Another Uncommon Ethical Dilemma We Must Now Consider

Alison Huffstetler, MD

Claudia Allen, PhD, JD

The myriad challenges posed by the COVID-19 pandemic are immense. We face shortages in personal protective equipment, brisk reallocation of clinicians, management of novel telehealth visits, and a looming increase in physician burnout. The family medicine community has engaged in remarkable efforts to ensure patients continue to receive necessary care. But as the pandemic begins to impact places like Washington, DC,  two imminent ethical questions arise: How will we balance care for the urban underserved of DC and the political figures, both of whom are sure to be affected by COVID-19? And how will we maintain professionalism while caring for our own medical colleagues?

Boris Johnson, Prime Minster of the UK, was admitted to the intensive care unit at St Thomas’s Hospital in London on April 5th.1 On the day of Johnsons’ ICU admission, there were 799 ICU beds available in the UK but 9,646 were needed.2 According to his physicians, Johnson clearly needed ICU-level care, but what about the other 8,850 patients who also needed ICU-level care? What ethical considerations exist when caring for high-powered officials? And even closer to home, how will we responsibly care for our colleagues, our nurses, and our families?

We will not presume to have a definitive answer, nor will we be able to solve the ventilator crisis in this post. But we will offer an evidence-based approach to the ethics of caring for very important patients (VIPs). 

  1. First, do no harm. Avoid the trap of protecting the VIP from an invasive or uncomfortable treatment if it is the standard of care. In the past, VIPs have suffered from lapses in quality care due to poor adherence to standards.3 Conversely, resist the urge to bend the rules toward overuse and avoid unnecessary tests, inappropriate medications, or delayed discharge.4 
  2. Acknowledge the situation. Opt for an up-front conversation with VIPs. Let the patient and family know that you will treat them as you treat all of your patients. Recognize that your feelings and decision making may be affected by the VIPs status. As a human reminder, it is ok (and warranted!) to show empathy for your friends, colleagues, and public figures. However, remind yourself that decisions should be rooted in the clinical picture and evidence base.
  3. Keep the right team in place. VIPs, families, or hospital staff might place pressure for a more senior, administrator-clinician to care for the VIP. This is often known as “chairman syndrome,” which refers to a demand to have care from the department chair, an individual who may be removed from frequent clinical care. Instead, the patient should be cared for by the team at the appropriate level of care and with the most expertise. Residents should not be removed from these teams as they consistently care for hospitalized patients and are equipped with tools to remain up to date on management. Do not escalate care without the appropriate clinical indications.5 
  4. Thoughtfully manage communication. There are two concepts here. First, ensure that you are speaking with the VIP and family routinely and honestly; aim to maintain an open line of communication with necessary boundaries. Second, patient case discussions and management decisions should only take place with direct team members. Consider a hospital pseudonym that can be used during verbal discussions and in the chart/nursing boards to reduce the likelihood of a confidentiality breech.
  5. Enlist the team to maintain these standards. It is not possible to avoid an effect on our mentality as we care for a patient who is prominent or personally close to us. What we can do is acknowledge the potential for confusing feelings, clarify them in our own minds by putting them into words, and enlisting the whole team to hold one another accountable. Give the whole team the task of keeping an eye on whether professional standards are being adhered to, and permission to hold one another accountable when anyone notices standards slipping.

We face unprecedented numbers of critically ill patients in the hospital. Family physicians are taking this opportunity to expand our presence and provide excellent care to patients. These patients will begin to include other physicians, administrators, hospital staff, friends, and well-known figures. We argue all of these are VIPs and all deserve our attention. Take time now to plan for and discuss what your team will do when caring for one another. Anticipate that these plans will change and acknowledge flexibility in the plan. Our patients will more equitably benefit from the strategies we put into place today. 

References

  1. Booth W, Adam K. Boris Johnson heads into second night in intensive care unit. The Washington Post. https://www.washingtonpost.com/world/boris-johnson-receives-oxygen-support-as-he-battles-covid-19/2020/04/07/0f21fa86-7885-11ea-a311-adb1344719a9_story.html. Published April 7, 2020. Accessed April 8, 2020.
  2. Institute for Health Metrics and Evaluation.| COVID-19 Projections. https://covid19.healthdata.org/projections. Accessed April 8, 2020.
  3. Lerner BH. Revisiting the death of Eleanor Roosevelt: was the diagnosis of tuberculosis missed? Int J Tuberc Lung Dis Off J Int Union Tuberc Lung Dis. 2001;5(12):1080-1085.
  4. Allen-Dicker J, Auerbach A, Herzig SJ. Perceived safety and value of inpatient “very important person” services. J Hosp Med. 2017;12(3):177-179. https://doi.org/10.12788/jhm.2701
  5. Guzman JA, Sasidhar M, Stoller JK. Caring for VIPs: nine principles. Cleve Clin J Med. 2011;78(2):90-94. https://doi.org/10.3949/ccjm.78a.10113

 

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