COVID 19 Blog on MORAL Balance

Use of PPE for CPR

Mon, 04 May 2020 15:27:00 +0000

Updated analysis in light of conflicting advice The Resuscitation Council and Public Health England regarding chest compressions being an aerosol generating procedure.

Moral Balance Analysis 4 - Pregnant Staff

Mon, 20 Apr 2020 13:12:00 +0000

Is it unethical to ask staff at some risk due to health conditions to be patient facing, when their pregnant colleagues who are at no/very little additional risk (on the basis of very limited evidence) are given the choice of being patient facing?
This Moral Balance Analysis was carried out by Nottingham University Hospitals NHS Trust’s Ethics of Clinical Practice Committee on the 8th April 2020.

The full analysis can be downloaded here.

CRITCON Levels - winter flu vs pandemic

Fri, 03 Apr 2020 14:24:00 +0000

CRITCON Levels are based (though for some reason are in reverse order) to DEFCON levels which tells us how close we are to nuclear war.

They have been modified for use by critical care networks in Winter Flu to describe the strain an ICU is under. See London Critical Care Network example.
CRITCON levels for Winter Flu do not work as well in pandemic situations. The difference is that the CRITCON levels for Winter Flu were designed to describe the current number of ICU patients and how they may, or may not be exceeding normal bed capacity. The desired ambition is to get the numbers of patients back within the normal bed state.

Differences between mass casualty triage and pandemic

Tue, 31 Mar 2020 14:36:00 +0000

Mass Casualties

Pandemic

We need different ethics.
And the answer is not reverse triage!

New one-page MORAL Balance Framework

Sun, 29 Mar 2020 10:12:00 +0000

We have created a new one-page version of MORAL Balance.

It lacks the Balancing Box - but may allow for quicker use and documentation.

First - be clear about what decision you are trying to make.

Second - identify and Make sure of the facts and Outcomes of Relevance to the Agents (an agent is anyone who cares about or is impacted by the decision).

Third - Level out the arguments. Try and achieve a Balanced decision.

UK intensivists are better prepared for the COVID moral test ahead

Fri, 27 Mar 2020 09:33:00 +0000

The below is the Ethicus 2 study. In the UK, for patients who die in the ICU, intensivists are nearly two times more likely to have made a treatment withdrawal decision compared to our Southern colleagues in Italy and Spain.

In Ethicus 1 (2003) we were 2.6 times more likely.

What can be seen is that Southern intensive care has become more like Northern intensive care over time.

Don’t let the ethics of despair infect the intensive care unit

Thu, 26 Mar 2020 11:22:00 +0000

MORAL Balance up on the Journal of Medical Ethics Blog.
Our thanks to David Shaw for leading this piece.

The ethics of reverse triage or ventilator throughput.

Thu, 26 Mar 2020 07:56:00 +0000

There is lots of discussion in ICU circles about reverse triage.

It goes something like this:
“Two people need a ventilator, one is in the emergency department, young, needing intubation, the other is on the ICU, elderly perhaps, not doing so well. If they had both arrived into the ED simultaneously and there was only one ventilator; the ICU doctor would have triaged to treat the young person first. So, given the actual scenario, reverse triage suggests the ICU doctor should go up to ICU and remove the ventilator and adopt palliation for the current patient already in the ICU, to make the ventilator available for the young person in the emergency department who has a greater chance of benefiting.”

A,B,D,C,Es of Good Communication

Wed, 25 Mar 2020 11:53:00 +0000

Adapted from NHSBT’s Deceased Donation Course for Intensive Care Medicine Trainees, which has provided end of life communication training to over 350 delegates and faculty. Download.

Accuracy #

say truth, admit if you don’t know
it is ok to mention resource constraints and its decision impact

Brevity #

don’t fill the silence with your voice
in grief thinking slows, even on the phone allow silence
listen and give time for questions, “What questions do you have?

Clarity #

use unambiguous language, simple non-medical words
“can’t save, going to die, dying, won’t suffer”

Delivery #

structure as a narrative - warning shot (sets scene), circumstances (explains reasons, telegraphs decision), decision then silence
use appropriate non-verbal technique, if phone tone of voice

Empathy #

explicitly state your sympathy “I am so sorry” “it is awful”
give comfort

#

Additional Hints

Don’t give into South Park Ethical Thinking

Tue, 24 Mar 2020 12:50:00 +0000

There is an episode in South Park – can’t remember which one, which goes something like this….

A blizzard hits South Park and some adults are stranded in a building.They propose drawing straws and cannibalism in order to stay alive.“What are you diabetic,” the short straw drawer begs.
They had only been stranded for a few hours!

COVID-19 will hit different regions and different hospitals, differently.
We must individualise our ethical response and use of resources.
Some patients – even non COVID patients – need our help now.

Pandemic Ethics are not just about COVID patients (Part 2)

Mon, 23 Mar 2020 09:28:00 +0000

An urgent question facing many NHS leaders in hospitals is, how do we meet the needs of non COVID-19 patients.

One such area is non COVID-19 cancer patients awaiting surgery?
How should one ethically prioritise these patients when resources (people, theatre space, ward and critical care beds, community help) are extremely limited.

A MORAL Balance Analysis can be viewed here.
My thanks to members of Nottingham University Hospitals NHS Trust’s Ethics of Clinical Practice Committee who helped identify additional facts and outcomes of relevance.

The Moral Test of our Generation

Sun, 22 Mar 2020 13:49:00 +0000

COVID-19 is the moral test of our generation.
I would see it as the biggest test since the Second World War.

It is testing us as a society – our health systems, our governments, our communities.

It is testing us as individuals.
My colleague Dr Harvey was concerned that many are failing the individual test.
This was his post on Facebook.

https://www.facebook.com/899475530/posts/10163357356595531/?d=n

Dale

Pandemic Ethics are not just about COVID patients (Part 1)

Sat, 21 Mar 2020 08:13:00 +0000

In all the talk, emails, What’s App messages, 24 hours a day media frenzy, you might start to believe that COVID patients are the only patients.

The other patients are still there…
Hoping they won’t need medical attention – perhaps delaying too long.
Hoping they can still get the treatment they need (operations, medications, a lifesaving transplant).
Hoping they can leave hospital as soon as possible.

I have been posed or overheard three ethical dilemmas in the last 48 hours. In none of these scenarios does the patient/s have COVID-19 but all are affected by the pandemic.

We can resist the ethics of Despair

Thu, 19 Mar 2020 10:41:00 +0000

We just need to remember that A,B,C comes before D.

A #

Ask – when you are struggling either with a patient or just coping emotionally – ask for help, talk to those whose opinions you value. There are people who want to help us. The medical students of Nottingham just emailed saying – “Need some assistances with childcare (or anything else!)… Hundreds of Nottingham Medical Students have expressed a wish to support you as much as possible whilst our placements and teaching have been postponed.”