Ethics Consultation in COVID Times

Q:  What happens to clinical ethics consultation in a pandemic?

A:  Ethics consultation continues, only more so.

During the first few months of the coronavirus pandemic, with a significantly lower overall inpatient census and fewer providers seeing outpatients, ethics consultation at the University of Kansas Health System (UKHS) increased rather than decreased. Not all of the increase is COVID related. Most consultations reflect issues that arise during normal times as well.

Typical Issues, New Perspectives

Some consultation has been COVID specific, including participation on the UKHS Pandemic Triage Team assisting in preparation of guidelines for allocation of scarce resources under crisis standards of care. If hospital admissions exceed our critical care capacity, who gets an ICU bed? If there is just one ventilator available and two patients need ventilation support, who gets it and who is allowed to die? Or the shortage may be of personnel, or dialysis, or medications. Who decides and how? These are matters of ethics.

Ethics consultation services, both at UKHS and the Center for Practical Bioethics, are always available. Always.

Early in this pandemic situation, we responded to queries about a provider’s duty to care and ethically appropriate exceptions to the rule. Other consultation addressed the need to encourage advance care planning further upstream of arrival at the Emergency Department by patients in COVID-19 crisis. Decisions then may need to be made emergently about resuscitation attempts on a patient who may not have wanted it, or for whom CPR will almost certainly be futile—and riskier also for those who provide it. Heightened risk to providers sometimes spawns awareness of ethics issues. This was discussed at great length most everywhere relative to shortages and conservation of personal protective equipment (PPE).

The UKHS Ethics Consult Service responded recently to several situations of ethics dilemma regarding decisions for patients who also are prisoners. Who decides for a ward of the state? Can the patient’s mother be contacted directly, or only by permission of the warden? Ought we allow prison guards in the COVID “hot zone”? Not all such cases arise as a direct result of a pandemic, but there seemed more of them recently, perhaps with correlation to the inordinately high incidence of coronavirus transmission within incarcerated populations.

Same Process, New Technology

Consult requests can come at all times, pandemic or not, and at all hours of the day and night. Health system ethics consultants typically are happy to respond with ethics assistance at 3 or 4 A.M. even on a holiday weekend, as happens occasionally for this consultant. I might heat up a cup of coffee before picking up the phone to return a call after the Ethics pager has gone off in the wee hours, but it is a privilege to collaborate with resident physicians and night shift nurses on ethical care to patients—whenever need arises.

The UKHS ethics consult service has been carried out during COVID times both virtually and with physical presence in clinical settings. For the most part, we are doing “tele-ethics.” Like tele-health generally, we too make optimal use of confidential email, phone calls, Zoom meetings, and ethics notes posted to the electronic medical record. Some of our consultation team members are considered “essential” healthcare workers in their primary roles of physician, nurse, social worker, or administrator. That has enabled us to offer physical presence at the bedside or on the unit when face-to-face communications are necessary or at least better than virtual only.

Ethics consultation continues during COVID times as it did before this global strangeness began. Pandemic conditions may have put the pause on elective services for a time, but Ethics is never elective. Ethics consultation services, both at UKHS and the Center for Practical Bioethics, are always available. Always.

By Tarris Rosell, PhD, DMin

Dr. Rosell is the Rosemary Flanigan Chair at the Center for Practical Bioethics and  Director of the University of Kansas Health System Ethics Consultation Service and Co-Chair of its Hospital Ethics Committee. He is also the Center for Practical Bioethics’ 2020 Vision to Action Award honoree.