key: cord-348964-1x3nmwwt authors: Patel, Love; Elliott, Amy; Storlie, Erik; Kethireddy, Rajesh; Goodman, Kim; Dickey, William title: Ethical and Legal Challenges During the COVID‐19 Pandemic – Are We Thinking About Rural Hospitals? date: 2020-04-13 journal: J Rural Health DOI: 10.1111/jrh.12447 sha: doc_id: 348964 cord_uid: 1x3nmwwt nan Another ethical challenge is health care provider concerns regarding occupational hazard. Health care providers, like any other humans, are not immune to flight or fight responses during stressful situations. Health care providers' willingness to work against a potentially lethal infectious agent has also been investigated in several studies. 7, 8 In these studies 80% of physicians reported willingness to work with patients with contagious and potentially lethal conditions, but only 55% agreed that "Physicians have an obligation to work during an epidemic even if doing so endangers their health." Rural communities, whose population makes up 20% of the US, frequently struggle with limited health care workforce and resources under ordinary conditions. When tertiary care hospitals reach capacity, rural hospitals and their communities may experience severely reduced access to critical care services and related resources as a result of timing and proximity, further exacerbating pre-existing real and perceived health care disparities. These disparities have not been well-studied, 9 but they are a source of concern during preparation for widespread disasters such as pandemic infection. Distribution of scarce medical resources including personnel, equipment, and services is a sensitive issue during a pandemic. 10 Complicating the picture, older adults with multiple preexisting medical comorbidities are more vulnerable for worst outcomes of this pandemic and make up a higher share of the population in rural areas, which are already ailing with poor medical resources. In addition to ethical dilemmas, another concern among health care providers and health systems are legal issues they may face during and after crisis situations. The history of medical malpractice dates back to the first half of the 19th century. 11 Legal and ethical education is very limited in medical schools and training programs across the US. 12 Law can help to establish a more flexible response by authorizing quick actions that otherwise would not have been permitted, for example waiving specific laws and providing liability protection for entities acting in good faith. 13 Conversely, law can be used to hold hospitals and health care workers accountable for patient injuries and harms, or for failing to plan for disasters. 14 During the current situation, as in any other disaster, health providers are entering into unknown territory of ethical and legal complexity. Ethical guidance and legal and medical frameworks are an increasingly common component of disaster response plans, particularly mass casualty events. Because standards of care address not only what care is given, but to whom, when, by whom, under what circumstances, and in what places, planning must address all these factors to define appropriate standards of care in planning prior to mass casualty events. 15 Although the Health and Medicine Division of the National Academies of Science, Engineering and Medicine offers important guidance about frameworks of overall Crisis Standards of Care plans, different states embrace somewhat different basic ethical frameworks. 16 Legal and ethical challenges are inevitable in health care, and impossible to understand fully prior to, and during, an unprecedented event like the one we are currently facing. Review committees were formed in the 1960s for approval of abortion decisions. In the 1970s, dialysis priorities were reviewed by ethics committees. 17 While only 1% of hospitals had HECs in 1983, this rate increased to over 90% by 2001. 18 Limited data exist on effectiveness of ethical case intervention in adult patients. 19 Ethics committees are involved in different roles in different hospitals, but most are involved in patient care discussions following a request from the bedside care team facing an ethical dilemma. Active and organized ethics committees are needed to facilitate thoughtful and equitable planning and execution of care throughout the medical care delivery system during the current crisis. The reorganization of ethics committees and development of institution-and system-level policies for allocation of health care resources requires input from multiple stakeholders. Physicians and nurses, legal professionals, ethicists, risk management staff, the general public, and patient advocates can all provide invaluable perspective and guidance during this process. Smaller hospitals, including community hospitals and rural institutions, frequently have less organized or non-existent ethics teams. 21 When ethics teams do exist in these facilities they may meet infrequently, be consulted infrequently, and lack robust support from the health care and lay communities. Further, local relationships in rural areas are often overlapping, which further complicates ethical decision-making as objective parties with appropriate knowledge and perspective are sometimes not available. Our health system includes both large urban hospitals, medium-sized suburban hospitals, and rural and critical access hospitals. This allows us to work in concert to prepare for the challenges, and to bring the strengths of each health campus to bear on our current crisis. At our large urban hospital the Clinical Ethics and Value Program was organized recently, about a year ago. Previous work of this team was limited to its home hospital, and included challenging decisions about goals of care; assisting with management of patients with substance use disorder; and clarifying how to manage challenges in frontline health care. Currently, the program has expanded its reach to bring together professionals with wideranging perspectives throughout the health system to ensure that our process for ethical decision-making during the COVID-19 pandemic includes the concerns of small and large facilities, and shares resources in a way that all the communities we serve can understand and support. Hospitalists, intensivists, ED physicians, medical staff leaders, and nurses are working closely with ethics specialists, administration and legal counsel, and preparing as a team for the worst case scenario. The AMA code of ethics advises, "Because of their commitment to care for the sick and injured, individual physicians have an obligation to provide urgent medical care during disasters. This obligation holds even in the face of greater than usual risks to physicians' own safety, health, or life." 23 The ability of health systems to support providers with practical tools such as clinical education, specialist consultation, and adequate PPE will be part of this story. Ethical support, with fair allocation of scarce resources and support for frontline staff experiencing moral distress as a result of the crisis, will also contribute. In the end, if history is any guide, most clinicians will choose to stay following the heroic example established through history and today. 24, 25 The point at which preparedness dissolves into panic will always be context dependent. But the tragedy in Italy reinforces the wisdom of many public health experts: the best outcome of this pandemic would be being accused of having over prepared. 22 COVID-19 and Italy: what next? Coronavirus disease 2019 (COVID-19) outbreak in Iran; actions and problems Augmentation of hospital critical care capacity after bioterrorist attacks or epidemics: recommendations of the Working Group on Emergency Mass Critical Care Ready and willing? Physicians' sense of preparedness for bioterrorism Factors predicting nurses' consideration of leaving their job during the SARS outbreak The Impact of Disasters on Populations With Health and Health Care Disparities. Disaster Medicine and Public Health Preparedness The ethics of responding to a novel pandemic America's first medical malpractice crisis Medical malpractice litigation: a fellow's perspective Legal preparedness: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement Assessing liability for health care entities that insufficiently prepare for catastrophic emergencies Ethical Guidance for Disaster Response, Specifically Around Crisis Standards of Care: A Systematic Review Allocation of ventilators in a public health disaster At law. Ethics committees: from ethical comfort to ethical cover A national study of ethics committees Ethical case interventions for adult patients Preparing for COVID-19: early experience from an intensive care unit in Singapore The Presence of Ethics Programs in Critical Access Hospitals Facing Covid-19 in Italy -Ethics, Logistics, and Therapeutics on the Epidemic's Front Line Must I Respond if My Health is at Risk? Physicians' legal duty of care and legal right to refuse to work during a pandemic