Moral Distress: COVID-19 Shortages Prompt Tough Decisions at Bedside

Damian McNamara

November 06, 2020

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Choosing which hospitalized COVID-19 patients receive potentially lifesaving care, making urgent calls for ventilators and other equipment, and triaging care based on patient age and comorbidities were among the challenges revealed in new feedback from healthcare leaders and frontline workers.

Even though many hospitals have contingency plans for how to allocate resources and triage patient care during crisis capacity, for many providers during the real-world COVID-19 trial of these protocols, they fell short.

Many hospital crisis capacity plans, for example, were too general to address all the specific challenges arising during the pandemic, investigators report in a study published online today in JAMA Network Open.

Dr Catherine Butler

"Our research shows that the types of challenges and approach to resource limitation in real-world clinical settings during the pandemic differed in practice from how we had prepared in theory," lead author Catherine Butler, MD, told Medscape Medical News. Insufficient dialysis treatment time, staff shortages, and routine supply scarcity are examples "for which there was not an established plan or approach for appropriate allocation."

"This left frontline clinicians to determine what constituted an acceptable standard of care and to make difficult allocation decisions at the bedside," added Butler, acting instructor in the Division of Nephrology at the University of Washington in Seattle and a research fellow at the VA Health Services Research and Development Seattle-Denver Center of Innovation.

The investigators conducted semi-structured interviews in April and May with 61 clinicians and health leaders. Mean age was 46, 63% were women, and participants practiced in 15 states. Most participants hailed from locations hard-hit by the pandemic at the time, including Seattle, New York City, and New Orleans.

Triage Tribulations

The qualitative study included comments from respondents on three major themes that emerged: planning for crisis capacity, adapting to resource limitation, and the multiple unprecedented barriers to care delivery.

Overall, planning and support from institutional leaders varied. One provider said, "Talking to administration, and they just seemed really disengaged with the problem. We asked multiple times if there was a triage command center or a plan for what would occur if we got to the point where we had to triage resources. They said there was, but they wouldn't provide it to us."

Another had a more positive experience. "The biggest deal in the ethics world in the last 2 months has been preparing in case we need to triage. So, we have a very detailed, elaborate, well thought-out triage policy…that was done at the highest levels of the system."

Clinicians said they participate on triage teams — despite the moral weight and likely emotional burden — out of a sense of duty.

Interestingly, some providers on these teams also reported a reluctance to reveal their participation to colleagues. "I didn't feel like I should tell anybody …even some of my close friends who are physicians and nurses here…that I've been asked to be on this [triage team]," one respondent said. "I didn't feel like I should make it known."

Adapting to Scarce Resources

Multiple providers said they faced difficult care decisions because of limited dialysis or supply shortages. "They felt that this patient had the greatest likelihood of benefitting from most aggressive therapy…I think there was probably like 5 or 6 patients in the ICU…and then you had this 35-year-old with no comorbidities," one respondent said. "That's who the ICU dialyzed, and I couldn't really disagree."

"I emailed all of [my colleagues], and I said 'Help! We need X, we need CRRT [continuous renal replacement therapy] machines, we need dialysates,' " another responded.

"One of the attendings had a tweet when we were running out of CRRT. He had a tweet about, 'Can anybody give us supplies for CRRT?' So, it got to that. You do anything. You get really desperate," the clinician said.

Other providers reported getting innovative under the circumstances. "My partner's son, he actually borrowed a couple of 3D printers. He printed some of these face shields, and then they got the formula, or the specifics as to how to make this particular connection to connect to a dialysis machine to generate dialysate. So, he also printed some of those from the 3D printer."

Dire Situations With Dialysis

Another respondent understood the focus on ventilators and ICU beds throughout the crisis, but said, "no one has acknowledged that dialysis has been one of the most, if not the most, limited resources."

Another clinician expressed surprise at a decision made in the face of limited availability of traditional dialysis. "A month ago, people said we were going to do acute peritoneal dialysis [PD]. And I said, 'No, we're not going to do acute PD. PD, it's not that great for acute patients, sick people in the ICUs. I don't think we're going to do PD.'

"Three days later we were doing acute PD. I mean, that was unbelievable!"

Some institutions rationed dialysis therapy. "We went through the entire list at the beginning of the week and [said], this person has to dialyze these days, this person would probably benefit from a dialysis session, a third group person we could probably just string along and medically manage if we needed to," one provider said.

Another respondent reported a different strategy. "No one was not getting dialysis, but there were a lot of people getting minimal dialysis. Even though people were getting treated, resources were very stretched."

Changing Family Dynamics

COVID-19 has naturally changed how clinicians speak with families. One respondent recalled looking at the ICU physician and being like, 'Have you talked to the son this week?' And she's like, 'Oh my God, no…Did you talk to the son?' I'm like, 'Oh my God, no.' "

They realized, the respondent added, "that none of us had called the family because it's just not in your workflow. You're so used to the family being there."

Multiple providers also feared a conversation with family regarding necessary changes to care given the limitation of resources during the pandemic.

"Most families have been actually very understanding. This is a crisis, and we're in a pandemic, and we're all doing things we wouldn't normally do."

Another respondent said, "We were pretty honest about how resources were limited and how we were doing with this COVID-19 surge. And I think

we talked about how the usual ability to provide aggressive dialysis was not the case with COVID-19. There was a lot of understanding, sometimes to my surprise. I would think people would be more upset when hearing something like that."

Many clinicians facing these challenges experience moral distress, the researchers note.

"Early in the pandemic, it became quickly apparent that possible resource limitation, such as scarce ventilators, was a major ethical concern. There was robust debate and discussion published in medical journals and the popular press about how to appropriately allocate healthcare resources," the University of Washington's Butler said.

"Transparency, accountability, and standardized processes for rationing these resources in 'crisis capacity' settings were seen as key to avoiding the impact of implicit bias and moral distress for clinicians," she added.

Lessons Learned

In terms of potential solutions that could mitigate these challenges in the future, healthcare leaders "could develop standardized protocols or guidelines for allocating a broader range of potentially scarce health care resources even before 'crisis capacity' is declared," Butler said.

Furthermore, no frontline worker should have to go it alone. "Medical ethicists and/or other clinicians familiar with ethical considerations in settings of scarce healthcare resources might provide bedside consultation and collaborate with frontline providers who must grapple with the impact of more subtle forms of resource limitation on clinical decision-making."

The study was partially funded by grants from the National Institute of Diabetes and Digestive and Kidney Diseases and a COVID-19 Research Award from the University of Washington Institute of Translational Health Sciences given to Butler.

JAMA Network Open. Published online November 6, 2020. Full text

Have resource shortages in your organization forced you to make any difficult decisions? If so, let's discuss in the comments.

Damian McNamara is a staff journalist based in Miami. He covers a wide range of medical specialties, including infectious diseases, gastroenterology and rheumatology. Follow Damian on Twitter:  @MedReporter.

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