Nov 23, 2020
Dr. Pennell and Dr. Friedman discuss the variety of ethical dilemmas for health care providers brought on by COVID-19.
NATE PENNELL: Hello, and welcome to the latest JCO Oncology Practice Podcast, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content, and offering enriching insight into the world of cancer care. You can find all recordings, including this one, at podcast.asco.org
My name is Dr. Nate Pennell, Medical Oncologist at the Cleveland
Clinic, and consultant editor for the JCOOP. I have no conflicts of
interest related to this podcast, and a complete list of
disclosures is available at the end of the podcast. Today I want to
talk about a very serious topic that all of us who care for cancer
patients really had at the front of our minds back in the spring of
2020. While it may already seem like a long time ago, when the
COVID pandemic was at its peak in the United States, New York City
was being inundated with of COVID. And for a while there was quite
a bit of uncertainty about whether they might run out of personal
protective equipment or ventilators. And there were very serious
discussions happening about allocation of resources.
I personally remember patients asking me, even here in Ohio, if
they might not be offered a ventilator if they became sick, because
of their cancer diagnosis. And while this certainly never came
close to happening in Ohio, I think it actually came closer than
we'd like to admit in places like New York. With me today to
discuss this really fascinating topic is Liz Blackler, who is the
program manager for the Ethics Committee and Consult Service at
Memorial Sloan Kettering Cancer Center in New York City.
We'll be discussing the upcoming manuscript from her and her
colleagues titles, "COVID-19-related Ethics Consultations at a
Cancer Center in New York City-- a Content Review of Ethics
Consultations During the Early Stages of the Pandemic," which was
published online August 27, 2020 in the JCOOP. Welcome Liz, and
thank you for joining me on the podcast.
LIZ BLACKLER: Thank you so much for having me here today. I'm
definitely looking forward to discussing our manuscripts with you.
Just to note, I do not have any relationships or disclosures
related to this study.
NATE PENNELL: Thank you. So what was it like to be really in the
epicenter of the COVID pandemic back in the spring?
LIZ BLACKLER: There was a lot of uncertainty. We were all just
trying to find our way, to figure it all out. Staff was just
reconciling what was happening in real time in the city and the
world, and then looking into our own hallways, seeing what was
happening there. I would say it was both chaotic and eerily quiet.
Our ethics consultation service, as with many ethics consultation
services in the hospital, went virtual. So only those people who
needed to be on site were there. And the rest of us were working
from home.
And so I think as a staff, we were adjusting to doing our jobs
remotely, and also watching and feeling the enormity of what was
happening at the hospital with patients, and feeling just a little
bit far away.
NATE PENNELL: So you are in charge of the ethics consult service. I
think anyone who's ever been involved in a case that needs to
involve the ethics consult service knows how incredibly interesting
a job that must be, and complicated. Can you just, before we get
into the COVID thing, explain what an inpatient ethics consult team
does, and who is on that team?
LIZ BLACKLER: Sure. So ethics consultations are most frequently
requested to help analyze and resolve complex value-laden concerns
that arise between or among clinicians, and patients, and/or
families. Anyone-- clinicians, non-clinician staff, patients,
family members, health care agents, surrogate decision makers can
request an ethics consultation. And depending on the situation, the
consultant may facilitate communication between the stakeholders.
This also involves clarifying treatment options and prognosis.
Our consultants also help opine moral reasoning and ethical
principles to certain situations. And we spend quite a bit of time
confirming and clarifying state and federal laws, and hospital
policy, and how it relates to the specific patient at hand. In
general, the ethics consultants work closely with all parties to
help identify acceptable courses of action. Our clinical ethics
consultation team is a standing subgroup of the ethics committee.
And the group is voluntary, and is comprised of 10 MSK employees
from a variety of disciplines. These consultants are additionally
trained in clinical ethics. And currently we have nurses and
physician assistants, nurse practitioners, social workers, and
physicians representing psychiatry and critical care medicine.
So we work in a single-modeled service, meaning consultants work
independently, and then reach out to other consultants for
assistance as needed. So we are a busy service at baseline. And
during COVID, our ethics consultations actually doubled.
NATE PENNELL: Yeah, I can see that when you start to delve into
your paper, and the issues that came up. And what are the special
ethical concerns that arose that might involve COVID in patients
with cancer that differed from the usual things you would see
patients about in the hospital?
LIZ BLACKLER: Sure, it was actually what spurred us to do a
retrospective review on our ethics consultation service. We
encountered two, I would think, unique issues that came up that we
had not previously seen before on the ethics consultation service.
Our very first COVID-19-related ethics consult focused on a patient
with decisional capacity who was admitted to the floor, and wanted
to be discharged against medical advice while he was waiting for
his COVID-19 test to come back.
In the beginning, it was taking a couple of days to get those
results back. Staff was very concerned if a patient would not
adequately quarantine at home, while we are waiting for the
results. In fact, he said he would not quarantine, that he would be
out in the subway, and this and that. So we were called in to
assist in clarifying whether respecting this patient's autonomy to
leave the hospital AMA outweighed our obligation to keep the
patient in isolation, and prevent him from potentially spreading
the infection.
We had never encountered an issue like that before. So in that
case, we were able to support the patient, and help him understand
the reasoning why he needed to stay. In the early days of the
pandemic, as we were just sorting out what was causing the spread
of COVID, I think we would have likely leaned towards figuring out
a way to keep him, as long as we could. It's always tricky in that
we don't want to override someone's autonomy, unless absolutely
necessary. And so there were two cases like this, where we really
had to weigh the risk to the public against individual autonomy of
the patient.
NATE PENNELL: Yeah, I know. It's very interesting to think about
something like that. At first blush, it seems as though there would
be no legal way to keep someone if they wanted to leave. But then
switch it out and say, well this patient has Ebola now, and wants
to go out on their own. And suddenly it jumps to the front of your
mind that maybe it's not quite so simple. It also, I think,
illustrates nicely what the ethics team does, which is not
necessarily to come in and deliver an academic treatise on the
ethical principles of who's right and who's wrong, but to help
negotiate the different parties to come to an acceptable
agreement.
LIZ BLACKLER: Exactly. And in a similar case, we had a family who
was wanting to leave the hospital, and go to a local hotel. But at
the time, the hotels were either COVID-positive hotels or
COVID-negative hotels. And this family insisted on having their
loved ones stay at the hotel that was a COVID negative hotel. And
so the staff called a similar consult line to know whether they had
an obligation to share the patient's medical status with the hotel.
And in a similar mind, we did just what you said. We pulled the
whole team together. We met with the patient and family, expressed
our concerns, and actually helped identify an acceptable hotel that
would make a concession, that was in the geographic location of
where they wanted to be, that would in fact sterilize and come up
with its own private entrance for this patient. So everybody was
happy, right? We knew he would be safe, and the family got to have
this loved one closer to home.
NATE PENNELL: I'm sure that doesn't always end up with such a good
result at the end. But that sounds like a good job. So you had some
fascinating consults. So most of your manuscript is describing some
of the examples of the types of scenarios that you had to address.
So can you take us through some of those, both just like the
general themes and then maybe some specific examples?
LIZ BLACKLER: Of course. So like I said, we performed a
retrospective review of all of our COVID-19 ethics-related consults
that happened between mid-March and the end of April. There were 26
consults total performed on 24 unique patients. The most common
ethical issue was related to code status. So these were patients.
Staff members were concerned about incubating, or performing
cardiopulmonary resuscitation, because of the high risk for
aerosolizing procedures.
If you remember, at the beginning of the pandemic, there was a high
level of anxiety about supply shortage of personal protective
equipment. So staff was very concerned about whether it was
ethically appropriate to provide CPR for our patients with poor
prognosis, because many, if not most of our patients at that time,
not only had advanced cancer, but they had concurrent COVID-19
infection. They had a poor prognosis. Because there was a lot of
risks to providing the CPR and intubation with minimal benefit, and
so more than half of our consults came through that were
questioning that, this idea of non-beneficial treatment.
NATE PENNELL: Well, I guess it's hard not to stop, and talk about
that a little bit. So you've got a patient with advanced cancer,
who presumably wants to be full code, but is COVID positive. How do
you even start to address something like that with the patient and
the staff who are worried?
LIZ BLACKLER: As you know, many of our patients with advanced
cancer and respiratory distress, it's quite hard to have
conversations with them for lots of reasons. I think complicating
the situation was we had a zero visitor policy at that time at the
hospital. So all hospitals in the state had zero visitor policies.
There was no family or caregivers or agents at bedside. We had
family at home listening to the news, and they're recognizing how
important something like a ventilator was for patients with COVID,
as a bridge to recovery. And many family members very much wanted
to give their loved one an opportunity to recover from COVID,
despite something like a stage 4 lung cancer diagnosis with no
[INAUDIBLE]
And so as you can imagine, on a day-to-day basis pre-COVID, we do a
lot of goals of care discussion. So we spend a lot of time with
patients and families trying to help them understand the
limitations to treatment at the end of life, and what is ethically
and morally appropriate, and what may not be the right thing to do.
And so we had to apply all of those same tactics in a very
expedited fashion, talking with family who were isolated and
removed from the situation, who could not be at bedside with their
loved one to try to help them come to terms with what was
happening.
What you may not know is New York state has a law that says full
code, cardiopulmonary resuscitation is the de facto intervention
for all patients, unless they consent specifically to a
do-not-resuscitate order. So we were obligated by law to perform
cardiopulmonary resuscitation on all patients with families who
wanted it. And so we spent a lot of time talking with our families
to help them understand what's happening. And some of those
patients did have cardiopulmonary resuscitation, and others
understood the gravity of the situation, and were more amenable to
do-not-resuscitate orders.
NATE PENNELL: Yeah, it must have been incredibly challenging. But
any other themes that arose in terms of the consults that you
received?
LIZ BLACKLER: Interestingly we had three or four consults that came
through by staff that were concerned that patients were requesting
a do-not-resuscitate order prematurely, that it was not standard of
care for their clinical situation. What we suspected that it was
the converse of what was happening. Patients and families had this
altruistic response to the local and national focus on scarce
resources. So saying, wow, we understand how difficult things are
right now. We're OK. Please focus your resources on someone
else.
NATE PENNELL: Wow.
LIZ BLACKLER: So that was--
NATE PENNELL: Yeah, I can imagine that would have been-- well
hopefully, I guess, that might not have been quite as challenging.
Because maybe some of that might have been a lack of understanding
about the prognosis, and people who actually did have a reasonable
prognosis might-- I don't know if they were convinced to change
their minds, or they generally just supported their decision.
LIZ BLACKLER: We did a little of both. I think in two of the
situations, we were able to help families understand the nuances of
the situation, and they agreed to a trial intubation. Other
families were insistent that this was not in line with their loved
one's wishes, which might have been separate from the COVID-19
pandemic.
One thing we did do with the hospitals early in the pandemic, we
requested, mandated if you will, that all outpatient oncologists
communicate and document the goals of care conversation with their
patients on admission within 24 hours. And so each patient that was
admitted to the hospital had a discussion. All those who could had
discussions with their outpatient primary oncologist about
diagnosis, treatment options at present, and what their wishes were
regarding goals of care. And that very much helped the ethics
consultation service and the services in the hospital provide care
that was aligned with not only treatment options, but the patient's
and family's wishes.
NATE PENNELL: That's really interesting. Because many people were
listening to this podcast might think, well, gosh. Shouldn't you do
that anyway when someone gets admitted to the hospital with
advanced cancer? But perhaps the pandemic offered an opportunity,
because patients were thinking about it now, as opposed to
oftentimes when they get admitted and it suddenly is a bit of a
shock to be presented with the question of what they would want if
they needed to be resuscitated.
LIZ BLACKLER: Agreed. I think it's a natural opportunity for us to
continue to strengthen our need for and goals of care conversations
for all of our patients, whether they're stage one cancers or stage
four cancers. And so I think it was this natural time where
everybody was talking about it. And it just felt it was-- it was
just made sense for us to do. And it is something that we've been
trying to continue as a hospital. These conversations are hard to
have. Patients and families are not always receptive. Clinicians
are not always ready to have those conversation either. And so if
anything, the pandemic brought us all together, and we all
recognize in the anticipation of scarce resources how can we best
take care of these patients. What's first and foremost is we have
to have a better understanding of what our patient's wishes and
preferences are.
NATE PENNELL: One of the things that continues, at least to some
extent in a lot of places, is the restrictions on visitors and
caregivers in the hospital, although perhaps not as strict as it
was back in the spring. How did the inability of caregivers and
powers of attorney and things like that to physically be present
impact your job? And I guess more broadly, how does being forced to
work over a sort of video conferencing impact these
conversations?
LIZ BLACKLER: Sure. I think the level of distress secondary to the
limited or lack of visitors at bedside, was palpable. So the
nursing staff, the clinical staff, and non-clinical staff who were
in the hospital at bedside every day were very upset. It was an
incredibly sad time. And that in itself led to more ethics
consultations, the amount of distress. And so we as a consultation
service, worked hard in our virtual platform to provide extra
support to staff who were trying to manage these patients to really
take care of them in a way, in a kind and compassionate way in the
midst of all of this chaos.
We started something called a virtual ethics open office hours. We
actually set up a virtual Zoom twice a week where my consultants
would sit on the Zoom call and just field questions, general
questions that were coming up from staff. Because there was a lot
of anticipation of what was to come, and how the hospital was
prepared, how we were prepared to take care of patients, if we were
to not have enough ventilators, or if we were not have enough blood
products. And so the anticipation of all of that was very extremely
stressful for staff, and I think compounded by the fact that there
was no support at bedside for the patients.
I would say as a consultant service, going virtual certainly had
its hiccups at first. But I actually think in the long run, we were
able to really support patients and caregivers in a different way.
There were more families that were able to participate in some of
the family meetings, if they were scattered around the tri-state
area or the country even. And so once everybody was acclimated to
using these platforms, staff and family alike, then there were more
opportunities for families to engage and participate in these
family meetings. We were able to outfit many of our rooms with
video access so that the patients who were able to participate were
also able to participate, to be there [INAUDIBLE]
NATE PENNELL: It sounds like you did the best with what you could.
And certainly it was tough on our patients, because they didn't
have anyone to be there with them. But I can see the benefits of
bringing people in who otherwise might have had trouble
participating. So I wanted to just briefly touch upon something
that I'm not sure if everyone realized this. But in anticipation of
being completely inundated and running out of ventilators and
whatnot, some hospitals were putting together protocols on how they
would allocate resources. And it sounds like you may have been part
of putting something like that together for your hospital. I know
it was never needed. But can you talk a little bit about that?
LIZ BLACKLER: Sure. I think one of our obligations as an ethics
committee is we have a duty to plan, and a duty to steward
resources, and a duty to be transparent about it. So early in the
pandemic, the ethics committee was asked to draft allocation policy
in the event that we had a scarcity of equipment, or staff,
resources, blood products. I remember being sent home from the
office to start writing that policy. And I actually haven't been
back since. What I will say is although an incredibly difficult
policy to write, it was heart-wrenching for all of the reasons that
you can imagine. It felt important to at least have a framework in
place just in case. And so we made a decision as an ethics
committee and consultation service to model the framework after the
New York State ventilator guidelines that were published in
2015.
We made some slight modifications to address our unique cancer
patient population. We chose the New York State guidelines, because
they were developed just a few years before with support from our
state government. The guidelines were also publicly available, and
we assumed had passed with public support. There are no perfect
guidelines. And so for us, in many ways we were lucky to have had a
blueprint, something to work with in our state. While acknowledging
that without state support, we were fully aware that if the crisis
standards of care were needed, they needed to be implemented
statewide with consistency.
We also struggled with trying to recognize that the policies needed
to take into account inequities in access and delivery of health
care, with special considerations for inherent bias, based on
socioeconomic, racial, ethnic, age, and others with disabilities. I
think as a bioethics community, we're working to update allocation
policy that acknowledges and begins to rectify such bias. And so
we're able to think about that now, looking back on what's happened
a few months ago. But in real time, what we had with the New York
state guidelines, which I think is a good start, those guidelines
are your classic guidelines that look to maximize benefit of
resource in order to save as many lives as possible.
The [INAUDIBLE] is given to patients for whom resources would most
likely be lifesaving. We put into place a classic triage process
that was grounded in a clinical scoring system. And we also made
sure to remove the triage decisions from the bedside clinician,
instead relying on a triage committee that would be made up of
critical care physicians, administration, ethics consultants, or
committee members, and other senior staff from the hospital to help
make these determinations based on this clearly spelled out
criteria, knowing that there were flaws in those criteria. And so
we did put together a policy. We thankfully did not have to
implement that policy. But we have the policy put into place.
NATE PENNELL: And that, I think, leads us really nicely into my
last question, which is really what did you learn from all of this
going forward? So if this happens again, hopefully not with COVID,
but another emergency or something that leads to strained
resources; what take-home lessons can you take from this that will
make that perhaps an easier situation the next time?
LIZ BLACKLER: Sure I'll approach it from a macro and a micro
standpoint. So within the hospital, one of the things that we
learned is that our clinician's preoccupation and distress when
confronted with these difficult choices in the pandemic, with the
anticipation of a scarce resource, was palpable. And that as an
ethics consultation service, we have an obligation to put together
a center-based initiative to really support staff in real time. And
so going virtual quickly, setting up services for staff that are
proactive instead of reactive, it has been very helpful. And so I
mentioned the virtual ethics clinics or office hours as one way to
reach a lot of staff quickly, and to provide support in real
time.
I think the other issue I touched on briefly, and that is working
within the state and the country to come up with acceptable
allocation policies that acknowledge bias, that acknowledged
disparities in health care, and delivery of health care, and access
to health care are extremely important. So one thing that has come
out of this that I'm very proud of, as a hospital we at Memorial
Sloan Kettering, we reached out to all of our colleagues in the
city and upstate New York, and have recently just for formed an
Empire State Bioethics Consortium. So all of the chairs of the
bioethics departments from around the state, we now meet on a
regular Monday night phone calls, to talk about what's happened,
anticipation for future, and really working on a broad range of
ethical issues that affect New York State.
NATE PENNELL: Liz, thank you so much for joining me on the podcast
today.
LIZ BLACKLER: Thank you so much for having me. I really appreciate
it.
NATE PENNELL: I'm glad we're going to have the opportunity to
highlight your manuscript, which I think is really going to be
beneficial to people who hopefully will not be presented with this
in the future. But if they are, it's something to get them
thinking. And until next time, I want to thank our listeners for
listening to the JCO Oncology Practice podcast. If you enjoyed what
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backslash journal, backslash op. And this is Dr. Nate Pennell for
the JCO Oncology Practice signing off. Thanks for listening.
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