AAN Issues COVID-19 Ethical Guidance for Neurologists

May 27, 2020

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The American Academy of Neurology (AAN) has issued new ethical guidance for neurologists and neuroscience professionals caring for patients during the COVID-19 pandemic.

The position statement was published online May 15 in Neurology.

The position statement was developed by the Ethics, Law, and Humanities Committee, a joint committee of the American Academy of Neurology, American Neurological Association, and Child Neurology Society, in collaboration with the Neurocritical Care Society Ethics Committee.

The authors recommend that people with chronic neurologic disease who need to see their neurologist in non-emergency situations should be offered telehealth appointments to limit potential exposure to COVID-19. 

It recommends that neurologists counsel their patients about how their relative risk of hospitalization and death as a result of COVID-19 infection may be affected by their neurologic condition and its management.

It notes that entering a hospital or outpatient facility may impose a greater risk of infection than normal, even if appropriate precautions are taken. For example, patients on corticosteroids or chronic immunomodulation may be more susceptible to acquiring COVID-19 infection. Even if desired services are available, neurologists and their patients ought to consider whether their care plans can safely be delayed in order to mitigate risk.

For patients with conditions severe enough to warrant hospitalization, such as those with stroke or epilepsy, the AAN states that neurologists must still endeavor to maintain the customary standard of care in this complex, new environment.

The AAN also recommends that neurologists work with their patients to complete advance-care planning documents.

"In the event that hospitals have to triage limited resources, it's possible that people with advanced neurologic disease may not be offered certain elements of lifesaving care, such as ventilators and ICU beds," said lead author Michael A. Rubin, MD, UT Southwestern Medical Center in Dallas, Texas.

"To ensure more control in the treatments they receive, people with advanced disease and their loved ones should discuss with their neurologist how reduced resources may impact their care and communicate their care preferences if they were to become seriously ill."

When resources are scarce, the position statement lists criteria that should be considered when determining how those resources should be allocated, noting that decisions should be based on need, prospect of benefit, best medical evidence, and the balance of personal freedoms with the interests of the entire community, with the main goal being to maximize the number of lives saved.

"Now is the time to complete advance-care planning documents for those who have not already done so, including preferences for DNR status. Advance directives may require special accommodations if they require an in-person witness signature. Lastly, we must assure patients with chronic illness that diminished resources in this healthcare crisis will not restrict their access to comfort and palliative care," the statement says.

It also advises that neurologists need to consider how to manage competing clinical assignments during the COVID-19 pandemic. "While neurologists still have an obligation to manage the patients for whom they were trained, as time permits, they should help manage the surge of respiratory failure," the statement notes, adding that "physician time should be prioritized to caring for those with the most urgent need first."

"While becoming a specialist does require taking responsibility for a focused patient population, it does not obviate the duty we have as physicians to support the greater community."

Government-declared states of emergency may provide liability protection in these circumstances, and hospitals should not ask their physicians to perform duties outside their expertise without associated legal protection, it states.

"Now is one of the most challenging times of our careers as neurologists," said James C. Stevens, MD, president of the American Academy of Neurology. "Clinics and hospitals are adapting to caring for the most ill, managing scarce resources, and trying to protect people without the disease.

"As neurologists, we must continue to adapt our daily practice, continue to care for our most ill neurology patients, and help contribute to the care of those afflicted with COVID-19," he said.

Neurology. Published online May 15, 2020. Full text

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