The world is facing a global pandemic with enormous personal, societal, and economic consequences that are unprecedented in the last decades. The novel coronavirus, SARS-CoV-2, and the associated disease COVID-19, has attacked countless individuals in more than 173 countries and territories worldwide.
Although more than 95% of the infections result in mild symptoms, in some patients, particularly the elderly with underlying comorbidities (such as cardiovascular disease, COPD, diabetes mellitus and obesitas), these symptoms can deteriorate in a severe bilateral pneumonia, requiring intensive care and mechanical ventilation in approximately 5% of all cases. In this subgroup the mortality is high. In approximately 2% of all confirmed infections the virus is fatal. In the Netherlands 75% of the deceased patients died at home, in nursing homes or at a hospital, but not on the intensive care units. They were not admitted to an intensive care unit because of severe chronic underlying conditions and old age, advanced directives, and withholding life-sustaining measures / resuscitation orders. Only 25% of the fatal cases died after admission on the intensive care.
The day after the first patient infected with confirmed COVID-19 was admitted to our intensive care unit, everybody knew about and shared the details of this novelty. As we normally discuss all patients admitted on the intensive care during a daily multidisciplinary meeting, for this patient a separate meeting was organised. We discussed all infection-related details, the proposed medication, the chosen treatment and we consulted the existing guidelines. The patient was admitted with a severe bilateral pneumonia, requiring mechanical ventilation. Of course, this is not new to us, we see this every year in patients with severe influenza, but still uncertainty was the most striking aspect during the deliberations. Uncertainty about the right steps to take – should we administer experimental antiviral medications? What do the clinical parameters mean?
We all had heard the horror scenarios of Wuhan in China and the Lombardy region in Northern Italy was fresh in our memories. Was this first patient the beginning of something the intensivists and nurses were not trained for – an enormous public health emergency of unprecedented and uncontrollable size? We don’t know. I saw moral distress in some of the nurses and physicians based on this uncertainty. I foresaw ethical implications I have never faced before.
Most of our intensivists and intensive care nurses, although trained to care for individuals with a wide range of life-threatening conditions, have never encountered a public health emergency like the ongoing global COVID-19 pandemic. They are professionals trained to care for the individual sick patient in need of intensive care as a goal and an end in itself, and not as an individual as part of a whole society facing scarce resources. The ethical standards of patient-centered intensive care differs considerably from the ethical standards of public health. It is uncertain if we can safeguard the good ethical standard of moral equality of persons when we possibly face more patients in need of care than there are beds and ventilators available at the intensive care unit. This uncertainty on how to fairly allocate limited resources can create serious moral tension for clinicians.
Besides that, there is a continuous pressure to protect and treat other, non-COVID-19, patients and to protect the health of the involved healthcare workers. Responsible leaders on the intensive care units have to face the occupational hazards that their physicians and nurses encounter in their work during a pandemic, and it is not only the risk that they get infected, but also emotional exhaustion and moral distress.
Much is uncertain; there is the uncertainty concerning the magnitude of the pandemic and the effect the infection can have on individuals. Intensivists and nurses can experience moral distress when they are aware about the tension between the duty of care for the individual patient, the duty to promote equality for every patient, their own health and the health of their loved-ones. Triage, in the sense of who will be given the scarce intensive care bed and mechanical ventilator is not only an issue among the severely ill COVID-19 patients in need of intensive care; it also concerns all other non-COVID-19 critically ill patients, including those who should be admitted after major elective oncological surgery and transplant surgery.
The COVID-19 patients can form a serious addition to the regular admission of patients in need of intensive care for hospitals in highly affected areas. Responsible leaders on intensive care units have the moral duty to safeguard this equality, to prohibit moral distress among the healthcare workers and also within society. Non-COVID-19 patients should not be harmed by receiving lower priority for admission than the possible overwhelming number of COVID-19 patients. As we already know from China, Italy and Spain, the mortality is especially high in elderly COVID-19-patients with underlying comorbidities. Almost 90% of the deceased Italian COVID-19-patients were above the age of 70. This is not exceptional for lower airway infections. Each year approximately 2.5 million patients die worldwide from a lower airway infection, of which more than half are above the age of 70. Lower airway infection is the leading infectious cause of mortality worldwide in adults older than 70 years. Sir William Osler (1849-1919) called the pneumonia ‘friend of the aged’. As already mentioned, in the Netherlands, 75% of all fatal COVID-19 cases concern elderly patients with severe underlying conditions. Although much is changed since Osler’s time, mortality is still high. Pneumonia and influenza combined are the eighth cause of death in the U.S. and lower respiratory infections is fourth in the top ten global causes of death.
In triage in times of scarcity of intensive care facilities, elderly COVID-19-patients with severe chronic underlying conditions, should not have admission priority above other non-COVID-19-patients in need of intensive care with an estimated better outcome. So, we possibly will face a situation in which not all patients can benefit from life-sustaining measures like mechanical ventilation as witnessed in Italy. Also, other shortage, concerning staff, supplies and space can form a distressing moral dilemma. The most difficult ethical dilemma is: who do we choose for admission? It is ethically fair to choose the patient with the greatest chance of successful treatment, but can we compare a patient who will be surgically treated for esophageal cancer with an elderly patient suffering from underlying comorbidities and COVID-19 related ARDS? Can we choose to admit one of these patients and reject the other?
We should apply here the fair innings argument. Healthcare resources should to be distributed fairly. The original fair innings argument is about claims on length of life, but it should also apply to quality of life. When in competition with patients who face a far better prognosis (also in terms of quality of life), it is fair that we should deny COVID-19 patients with an obviously grim prognosis who already have an diminished quality of life, when resources are scarce. Hopefully we will not have to make these choices in patients with more favourable prognoses, but only thinking to do this can already cause moral stress, especially in our young colleagues. Triage decisions made on medical arguments and disproportionate use of scarce resources are usually not causing moral distress, but deciding that patients cannot be treated as result of shortage of staff, space and supplies can be emotionally very distressing.
Another ethical concern in the care for COVID-19 patients in isolation in the intensive care unit, which I heard these days from several intensive care nurses, is that they experience moral distress due to the fact that severely ill and dying patients on the intensive care unit are completely separated from their loved ones. They see this, dying is isolation, as dehumanisation and inhumane care. To safeguard the emotional wellbeing of healthcare workers in the emergency departments and intensive care units we should anticipate this, offer individual peer-support and ad hoc group intervision, because the ethics in the time of Corona are really different.