As the COVID-19 crisis deepens, healthcare providers wonder what lethal risk they should be asked to take

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The 1922 version of the Canadian Medical Association’s code of ethics was straightforward and unequivocal. “When the plague prevails, it is their duty (as doctors) to face the danger and to continue their efforts to relieve the suffering, even at the risk of their own lives.”

The request “even in danger of death” was deleted when the next revision was published four years later. The plague of COVID-19 begs the question: what lethal risk should we ask doctors and other healthcare providers to take?

In New York, “doctors are getting sick everywhere,” William P. Jaquis, president of the American College of Emergency Physicians, told the New York Times. Two nurses from New York have already died. In Italy, where hospital systems are on the verge of total collapse, 4,824 health workers had been infected with the virus as of March 22; 61 doctors died, including 40 in Lombardy, the most affected region in Italy.

What lethal risk should we ask doctors and other healthcare providers to take?

As the intensive care units began to fill up, doctors began to isolate themselves to avoid bringing COVID-19 home. There is a current of low level anxiety as doctors and nurses are faced with the two most pressing concerns facing the system today: the prospect of having to severely ration personal protective equipment (PPE) and mechanical fans.

“There are places that are missing, there are decisions that are made because we don’t have the supply, period. Right now, nobody has a complete understanding, a Canadian understanding of the amount of PPE in stock at each facility, ”said Dr. Andrew Morris, infectious disease specialist at Sinai Health System and University Health Network from Toronto.

Staff are already using cell phones and monitors to communicate with unvented COVID-19 patients to limit face-to-face contact and slow the “burn rate” – the amount of PPE they burn each time whether they snuggle up, wear gloves or put on masks to talk to a patient.

“For every patient who uses a ventilator, for every day, you talk somewhere in the order of hundreds of pieces of PPE when you add the gowns, the gloves, the masks,” said Morris.

“When the Prime Minister says they have all this supply coming, how is it going to be distributed? How will they understand where the need is? They have no idea because no one has done this job, “said Morris. “We started this work here; we are working on it frantically to understand it. “

The federal government has placed orders with various companies for 157 million surgical masks, 60 million N95 masks and 1,570 respirators, and plans to order another 4,000, according to the Minister of Public Services and Procurement, Anita Anand.

Right now, wherever people try to balance the need to protect health care workers with the need to protect supply. But some doctors, as well as nurses, ask: do they have an obligation, a duty to care, in the face of a shortage of supplies and equipment?

According to the Canadian Medical Protective Association, the powerful body that provides legal defense to doctors across the country: “Doctors may be allowed in exceptional circumstances to refuse to practice if they reasonably believe that the work environment is dangerous unacceptable legitimate that is not inherent in their ordinary work. ”

A robot operated by medical teams helps treat patients suffering from COVID-19 at Circolo Hospital in Varese, Italy.


Flavio Lo Scalzo / Reuters

Although refusal to work due to inadequate equipment may put a doctor at risk of hospitalization or college authorization, hospitals generally have an obligation to provide a safe work environment, said the CMPA.

Doctors are also concerned about legal or ethical issues surrounding the decisions they may face in the near future, such as who receives treatment and who should die if ventilators and intensive care beds become in high demand. “As always, members should document the rationale for their decisions in crisis situations to help with medico-legal difficulties,” said the CMPA guide.

When a person’s breathing deteriorates to the point of having to be attached to a ventilator, there is a brief window “during which they can be saved,” reads an article published this week in the New England Journal of Medicine. Remove the fan and the person usually dies within a few minutes. “Unlike decisions about other forms of life-sustaining therapy, the decision to initiate or stop mechanical ventilation is often a life and death choice. “

Ontario and other provinces are developing criteria for rationing critical care – how to save the most lives? Should the young take precedence over the old? How long do we give someone to recover before withdrawing life support? Three days? Seven? Italian reports describe doctors crying in the corridors. “The anxiety clinicians may feel when asked to remove ventilators for reasons unrelated to the well-being of their patients should not be underestimated – it can lead to debilitating and disabling distress for some clinicians, ”wrote the authors of the NEJM article.

In Canada, the most immediate concern is the shrinking supply of protective equipment. “(The doctors) have questions about the reuse of protective equipment, questions about what is appropriate regarding the use of homemade equipment,” said Dr. Todd Watkins, associate executive director of the CMPA.

Doctors can refuse to work if they reasonably believe that the environment creates an unacceptable risk, just as a firefighter should not run into a burning building without safety equipment.

“Doctors cannot refuse to see sick or infected patients, but one would expect them to have the right equipment to do their job,” said Watkins.

“And that’s what we tell the doctors, but it doesn’t necessarily go far enough. Because at the end of the day, the building is still burning, patients are still sick and need to be treated, and doctors feel this huge obligation to take care of themselves.

“So this is really putting doctors in a very difficult position, because they are concerned about their patients, they are concerned about their own health. They are concerned about the transmission of the infection to their families. And they are concerned about the asymptomatic spread. “

Medico-legal issues related to rationing care, said Watkins, are secondary. “I think what really worries them is” do I have the guidelines to make the right decisions and do I have the support structure to make an unthinkable decision to ration two patients and a ventilator. “

“What they are looking for now is really advice, standards on how to make these decisions if they are forced to do so. “

Some American doctors worry about the duty of care without adequate protective equipment. “My friends from Italy and Spain did not seem to struggle with that much,” said Dr. Anand Kumar, a critical care doctor in Winnipeg. In Canada, “we are a little less focused on individual well-being here and more connected to the social contract where we take care of each other,” said Kumar. “I just think Canadian doctors will be less likely to consider staying at home if help is needed on the front lines of this battle.”

When SARS struck in 2003, doctors and other healthcare professionals were confronted, as they are now, with a mysterious coronavirus of unknown origin for which there was no known cure or cure. In Toronto, two nurses and a doctor died. While health workers generally displayed “heroism and selflessness,” according to a 2005 report from the Joint Center for Bioethics at the University of Toronto, some resisted the care of those infected; others refused to report for work. But what risk should we have asked them to take? “There is currently a vacuum in this area,” wrote Dr. Ross Upshur and his co-authors.

Doctors treat COVID-19 patients in an intensive care unit in Rome, Italy.


Antonio Masiello / Getty Images

“Due diligence was a problem in SARS,” said Upshur, who also chaired a World Health Organization task force on pandemic duty and published numerous articles on the subject. “The question of whether you should be prepared to provide care only if you have access to personal protective equipment is an interesting one,” said Upshur.

For millennia, doctors have provided care without any PPE, he said. COVID-19 is a global pandemic, “and the sad fact is that in most health systems around the world, doctors, nurses and health care providers have limited access to no personal protective equipment,” a said Upshur. Many health centers around the world have no running water or soap.

“Our colleagues in low- and middle-income countries and very underdeveloped health care systems do not have the protections afforded us in high-income countries, and they show up for work.”

But the supply of doctors is not unlimited, he said. What happens if a large number of doctors fall ill and are in quarantine? Canada already lacks 1,000 emergency physicians.

And the doctors know what they signed up for, said Upshur. “If you are entering the health profession, at any level, and you do not know or do not know that you could be exposed to infectious diseases, we have not done our job to prepare people to enter the profession. ” There have been three major viral outbreaks in Canada only since 2003 – SARS, H1N1 in 2009 and now, COVID-19 – “all of which posed a particular risk to health care providers,” said Upshur.

I think all health professionals will have to look in the mirror and ask themselves very difficult questions

“Health professionals face the risks of infectious diseases. It is an integral part of his work. However, the company also has a reciprocal obligation to provide as much protection as possible, he said.

“But what we see and face now are the ideas that we don’t have unlimited resources. And this scarcity then makes ethical questions much more important to settle. But we should have fixed them before that happened. “

“I think all health care professionals are going to have to look in the mirror and ask very difficult questions about why they became doctors and what they see as their obligations to the patients they serve.” “

Doctors are heading for the crisis nearby, said Dr. Sohail Gandhi, president of the Ontario Medical Association. Doctors volunteered for COVID-19 assessment centers and front-line work. “The main concern is” am I doing the right thing for my patients? None of us think of legal concerns first. »»

“We’re all on the wire,” added Morris. “It looks like the Viking ships are on their way, we don’t know how many ships there are, we know that when they arrive, they will loot, destroy. We do not know how much we will be able to repel them.

“We just hope they send only one ship, and we have enough people to fight them. We just don’t know. “

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