screen, detect, and try to prevent delirium in these pa-

tients. Given the morbidity and mortality associated with

delirium, it is imperative that we recognize and treat it in

an expedited manner. In truth, early detection of deliri-

um and measures to prevent its occurrence are small

practice changes that might produce important outcome

improvements.

Background

Prior to the advent of COVID-19, delirium has long been

known to be common in the hospitalized elderly,5, 6, 7

although it also has been seen in pediatric populations.8

The phenomenon of delirium in patients in the acute care

hospital setting, especially in the ICU, is well estab-

lished.9, 10

At the beginning of the COVID-19 pandemic, when

patients required admission to the hospital for acute hy-

poxic respiratory failure, particularly to the ICU, altered

mental status was often attributed to the most obvious

sequelae of COVID-19 infection (i.e. impaired pulmo-

nary function resulting in profound hypoxia and hypox-

emia, ultimately resulting in organ damage). What was

less clear early on in the pandemic was whether infection

with COVID-19 independently contributed to delirium

and associated cognitive impairment, regardless of pa-

Introduction

Abstract As the neurobiology of COVID-19 advances, delirium looms ever larger as a predictor of poor outcome. That is why it is im-

portant to identify when delirium is already present and developing. That will require a change in standards of practice which

only call presently for daily delirium assessments when patients are in an intensive care unit (ICU). We argue that quick deliri-

um assessments should be added to routine nursing assessments from the time a patient suspected of COVID-19 arrives through

the acute care hospital course of all COVID-19 positive patients.

86 Journal of Hospital Ethics

tients’ pulmonary function. Given the degree of hy-

poxia in these patients’ experience, primary efforts

have mostly focused on preserving and/or restoring

cardiopulmonary function. The more we begin to un-

derstand about COVID-19 as a pathogen, however, the

more we can begin to see the multifactorial nature by

which this virus wreaks havoc on the brain. Even be-

fore the COVID-19 pandemic, we’ve known about

coronaviruses and their potential to directly invade neu-

ronal tissue.11 More recently, we’ve discovered yet

more potential mechanisms by which COVID-19 infec-

tion can directly contribute to multi-organ failure, in-

cluding direct neuronal damage (i.e. COVID-19 infec-

tion can trigger widespread systemic inflammatory and

immune-mediated responses, as well as increase hyper-

coagulability and risk for thrombus/embolus for-

mation).12, 13, 14 The more we understand about COVID

-19 and its ability to independently cause neurotoxicity

and delirium, the more we are compelled to identify

and address this aspect of the infection conscientiously

and proactively.

Most cases of delirium are the result of a combina-

tion of factors to include patient predisposition (e.g.

age, chronic medical comorbidities, presence of pre-

existing cognitive impairment), precipitating factors

such as acute illness, treatment with certain medica-

tions, especially sedative-hypnotic, anxiolytic, and anti-

cholinergic agents, and environmental effects, such as

the disorienting processes of an ICU 15 or environmen-

tal under-stimulation such as that which patients experi-

ence during mandatory isolation.

The Diagnostic and Statistical Manual of Mental

Disorders, 5th Edition,16 defines delirium as an acute

disturbance in a patient’s level of attention and aware-

ness, accompanied by other cognitive impairment, that

represents a change from baseline and tends to fluctuate

throughout the course of the day. There are three (3)

major subtypes of delirium, all based upon psychomo-

tor activity: hyperactive, hypoactive, and mixed type.

Hyperactive delirium is characterized by restlessness,

combative behavior, hypervigilance, and agitation,

which is often misdiagnosed as anxiety or acute psy-

chosis. Hypoactive delirium is characterized by lethar-

gy, sluggishness, and decreased responsiveness, which

is often misdiagnosed as depression. Hypoactive deliri-

um may be associated with poorest prognosis and is the

most prevalent yet is the most likely subtype of deliri-

um to go undiagnosed.17 Mixed-type delirium includes

aspects of both hypoactive and hyperactive delirium.

This information is general knowledge that presag-

es the advent of delirium in the SARS-CoV-2 virus.

Now, though, we know that delirium, on top of its gen-

eralized probabilities, is highly prevalent and likely a

distinct component of the evolving COVID-19 puzzle.

That is, it appears that COVID-19 has direct effects on

the CNS that increase the probability that COVID-19

patients will develop delirium.18 This COVID-19-

specific information should be setting off flashing

lights that early detection of delirium in these patients

may have significant influences on outcome.

In summary, in COVID-19, given that the over-

whelming focus has been on the obvious manifesta-

tions, such as the impact on cardiopulmonary function,

the neurologic sequelae of the virus, including its con-

tribution to the development of delirium has yet to gar-

ner the attention it deserves.19 What appears known

about delirium in COVID-19, that is consistent with the

general delirium literature, is that delirium is an already

well-appreciated complication of respiratory illness,

such as pneumonia, especially in the elderly. Recent

studies have predicted that 20-30% of COVID-19 pa-

tients manifest at admission, or develop once hospital-

ized, frank delirium or altered mental status,20 with

rates as high as 60 – 70% in patients with severe ill-

ness.21 This finding holds up regardless of age. Deliri-

um in COVID-19 patients, as in any hospitalized pa-

tients, predicts worse outcomes.

Further, the best management of delirium, whether

related to COVID-19 or not, is prevention. Prevention

should start with assessment and early identification.

Once identified, assessment of delirium should be fol-

lowed by non-pharmacological, management strategies

such as frequent reorienting, which can be accom-

plished by care team members or contact with family,

and environmental strategies. Environmental strate-

gies include, but are not limited to, placing a clock, day

of the week and date in a delirious patient’s room.

There are other, non-pharmacologic strategies but a full

discussion of such interventions is beyond the scope of

this article. For a review of the pharmacological strate-

gies specific to COVID-19 delirium, which are still

little-researched and thus quite variable.18, 22 The rest

of this article will focus on the importance, utility and

ease of assessing for identification of delirium through

early and daily delirium screening. That is because just

mastering this negligibly burdensome improvement in

standards of practice can be expected to yield substan-

tial improvements in outcomes for COVID-19 patients.

Just this little change can be expected to make a big

difference.

How Should This Additional Delirium Assessment

Be Done? Screening assessment for delirium should be done con-

sistently on every hospitalized patient at arrival and

throughout the day. This allows the team to quickly

identify patients with altered sensorium. Since hypoac-

tive delirium is often missed, screening will be advanta-

geous for early identification. Currently, assessment of

delirium or mental status changes in COVID-19 is not

Journal of Hospital Ethics 87

usually part of a routine assessment.2 This critically

important change in routine daily care and management

of COVID-19 patients should be initiated everywhere

and promptly. This is the singular ethics obligation

being recommended in this paper.

As one would expect, when this suggestion is

brought up to treatment team members one of, if not

the first, response is resistance. Professionals ground

this resistance in a perfectly reasonable concern about

adding more time to their already exhausting days. The

pandemic-specific, crushing exhaustion experienced by

treating teams everywhere, teams at their breaking

point, means that learning anything new that would add

more time seems like too much to ask.

But this resistance may also come from inaccurate

assumptions about the extra time and effort such deliri-

um assessment would actually add. The understandable

resistance reaction ignores that several delirium screen-

ing tools take little time or effort to administer and re-

quire no specialized training. The minute one starts

talking about doing something that is likely to improve

care and that takes less time than what clinicians are

presently doing, that is a conversation that receives

everyone’s attention. For example, one of the most

commonly used, validated assessment tools, is the short

version of the Confusion Assessment Method (Short

CAM).23 Even though this tool has become common-

place and often used daily in the ICUs that have incor-

porated a daily delirium screen, it can take quite a bit of

time for busy ICU nurses and house staff (usually

about 5 minutes, but sometimes longer) to administer.

It also requires specialized education and training to

produce valid results.24 Last, and specific to COVID-

19, the Short CAM requires that an interview be at-

tempted, which may be irrelevant to assessment of ICU

patients and yet the attempt calls on physicians or nurs-

es to stay in the room of a COVID-19 patient longer

than need be, an unnecessarily long exposure when risk

from exposure is so great.

These reasonable and realistic concerns, however,

can be minimized or avoided by using an even easier-to

-administer instrument. Of the several that are availa-

ble, another one that is already internationally used and

validated, is the 4A’s Test (4AT).25 This assessment

tool takes less than 2 minutes to administer. The 4AT

has additional benefits over the Short CAM. They in-

clude no interview, no specialized education or train-

ing, and it can be used even with patients with hypoac-

tive symptoms. This is especially important in COVID-

19, as these patients may only be showing hypoactive

symptoms of delirium on arrival to the ED. The 4AT

could easily be added to daily nursing assessments,

whether the patient is admitted to the floor or to an

ICU.

A delirium assessment tool that takes less than 2

minutes should be able to be integrated into a general

assessment for patients coming in through the ED. It

might be especially important to perform such an as-

sessment in the ED because the results may have mate-

rial relevance to monitoring progression and resolution

of delirium throughout the course of the hospitaliza-

tion.

The social isolation COVID-19 patients endure is

multifactorial and can significantly contribute to the

development or worsening of delirium. The need for

clinicians to wear protective gear and the fear of con-

tracting and/or spreading the virus, hospital policies

restricting or completely prohibiting visitors, along

with an inability to freely ambulate creates a “delirium

factory,” 26 increasing the risks of delirium in these

patients. Strategies to mitigate these risks include the

use of computers to allow video conferencing between

patients with family members and friends in an attempt

to keep these patients oriented or reoriented, approxi-

mating some of the processes standardly prohibited by

the no-visitor/restricted-visitor policies. Or a hospital

could create a COVID-19 wing where patients with

COVID-19 can commiserate and heal together. Perhaps

such changes might reduce the number of delirious

COVID-19 patients who end up needing higher levels

of care due to worsening mental status changes.

For our readers who may be unfamiliar with such

real-time efforts, though, it is important to illuminate

the time drains, logistic headaches and risk factors of

just having a delirious, COVID-19 patient get to ‘face

time’ with family members or friends. The burden on

time expenditures for care team members ought not be

minimized. For those of us who are involved in coor-

dination of these ‘face time’ happenings know well of

this activity’s complexities. First, it takes just having

the numbers of laptops or comparable devices to cover

a COVID-19 general medical/surgical floor unit or a

specialized COVID intermediate or intensive care unit.

These devices regularly breakdown, extras need to be

available. When they do break down, team members

waste time scrambling to find functional machines.

Often nursing and/or social work sets up these remote

visits, which take much time on the part of these clini-

cians just to get a remote visit scheduled. Then, once

scheduled, when the exigencies of everyday care in an

acute care hospital mix with schedule changes on the

part of families and friends, just the seemingly simple

actions of ‘face timing’ delirious COVID-19 patients is

often a frequent source of frustration, acting as a natu-

ral disincentive to trying it multiple times a day.

Adding a simple, quick, daily delirium screen for

COVID-19 inpatients pails against the time required

for other care needs for these patients. Surely, when

performing a daily delirium screen is so much less bur-

densome and aggravating than even such seemingly

88 Journal of Hospital Ethics

simple activities such as ‘face timing’ COVID-19 pa-

tients with their family and friends, the prospects for

improved outcomes such daily screening could produce

surely calls on this small change in present standards of

practice.

Conclusion: Next Steps

When dealing with the rapidly evolving science of the

SARS-CoV-2 virus, one answer to the question, ‘What

might be helpful now?’, is almost always, ‘More re-

search’. For example, it seems odd that there is still

equipoise between those who think early identification,

monitoring and treatment of delirium have the prospect

for improving outcomes for COVID-19 patients and

those who think it will not make any difference.27 Per-

haps someone reading this article might want to explore

why such equipoise still exists.

At a minimum, one hopes that this little piece pro-

vides a kickstart that can begin discussions in hospital

ethics committees and in psychiatry, general medicine,

intensive care and nursing departments about changing

the present standard of practice before more opportuni-

ties to improve the care of COVID-19 patients by early

delirium detection and regular monitoring are lost.26

Given the state-of-the science related to the probabili-

ties that hospitalized COVID-19 patients are at such

high risk for having delirium either upon hospital arri-

val or once admitted, and delirium is such a brightly

shining arrow pointing to bad outcomes for these pa-

tients, that the ethics of what would be such a small

practice change seems beyond need for further convinc-

ing. What seems needed is spreading the word. Per-

haps this little article has given this imperative a good

push.

AUTHORS

Evan DeRenzo, PhD is a Senior Clinical Ethicist with the

John J. Lynch MD Center for Ethics at MedStar Washington

Hospital Center, Washington, D.C. Formerly Assistant Di-

rector, Evan has returned to staff faculty status to focus on her

clinical responsibilities, her writing projects, and her partici-

pation in the Learning Collaborative of the National Health

Care for the Homeless Council (NHCHC). The Learning

Collaborative, conducted by the NHCHC and supported by

the Health Resources and Services Administration (HRSA),

US Department of Health and Human Services, is a 3 year

preparatory group working to develop medical respite facili-

ties in their own regions for those experiencing homelessness

prior to a hospital stay who required additional time for recu-

peration when ready for acute care hospital discharge. Dr.

DeRenzo is focusing her efforts on the Washington, DC Met-

ro Area.

Catherine Bledowski, MD is an Attending Psychiatrist on

the Consultation-Liaison Psychiatry Service at MedStar

Washington Hospital Center and an Assistant Professor of

Clinical Psychiatry at Georgetown University School of Med-

icine in Washington, D.C. She also serves as site co-

supervisor for the Consultation-Liaison Psychiatry Fellowship

program at Georgetown University. Dr. Bledowski received

her Doctor of Medicine degree from the University of South

Carolina School of Medicine, followed by completion of her

residency in Psychiatry and fellowship in Consultation-

Liaison Psychiatry at Virginia Commonwealth University/

Medical College of Virginia in Richmond, VA.

Jozef Bledowski, MD is the Medical Director of the Consul-

tation-Liaison Psychiatry Service at MedStar Washington

Hospital Center and an Associate Professor of Clinical Psy-

chiatry at Georgetown University School of Medicine in

Washington, D.C. He also serves as site co-supervisor for the

Consultation-Liaison Psychiatry Fellowship program at

Georgetown University. Dr. Bledowski received his Doctor

of Medicine degree from Virginia Commonwealth Universi-

ty/Medical College of Virginia, where he also completed his

residency in Psychiatry and fellowship in Consultation-

Liaison Psychiatry.

Chee Chan, MD is a board certified Pulmonologist and Criti-

cal Care Medicine physician at Medstar Washington Hospital

Center (MWHC). She completed her Internal Medicine resi-

dency at the University of Medicine and Dentistry at Newark

New Jersey and went on to pursue Pulmonary and Critical

Care fellowship training at the Warren Alpert Medical School

of Brown University in Providence, Rhode Island. She has

since been here at MWHC. She enjoys teaching the medical

residents and fellows. Her research interests include out-

comes in the ICU along with venous thromboembolism and

heparin induced thrombocytopenia. She has a particular in-

terest in COVID19 since the pandemic began.

ACKNOWLEDGEMENT

Thank you to the medical librarians of the William B. Glue

Health Sciences Library, MedStar Washington Hospital Cen-

ter, for their assistance in the preparation of this manuscript.

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carelli JW, Madva E, Nisavic M, Praschan N, Quijije NV,

Beach SR, Smith FA. Neurocovid: Pharmacologic Recom-

mendations for Delirium Associated With COVID-19. Psy-

chosomatics 61 (6) 2020: 585-596.

23. Short CAM: Short Confusion Assessment Method

https://www.cgakit.com/p-2-cam. Accessed February 19,

2021

24. Inouye SK. The Short Confusion Assessment Method

(Short CAM): Training manual and coding guide. Boston:

Hospital Elder Life Program; 2014. http://

www.hospitalelderlifeprogram.org/uploads/disclaimers/CAM

-S_Training_Manual.pdf

25. 4 AT: Rapid clinical test for delirium. https://

www.the4at.com/. Accessed February 19, 2021

26. Kotfis K, Roberson SW, Wilson JE, Dabrowski W, Pun

BT, Ely EW. COVID-19: ICU delirium management during

SARS-CoV-2 pandemic. Crit Care (2020) 24:176.

27. Marra S, Korfis K, Hosie A, MacLullich AMJ, Pan-

dharipande PP, Pun BT. Delirium monitoring: Yes or no?

That is the question. Am J of Crit Care, March 2019, 28

(2):127-135.

90 Journal of Hospital Ethics

IN PRACTICE

Shared Decision Making in The Presence of COVID-19

And The Absence of Families Lynette Cederquist, MD, Biren Kamdar, MD, Alex Quan, and The Editorial

Group of the John J. Lynch, MD Center for Ethics Case Complexity: 1 2 3 4

Mrs. C was 47 years old. She was brought by ambu-

lance to her community hospital emergency room,

where she was diagnosed with hypoxic respiratory fail-

ure secondary to COVID-19. After being emergently

intubated, she had a pulseless electrical activity (PEA)

arrest, requiring 17 minutes of cardiopulmonary resus-

citation (CPR). Spontaneous circulation was restored

and the patient was stabilized for transport. She was

subsequently transferred to the closest tertiary care hos-

pital where brain imaging revealed severe anoxic brain

injury.

As had been the case since the beginning of the

COVID-19 pandemic, to attempt to prevent the spread

of the coronavirus, the hospital – like every hospital

around the country - had initiated a restricted visitation

policy. Essentially, patients cannot have visitors unless

the patient is assessed to be imminently dying. Be-

cause Mrs. C was relatively stable, she was not so as-

sessed even though her kidneys were now beginning to

decline. The reason for the visitation restriction was

explained several times to the patient’s husband and

adult children. The family was updated regularly by

the Intensive Care Unit (ICU) team. Although the

team, including the patient’s ICU attending physician,

regularly described to the family that the patient was

not awakening from her arrest and that her kidneys

were now failing, nonetheless, the family requested,

then insisted, on continued, full life-sustaining treat-

ment, including initiation of dialysis if it became need-

ed.

Over a period of a week or more, multiple goals of

care conversations were conducted, including vide-

oconferences to demonstrate the patient’s devastating

neurologic injury. On hospital day 20, the ICU attend-

ing physician, the patient’s resident, and nurse practi-

tioner, joined by the hospital’s clinical ethics consult-

ant, held a teleconference with the patient’s spouse and

adult children. Acknowledging the impossible situation

facing the family, the physician summarized prior con-

versations, including comments that continued life sus-

taining treatment was not producing any improvement

in the patient’s condition and was therefore not provid-

ing the patient any benefit. The team sensed that the

patient’s husband was moving towards a willingness to

shift to comfort measures only, when the resident de-

cided to step in and, unfortunately, made things worse.

The resident said that the team didn’t want to make the

patient suffer.

With that, the most suspicious of the adult children

said, “I thought you said our mother’s brain was so bad

that she wasn’t able to communicate or appreciate any-

thing around her,” to which the resident responded

with, “that’s right.”

Perhaps because of an apparently deep religious

faith, the son then responded with, “I could understand

what you mean if you had said that you want to make

sure our mother isn’t experiencing any pain. She might

have pain and not be able to express it. But to suffer, I

think, our mother needs to have much more awareness

than you have told us she has.”

PRESENTATION

Journal of Hospital Ethics 91

Immediately, the resident recognized his mistake. Suf-

fering is a conscious human phenomenon. A patient

who lacks consciousness in light of an anoxic brain

injury cannot suffer.

Fortunately, this ICU attending was experienced at

having residents make this mistake and skilled at get-

ting out of the bind that the inexact usage of the word

‘suffer’ can produce. He side stepped quickly and re-

plied in a way that honored the son’s awareness of the

profound difference between suffering and physical

pain. He said, “Yes, we don’t think the patient can be

suffering as you so rightly point out. For that, we are

all deeply grateful. Rather, we are concerned that the

slower and more drawn-out her death might be is likely

to produce more complications that might cause her

actual pain or discomfort”.

The attending then raised the issue about restrictive

visitation policies while also expressing just how diffi-

cult the situation had become for the team, as well. He

explained that when all could agree that, sadly, the time

had come to shift Mrs. C’s care to a plan focused exclu-

sively on her comfort and letting nature take its course,

two family members at a time would be allowed into

the hospital to say their good-byes. Communicating the

distressing aspects of Mrs. C’s situation as also affect-

ing the team resonated with the family. The next day,

the husband called and requested firm recommenda-

tions from the ICU team, resulting in a change in status

to Do Not Resuscitate (DNR) and a no-escalation order.

The patient continued to deteriorate, and two days

later the ICU team called the husband, telling him that

he and the patient’s children should come in if they felt

they needed to do so. The team explained that the pa-

tient’s blood pressure was becoming unstable and that

they believed the patient was now actively dying. The

family decided, however, that it would be too much for

them. Because the patient had been transferred, the

family now lived many hours away. It was unrealistic

for them to make the trip.

The attending, with deep compassion, emphatically

but gently assured the family that the patient would die

comfortably which she did only a few hours later.

Thus, by being very careful not to rush the husband or

force him to explicitly agree to remove the patient’s life

-support, these sad conversations were allowed to pro-

gress at a pace that carefully brought the family along.

By simply explaining to the family – and not asking

anything of them – that it would not be in the patient’s

best interest to pound on her chest and likely break her

ribs when her heart stops, the terrible implications

could be processed appropriately by the family. By

taking an unhurried approach, the attending guided this

bereft, physically separated family, through an end-of-

life process in which the family could feel that the deci-

sion-making had been shared.

Because this husband didn’t feel rushed, he was able to

trust the ICU team to facilitate a peaceful death for his

wife. The hospital chaplain was summoned. The tech-

nology was arranged so the hospital chaplain and the

family could pray together. With tranquil music play-

ing, the patient died, a nurse holding her hand as she

slipped away.

Once a COVID-19 positive patient enters a hospi-

tal, and viral spread mitigation policies separate pa-

tients and families, it is critically important that physi-

cians be skilled at having end-of-life conversations with

families that do not insist that they make decisions to

shift to comfort measures only. Skill in these difficult

conversations at the highest level is demonstrated when

physicians bring families along gradually. Only this

allows families to feel that their beloved family mem-

ber died in peace, a feeling of comfort to survivors of

this terrible pandemic.

ETHICAL ISSUES

Navigating Shifts in Shared Decision-Making For families and surrogates of patients suffering from

COVID-19, the pandemic has made nearly impossible

the ability to see their loved ones in the hospital day-to-

day. Combined with media coverage exalting the ef-

forts and expertise of first-line providers donned in

PPE, the balance of power that the movement of shared

decision-making has sought may be more off-kilter.

Families and surrogates may now be more hesitant to

voice their preferences and concerns, or mistrust of the

medical profession on the part of members of the public

that may simmer under the surface under ordinary con-

ditions, may be quicker than usual to boil over. Both

extremes may compromise the spirit of shared decision-

making in medicine.1 Hence, with families absent, pro-

viders may find it necessary to adopt a more clinician-

directed approach to decision-making.

In cases where the family or surrogate do assert

decision-making via substituted judgment, without the

ability to visually appreciate the severity of their loved

one’s illness, families may be inclined to request non-

beneficial and/or excessive treatments, propagated by

unrealistic hopes of recovery. Therefore, a cycle of non

-beneficial treatment and unrealistic hope may perpetu-

ate, leaving providers in a quandary and possibly ex-

posing patients to unnecessary pain and/or suffering

with the continued use of life-extending technologies

that are not providing clinically meaningful benefit.

The family in this case initially adopted a stance of

unrealistic hope, requesting aggressive life-sustaining

therapy. However, once the family recognized that the

physician and nurses were the few people able to see

and touch the patient, and because the clinicians updat-

ed the family without asking removal of life-extending

technology, the family hesitantly but increasingly built

92 Journal of Hospital Ethics

a trusting relationship with the doctor and nurses. This

shift in trust empowered the provider to frame decision

-making and information sharing in a more clinician-

directed manner while at the same time elucidating and

honoring the family’s wishes and values.

Shared Decision-Making and End-of-Life Discus-

sions via Telephone or Videoconference

Because of the virus mitigation, visitor restriction poli-

cies, ICU physicians are experiencing the challenges of

shared decision-making via virtual medicine. Mortality

in patients requiring mechanical ventilation due to

complications from COVID-19 has been reported to be

as high as 76% and 97% in patients under and over age

65, respectively, making remote end-of-life discussions

an increasingly common occurrence.2

Updating families or delivering bad news over

virtual communication raises concerns about the situa-

tion or environment the recipient is in to engage in crit-

ical care discussions. Virtual communication places

inherent constraints on a provider’s ability to judge

family or surrogate’s emotional states or reactions re-

garding the information being conveyed. Monden,

Gentry, and Cox outline five phases for effectively de-

livering bad news: preparation, information acquisition,

information sharing, information reception, and re-

sponse.3 However, on the virtual platform, ability to

manage these communications may be jeopardized.

Without knowing the exact situation or environment in

which the information will be received, and without

being able to anticipate, witness, and respond to emo-

tional responses, the provider can never feel fully pre-

pared for a conversation, or anticipate the outcome.

Following-up with a patient’s family after end-of-life

discussions begin may sometimes require numerous

requests to communicate virtually in a short span of

time, possibly intruding or infringing on the family’s

personal space and risking deterioration in clinician

rapport with family. Thus, it can be emotionally taxing

for both family and the providers to hold conversations

about illness, death, and dying on a virtual platform.

In the absence of family at bedside, it is incumbent

upon providers to be circumspect about how clinician-

directed their actions can and should be.4 They should

be aware of the inherent limitations of communicating

virtually and make every effort to engage the patient,

family, or surrogate early, just as they should if they

were present at the bedside. On the other hand, when

the patient, family, or surrogate look to the provider to

take on a more unilateral role given family absence, the

clinicians should accept that responsibility. Kon and

colleagues described a sliding scale of shared decision-

making which allows an ethically supportable shift

towards a more clinician-directed approach to decision-

making when patients and families prefer such an ap-

proach.5 If agreed upon, this approach may prove valu-

able in guiding providers and families struggling to

navigate complicated situations and end-of-life deci-

sions imposed by the COVID-19 pandemic.

RECOMMENDATIONS 1. Before any conversation with the family and the

physicians, please give the family time to see and talk

to the patient through use of video technology.

2. During the provider/family conversation, rather than

asking the family what they know (and put them

through the stress of being put on the spot), know

ahead of time what the patient’s condition was when

the team updated the family last and start from there.

3. Ask, “Is there anything that I just said that is differ-

ent from your understanding?” – and allow enough

silent time for more timid family members to speak-up.

4. Then update the family as to the patient’s status.

5. When finished, please ask if the family has any ques-

tions or concerns so far – again, allowing for enough

silence to give family members time to speak-up.

6. Then move – slowly and gently – to a factual, neutral

presentation of what is the best expectation of the treat-

ing team.

7. Finally, proceed with team recommendations.

REASONING

The recommendations are written as they are to assist

clinicians in developing a rapport and trusting relation-

ship with a family whom the team has never met, and

whom can only come into the hospital when they have

agreed not to contest a shift to a ‘no-escalation’ or a

comfort measures only plan of care. This is an incredi-

bly difficult task. And there is little or no help for

scripting busy and exhausted clinicians who are trying

to have what, under ordinary circumstances, are among

the most difficult conversations to have with families.

These difficult conversations have now been made ex-

cruciatingly more difficult because they are being con-

ducted remotely.

There is an emerging literature on how COVID-19

is providing the impetus for medical schools to expand

their curricula related to telemedicine communication

skills.6, 7 There appears to be a focused and promising

effort on the part of a Canadian group of family prac-

tice physicians to develop an approach to separating the

concepts of physical distancing and social connected-

ness built on well-established understanding of rela-

tionships as the drivers of healing.8 Scripted assistance

for ICU physicians, however, working to come to a

shared decision remotely with families about capping

or withdrawing life-extending technologies is not yet

available.

Like so many in the acute hospital setting, clinical

ethicists are learning as this pandemic progresses.

Journal of Hospital Ethics 93

What is certain is that processes for engaging in shared

decision-making will look quite different post-

pandemic than they did pre-pandemic. The pandemic

will almost certainly change how ICU physicians com-

municate with patients and/or families at the end of life.

AUTHORS

Lynette Cederquist, MD is a Clinical Professor of Medicine

in the Department of Medicine, the Division of General Inter-

nal Medicine at the University of California, San Diego. She

serves as the Director of Clinical Ethics program at UCSD

Health and oversees the hospitals’ Ethics consultation service

as well as Chairs the Hospital Ethics Committee.

Biren Kamdar, MD is an Associate Professor of Medicine in

the Division of Pulmonary, Critical Care and Sleep Medicine

at the University of California, San Diego. He is an intensivist

focused on improving outcomes in the ICU, in particular

designing and implementing interventions to improve sleep

and delirium in critically ill patients.

Alex Quan is a practicing EMT-B and a current senior at

Santa Clara University, studying neuroscience, art history,

and philosophy. He is the 2020-21 Honzel Fellow at the

Markkula Center for Applied Ethics

REFERENCES

1. Agbadje TT, Elidor H, Perin MS, Adekpedjou R, Legare F.

Towards a taxonomy of behavior change techniques for pro-

moting shared decision making. Implementation Science.

2020, 15:67.

2. Richardson S, Hirsch JS, Narasimhan M, et al. Presenting

Characteristics, Comorbidities, and Outcomes Among 5700

Patients Hospitalized With COVID-19 in the New York City

Area. JAMA. April 2020. doi:10.1001/jama.2020.6775.

3. Monden KR, Gentry L, Cox TR. Delivering bad news to

patients. Proc (Baylor Univ. Med Center) . 2016;29(1):101-

102.

4. Westaphal GA, Ramos J. Shared decision-making in the

context of COVID-19. Rev Bras Ter Intensiva. 2020;32

(2):200-202.

5. Kon AA, Davidson JE, Morrison W, et al. Shared Decision

Making in ICUs: An American College of Critical Care Med-

icine and American Thoracic Society Policy Statement. Crit

Care Med. 2016;44(1):188-201.

6. Jumreornvong O, Yang E, Race J, Appel J. Telemedicine

and medical education in the age of COVID-19. Academic

Medicine. 2020. Doi:10.1097/ACM. 0000000000003711/

7. Newcomb AB, Duval M, Bachman S, Mohess D, Dort J,

Kapadia MR. Building rapport and earning the surgical pa-

tient’s trust in the era of social distancing: teaching Patient-

centered communication during video conference encounters

to medical students. Journal of Surgical Education. https://

doi.org/10.1016/j. jsurg. 2020.06.018.

8. Bergman D, Bethell C, Gombojav N, Hassink S, Stange

KC. Physical distancing with social connectedness. Ann

Fam Med 2020;18:272-277.

94 Journal of Hospital Ethics

When Extracorporeal Mechanical Oxygenation

Needs to be Turned Off The Editorial Group of the John J. Lynch, MD Center for Ethics Case Complexity: 1 2 3 4

Erica Samson was an otherwise healthy 20-year-old

college student when she contracted the coronavirus.

She was home, taking college classes remotely, when

she started not feeling well. Within days, she could

hardly breathe and was taken to her closest hospital,

where she was quickly put on a ventilator. After sever-

al days went by, she was not only not getting better, but

she was getting worse.

Her intensive care unit (ICU) team was puzzled

until Erica’s mother told them that as a child she had

had asthma on and off. It had been so long ago and so

mild that her mother, in her upset about how quickly

Erica had gotten so sick, had just completely forgotten.

Now that they had an answer for why her lungs were

not improving, they flew Erica to the regional, tertiary

care center with the expectation of putting her on

ECMO. ECMO stands for extracorporeal mechanical

oxygenation and is the most sophisticated machinery

that could help Erica.

ECMO is designed to give a patient’s lungs a rest;

essentially taking over for the patient’s lungs until they

are sufficiently better to be able to resume their natural

function. ECMO is not a treatment, per se. It is a high-

ly sophisticated life-extending technology designed to

take over for a patient’s lungs (or if needed, heart, or

heart and lungs), until the lungs can again take over the

job of breathing for the patient.

After weeks on ECMO, however, Erica was not

improving. The hospital’s multidisciplinary team was

concerned that Erica was not going to make it. She was

no longer capacitated as she was becoming increasingly

lethargic. The multidisciplinary team agreed it was

time to start talking to Erica’s mother (her only family

member; her father had always been absent and she had

no siblings) about turning the ECMO machine off.

As part of the ECMO consenting process, which

Erica was a part of and in which her mother was also

involved (at Erica’s request), the consent includes lan-

guage that this would be a medical decision, i.e., the

decision to turn ECMO off if it is not helping the pa-

tient any longer. When that decision is made because a

patient has improved enough to breathe on their own,

everyone is just happy and ordinarily doesn’t question

the medical decision. But when things are going badly,

so that the ECMO machine is not helping and it is time

to allow the patient’s care to be shifted to comfort

measures only, problems often arise.

That is because unlike most other life-extending

technologies, when one option isn’t working, there’s

usually something else to try. ECMO, however, is the

end of the road. There is no other path than comfort

measures only when ECMO needs to be turned off be-

cause it no longer is providing the ‘resting’ benefit for

which it is designed. On a rare occasion, even when it

is assessed that the patient will die when ECMO is

turned off, an extraordinary patient may be able to

sustain themselves, but usually not. Usually, turning

the ECMO machine off means certain death for the

patient.

Needless to say, although a consent may say turn-

ing ECMO off is a strictly medical decision, these deci-

sions are never made in a vacuum. In Erica’s case, her

PRESENTATION

Journal of Hospital Ethics 95

mother has been a loving presence since she arrived.

And now, understandably unable to face the prospect

that she could lose her only daughter, a child who only

12 weeks ago was a healthy, happy college student, she

is beginning to fight with the team as they begin these

discussions.

At Erica’s hospital, every time a patient goes on

ECMO, one of the hospital’s clinical ethicists is con-

sulted, so the general ethical issues here are premised in

the ECMO assignment. The clinical ethicist participates

in the weekly, multidisciplinary ECMO rounds. It is

now time for Erica’s clinical ethicist to formalize her

recommendations to the team.

RECOMMENDATIONS

1. Ethics recommends that the patient’s attending and

primary nurse begin meeting with the patient’s mother

every day (rather than once a week) to discuss Erica’s

clinical status.

2. Ethics recommends that when the attending and pri-

mary nurse meets with the patient’s mother, the pa-

tient’s mother be given a particular set of conditions to

monitor that would indicate improvement in Erica.

3. Ethics recommends that when the attending and pri-

mary nurse meets with the patient’s mother, in addition

to identifying specifics in Erica’s condition to monitor

that the mother be given a time trial of how long to be

watching for improvement in the specified clinical con-

ditions.

4. Ethics recommends that the hospital’s spiritual care

department assign someone who already knows the

patient’s mother to join her for some part of her vigil

each day. That is, in addition to the spiritual care sup-

port the patient’s mother has been receiving from the

palliative care team.

REASONING

The tragedy of losing a previously healthy, happy col-

lege student is felt well outside the confines of the ICU

on which this ECMO patient resides. Because this is a

large (900+ bed), Level 1 Trauma, Tertiary Care Cen-

ter, there are multiple ICUs and the nurses who are

trained at the level of practice in these units, along with

the comparable physicians, cover multiple units and

take Erica with them in their hearts as they practice

throughout the hospital. Losing such a previously vital,

healthy young person can be among the worst deaths in

an adult hospital. Although that might smack of age-

ism, because most of the deaths are of older adults, it is

a natural reaction for which clinicians can not be fault-

ed. Only if decision-making for a young patient is

qualitatively different from other, older patients, could

one hold such clinicians at fault. Clinicians are hu-

mans, too, who have children and aunts and uncles and

grandparents of their own.

In Erica’s case, there have been no problems, such

as leaving her on ECMO past when her clinical status

would call for turning the ECMO machine off. The

team is doing their best to work with the patient’s

mother to get her prepared for the time when it should

be. But even now, the tug-of-war is brewing.

One of the reasons is that a decision to place a pa-

tient on ECMO is often made under emergent or emer-

gency conditions. While true that informed consent is

often rushed and those consenting are distracted and

frightened so that the complexities of a high-tech res-

cue intervention are difficult to grasp, ECMO is a par-

ticularly complex intervention to explain under high

stress conditions, especially because its utility in pa-

tients with COVID-19 is scant.1 Although the Extra-

corporeal Life Support Organization (ELSO) is track-

ing all patients with coronavirus who are put on ECMO

world-wide, ELSO does not have sufficient data so far

to make a recommendation either for or against placing

patients with COVID-19 on ECMO. And of the data

extant, the findings are grim. Of the published data to

date, most report out 100% mortality or close to it.2-4

Given, however, that data show an improving picture 5

and it represents the last-ditch effort for these patients,

clinicians are more likely than not to give it a try if the

patient approximates eligibility.

The reason that there is some expectation of suc-

cess is that ECMO has been shown to be useful in acute

respiratory distress syndrome (ARDS) due to other

viral infections. They include influenza A (H1N1) and

SARS-MERS viruses.6, 7 So for now, ECMO holds out

the last possibility for saving many lives ravaged by

COVID-19.

Unfortunately, right from the beginning, preparing

patients and families for the worst news starts off by

using therapeutic terminology that confuses things,

tipping expectations in likely the wrong direction. As

previously noted, ECMO is not, technically, a therapy.

The common sense understanding of a therapy is that it

is a medical intervention designed to cure or ameliorate

a disease process. ECMO is a rescue technology de-

signed to take over for the lungs, but it won’t repair

them. It is not an intervention that will in any way treat

the underlying disease. But therapeutic language is of-

ten applied to ECMO obscuring its actual technical

function. Although the clinicians using ECMO under-

stand this distinction, it is ordinarily lost on the non-

clinician patient and family members.

Second, ECMO presents another ethical problem,

also previously mentioned. That is there is no alterna-

tive to ECMO. If ECMO doesn’t work, there is noth-

ing more to try.

96 Journal of Hospital Ethics

For example, if a patient is on a ventilator so long

that it needs to be removed before it increases the like-

lihood of complications well beyond the normal com-

plication rate of being critically ill on a ventilator, there

are two choices: the patient can be shifted to comfort

measures only, with the tube removed, being what is

colloquially referred to as ‘terminally extubated’. Or, a

patient can have a tracheostomy to continue mechani-

cally supported breathing, colloquially referred to as

having a trach, and a percutaneous endoscopic gastros-

tomy, which is a feeding tube, colloquially referred to

as a ‘peg’, and then be transferred to a lower level facil-

ity to see if over time these interventions will help the

patient improve. There is no comparable example with

ECMO. ECMO is the end of the line.

Thus, when it was becoming clear to Erica’s doc-

tors and nurses that she was not improving; that her

lungs were just as bad or worse than when she arrived,

it was time to start preparing her mother. But how does

one prepare a mother for a daughter’s death? Such

death is out of season. Some say the worst thing that

can happen in one’s life is to out-live one’s children.

Nevertheless, the discussions had to start. Erica

could not be supported indefinitely on ECMO. If she

were, ultimately one could expect her fingers and toes

to necrose because of all the pressors, medications to

keep her blood pressure up, that she was required to

take. Common complications of ECMO are blood

clots, which can occur anywhere in the body, break off

and travel to the brain causing a stroke. Little by little,

if she wasn’t going to get better, she would ultimately

die on ECMO, which is not an easy death.

And of course, that’s what happened. Each day

Erica’s mother would negotiate with the team for a

little more time, and then just a little more, until Erica

suffered a cerebral hemorrhage. Days after that, Eri-

ca’s mother agreed to turn the ECMO machine off. She

was not angry at the team; she appreciated how hard

they worked; how hard they tried — COVID-19 is just

a terrible disease and ECMO is an imperfect rescue

technology. Perhaps when the pandemic is over and

the review articles are all written, it will be seen that

either criteria for ECMO eligibility will need revision.

Perhaps ECMO is more like most innovative technolo-

gies in that many of the initial patients for whom it is

used end up dying or resulting in unanticipated clinical

outcomes. But, as time goes on, and the ethical dimen-

sions of ECMO technology when applied to COVID-19

continue to be assessed, what we can hopefully expect

are appropriate regulations being developed and imple-

mented, so as to better condition the outcomes of pa-

tients like Erica.

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Journal of Hospital Ethics 97

Inpatient Psychiatry in a Pandemic:

The Organization and The Individual Christian Carrozzo, PhD (c) Case Complexity: 1 2 3 4

Mr. King is a 27-year-old male currently admitted to

the psychiatric inpatient unit at a major urban hospital

during the coronavirus pandemic. Although typically

well-managed, Mr. King suffers from schizophrenia

and has often refused to maintain his prescription regi-

men. A recent incident in which, while not medicated,

Mr. King was found about 20 blocks from his apart-

ment loudly and aggressively expressing profanities to

both people and statues of a local church at 6 o’clock in

the morning, resulted in his arrest by the police who

were quick to bring him to the hospital on a legally

justified involuntary admission for psychiatric evalua-

tion. After Mr. King’s psych evaluation, which deter-

mined the need to hospitalize him and begin a medica-

tion regimen that would ultimately return Mr. King to a

behavioral baseline that merits his safe discharge, he

was additionally tested for COVID-19. Mr. King’s test

returned a positive result for coronavirus infection.

Given his COVID-19 diagnosis, Mr. King has now

been involuntarily admitted to a special unit in the hos-

pital separate from the standard psychiatric unit that is

equipped to care for the often complex medical aspects

of COVID-19 patients, while also with psychiatric sup-

port staff and a consult liaison service. Although he is

hardly compliant with his medication, the most signifi-

cant challenge remains for him to consistently attend to

his own personal protective equipment (PPE), denying

that he is COVID positive, pulling and tugging at his

masks, sometimes ripping them off entirely, or simply

losing them in the open, common areas of the unit. In

terms of immediate safety concerns, although Mr. King

is not displaying in any way violent or aggressive be-

havior, the inpatient unit staff is well aware of the sta-

tistics surrounding COVID-19 transmission within the

psychiatric patient community when such patients are

suffering from functionally debilitating illnesses that

create significant barriers to the self-care required for

patients and staff to remain protected from transmis-

sion.1, 2

Often, the standard practice in this type of general

circumstance is to consider an emergent intervention

(one that would not require Mr. King’s consent) given

the safety risks he is presenting by being irresponsible

with his mask. However, this particular unit has relaxed

this protocol in light of so many patients experiencing

difficulty with their PPE, making it a difficult standard

to maintain. Mr. King would have to be displaying the

sort of aggressive behavior that put himself or others in

immediate danger, prior to this particular unit likely

deciding that emergent medication would be justified.

Several conversations were held with department

leadership over the possibility of demarcating a section

of the unit that could be devoted to COVID-19 positive

patients, exclusively. The idea being, a devoted unit

could both relieve the special medical unit from the

challenges and concerns about proper care associated

with isolating psychiatric patients like Mr. King in spe-

cial medical units with some psych support but perhaps

not best equipped to manage the psychiatric care of

COVID-19 patients, safely. Dr. Torrance, the depart-

ment chief, has been researching about similar efforts,3

and believes this to be a worthwhile project that could

PRESENTATION

98 Journal of Hospital Ethics

potentially save lives while creating a therapeutically

conducive environment for COVID-19 psychiatric pa-

tients experiencing behavioral difficulties similar to Mr.

King. It happens to be the case that the hospital system

is state-certified for 237 beds, of which only 217 are

currently in operation, allowing the department to des-

ignate 20 beds for a stand-alone secondary unit for

COVID-19 positive patients. Beyond a medical unit

focused on COVID-19 that is merely prepared to han-

dle some psychiatric support, the COVID-19 psychiat-

ric unit would be equipped with medical and psychiat-

ric nurses, psychiatric and family-practice attending

physicians, a psychiatric nurse practitioner, as well as a

social worker.

Next steps would involve the selection of patients

who would be transferred to this unit. Those psychiatric

patients who are experiencing quite severe symptoms

related to COVID-19 would nevertheless remain in the

original special medical unit, since management of

their COVID-19 disease would be considered a priority

over adjustments or compromises to their psychiatric

care. Those psychiatric patients with less severe or no

symptoms related to their COVID positive status, so as

to not require special medical management of their

COVID-19 disease, would be moved to the new

COVID positive psychiatric unit.

Dr. Torrance decides that Mr. King’s symptoms

are subtle enough to be considered for the new unit and

decides to speak to Mr. King about transferring. When

Dr. Torrance explains to Mr. King that the new unit

will be further isolated from the special medical unit he

was previously in, as well as the medical side of the

hospital, Mr. King becomes agitated, expressing that he

is not COVID positive and that his freedom has already

been violated, therefore he will not be moving to yet

another, even more isolated unit, where he “will most

definitely get COVID from all those sick people”. Mr.

King goes on to express that the only place he needs to

go is “home”, and repeats that he is not COVID posi-

tive.

Dr. Torrance is now at a loss – the difficulties be-

ing experienced by the special medical unit, including

the trouble with Mr. King’s psychiatric condition great-

ly affecting his beliefs as to his infection and thus his

commitment and/or ability to appropriately wear a

mask, as well as adhere to other safety precautions that

are in place given the pandemic, were to be solved by

the COVID positive psychiatric unit, so long as the

COVID positive patients were able to be transferred.

Mr. King’s unsafe behavior is simply too great a trans-

mission risk for the other patients in the special medical

unit, unless a panel is convened to perhaps consider

medication against objection (MAO), sufficient to

transfer him to what the department would now consid-

er the most appropriate unit.

Dr. Torrance, in the excitement of developing a

new COVID positive psychiatric unit is now consider-

ing whether the entire project should be discarded giv-

en situations like that of Mr. King’s, or if there is some

way to maintain safety, the appropriate psychiatric and

COVID-related care of individuals like Mr. King, and

continue the project for the long-term good it will bring

the hospital. Dr. Torrance contacts the clinical bioethics

department for an analysis regarding his next move.

ETHICAL ISSUES

This case presents a variety of factors that could each

contribute to distinct ethical considerations. Dr. Tor-

rance’s question to the bioethics consultant is whether a

move to medicate against objection can be supported,

given that partly its motivation is to demonstrate a suc-

cessful project and thus safeguarding the COVID posi-

tive unit as a worthwhile venture. Although an im-

provement in the general quality of psychiatric care Mr.

King would be receiving in the COVID positive unit

could be argued as justifying a move for MAO, there

are various particular psychiatric considerations that

could make the situation worse from the patient’s point

of view, and, at the end of the day, the transfer is not

absolutely necessary, any more than the creation of a

COVID positive psych unit is ‘necessary’, should the

original special medical unit be better prepared to man-

age patients who require isolation.

RECOMMENDATIONS

1. Consider joint meeting of Mr. King’s psychiatric

care team to discuss and evaluate Mr. King’s condition

as one that would indicate a MAO panel be convened.

The primary considerations here ought to be whether

the patient lacks decision-making capacity in relation to

an understanding of his mental health and the reasoning

behind the prescriptions being recommended, and

whether there are legitimate concerns over safety in

terms of Mr. King either harming himself or others, not

whether a failure to successfully transfer Mr. King to

the COVID positive inpatient psychiatric unit (IPU)

will affect the project’s longevity. The benefits of the

unit as understood by the psychiatric department should

be presented to leadership with the realistic possibility

of having to manage situations similar to this with the

potential management of future COVID positive, invol-

untary, patients to the new unit.

2. Consider that newly admitted COVID positive inpa-

tients could be taken directly to the new unit, i.e., the

problem of transfer from a special medical unit might

be a temporary one. This makes the problem with trans-

ferring Mr. King appear more circumstantial and lim-

ited, thus perhaps not a concern for future admitted

patients, but from this assessment it does not follow

Journal of Hospital Ethics 99

that a circumvention of his autonomy is appropriate as

simply a matter of managing the new COVID positive

psych unit’s ‘growing pains’.

3. Consistent with hospital policy, if a MAO panel is

suggested by the team given appropriate assessments of

capacity and safety, a patient advocate should accom-

pany the team to assess the nature of Mr. King’s beliefs

and his degree of psychosis as justifiably unsafe in

terms of potential harm to himself or others, allowing

him one last opportunity to willfully take his medica-

tion before moving to an IM drug administered against

his will that would permit his physical transfer to the

new unit. A bioethicist can serve as patient advocate,

however, will retain neutrality in their analysis of the

reasoning and values at play.

REASONING

An ethicist should carefully distinguish each factor for

its relevance to the question being asked by Dr. Tor-

rance. That question being, in light of the circumstanc-

es, should a MAO panel be convened, simply to medi-

cate Mr. King sufficiently to transfer him without issue

to the new COVID positive psych unit. One considera-

tion is how this might affect his psychiatric condition

should he suddenly realize he has been placed in a unit

with nothing but COVID positive patients, while under

the false belief that he has not contracted the virus. A

capacity assessment in terms of Mr. King’s inability to

rationally comprehend his circumstances might be

straightforward in this case, but the safety component

to justifying an intervention against objection, let alone

an emergent intervention that requires no additional

justification, is not entirely clear.

The careful management of this situation also con-

tains an organizational component: how well this new

COVID positive psychiatric unit functions will signal

to system leadership as to whether the project can con-

tinue to be supported, something the psychiatric physi-

cians and staff of the hospital believe, despite an occa-

sional challenge, will be incredibly beneficial to the

hospital’s psychiatric inpatient community in the short-

as well as long-term. Many issues could also be as-

sessed as growing pains for the new unit; issues that

will systemically dissolve once the unit is in full opera-

tion.

Even if the organizational considerations are not

sufficient to reasonably suggest MAO on an individual

person, it could be that attending to the good of the

individual from the perspective of his psychiatric ill-

ness and the safety of himself and those around him, in

this case will itself also result in support for the project

going forward. As listed in the recommendations, the

COVID positive psych unit project should be presented

transparently for all its potential good as well as its

challenges. A sober view of the benefits of any endeav-

or will likely include estimations of its more complex

features when implemented. Support for the project

will likely be stronger when presented as a project-in-

development, than if presented as prepared to solve all

safety issues while finding itself stumped at the first

transfer.

AUTHOR

Christian Carrozzo, PhD (c) is Founder of the Program for

Neuroethics and Clinical Consciousness, Faculty for the De-

partment of Psychiatry, and Senior Editor to the Journal of

Hospital Ethics at the John J. Lynch, MD Center for Ethics,

MedStar Health. Carrozzo was named Distinguished Alum-

nus in Philosophy, College of Humanities and Social Scienc-

es, George Mason University, and is a Doctoral Candidate in

Philosophy at the University at Albany, State University of

New York.

ACKNOWLEDGEMENT

This case was presented for discussion at the Psychiatric Eth-

ics Conference, MedStar Washington Hospital Center, March

5th, 2021. Special thanks to the Department of Psychiatry for

their insightful comments and suggestions on an earlier draft

of this article.

REFERENCES

1. London, Stephanie. "COVID-19, Autonomy, and the Inpa-

tient Psychiatric Unit." Academic Psychiatry 44, no. 6 (2020):

671-672.

2. Druss, Benjamin G. "Addressing the COVID-19 pandemic

in populations with serious mental illness." JAMA psychiatry

77, no. 9 (2020): 891-892.

3. Augenstein, Tara M., W. R. Pigeon, S. K. DiGiovanni, K.

P. Brazill, T. E. Olivares, C. Farley-Toombs, H. B. Lee, and

M. N. Wittink. "Creating a novel inpatient psychiatric unit

with integrated medical support for patients with COVID-19."

NEJM Catalyst Innovations in Care Delivery (2020). DOI:

10.1056/CAT.20.0249

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