B.C.'s front-line health-care workers preparing for a surge of COVID-19 patients have watched their counterparts in other parts of the world make life-or-death decisions to ration care.
It’s not a choice they will have to make alone, if it comes to that here.
The province has provided a decision-making framework around the allocation of scarce resources such as ventilators, “so that no single individual clinician or a health-care worker will have to make those entirely terrible decisions on their own,” Dr. Bonnie Henry, the Provincial Health Officer, explained last week when she announced the plans.
The ethics framework for decision-making does not provide answers on a case-by-case basis, but it lays out what will guide those decisions, if the pandemic drives demand for care beyond the province’s capacity. “Everyone matters equally but not everyone may be treated the same,” it explains.
In a health-care crisis, the delivery of care and services needs to be fair, the document states, but part of that equation is determining who will benefit the most – if there are not enough ventilators to meet demand, for example. “Those who most need and can derive the greatest benefit from resources ought to be offered resources preferentially,” it says. As vividly seen in hospitals in northern Italy, overwhelmed by COVID patients, that can mean that patients with the highest odds of survival will be given ventilation ahead of older or more sickly patients.
“Those guidelines are very, very distressing for all health-care workers,” said Christine Sorensen, president of the BC Nurses’ Union.
“That’s incredibly difficult for a nurse or a doctor to know that we can’t give that same level of care that we have been trained to do,” she said. But individual ethical guidelines between a patient and a caregiver are a different matter than the resource-allocation decisions that may have to be made in a crisis, to best serve the greater population.
In small, regional health facilities in B.C., that’s already a reality, she said.
“We’re seeing these situations already occurring. You know, small sites where nurses are now being told of new procedures on how to make the decision on whether or not that patient gets intubated or not,” she said, referring to the practice of inserting a tube into a patient’s airway so they can be placed on a ventilator to assist with breathing. Most COVID-19 patients who develop critical symptoms require mechanical ventilation.
Eike-Henner Kluge is a leading medical ethicist who established the Canadian Medical Association’s Department of Ethics. Dr. Kluge said B.C.'s ethics framework will ease the challenge facing health-care workers if they are forced to ration care. But it still leaves a crushing weight on their shoulders, because they will have to decide how to apply the guidelines in individual cases. “That’s where the burden really arises and where this is unavoidable, inescapable. And that’s what can lead to burn-out.”
B.C. has also produced duty to care guidelines to deal with another tough issue: The scarcity of personal protective equipment (PPE).
Hospitals across Canada are already rationing PPE because the scale of the pandemic has created global scarcity for masks, gloves and other materials.
How much risk can we ask them to take? Do nurses and doctors and other key health-care workers have to treat patients if they don’t have access to equipment to protect themselves?
Health-care workers “should acknowledge their ethical duty to provide care and understand that this duty remains even when it involves potential exposure to some risk of harm,” the guidelines say.
“However, when an individual health-care worker faces certain and significant harm to their person, such as may be the case in the absence of PPE, that duty may be discharged. This ethical duty is discharged only when the risk of harm to a health-care worker’s person is certain, significant, and cannot be adequately mitigated.”
The province is seeking to ensure that health-care workers have priority access to any PPE it can access now. Dr. Kluge said it is appropriate that we give priority to protecting health-care workers because of the risks they must take to do their job. “When licensed health-care workers enter their profession, they de facto acknowledge this [risk] and accept it," he said.
But we are asking a lot. In return, we have to do everything we can to ensure the health-care system isn’t pushed to the point that nurses and doctors here are forced to make those entirely terrible decisions.
The Globe and Mail
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