key: cord-0997179-99c1ild2
authors: Pegg, Anne-Marie; Palma, Miguel; Roberson, Cliff; Okonta, Chibuzo; Nkokolo Massamba/Koudika, Marie-Hortense; Roberts, Natalie
title: Providing end-of-life care in the emergency department: Early experience from Médecins Sans Frontières during the Covid-19 pandemic
date: 2020-06-01
journal: Afr J Emerg Med
DOI: 10.1016/j.afjem.2020.05.012
sha: d24ec653119642d58e91b72ad5f99bdf2891cdd5
doc_id: 997179
cord_uid: 99c1ild2

nan

The current COVID-19 pandemic is likely to push operational and medical personnel to unprecedented levels of difficulty in allocation of resources, particularly for oxygen sourcing and delivery systems. While a thorough understanding of COVID-19 illness characteristics is still emerging, vital clinical decisions will need to be made rapidly and with less precise prognostic certainty. Ongoing therapeutic treatment of patients with a grave prognosis will likely be unsustainable in many contexts, given the exponential expansion characteristic of the pandemic and the likely degradation of operational capacity as resource scarcity worsens (See Appendix: The gradual degradation of quality as resource scarcity worsens).

This strategic framework offers a general organizational structure for team members to monitor and assess available resources and to promote informed and collaborative decision-making on palliative care. This framework should NOT be considered a protocol or guideline for clinical care, rather a conceptual framework that may be adapted to the epidemiologic, cultural, and operational circumstances encountered in the field when the decision is reached to discontinue therapeutic care and offer palliative care. Societal norms on death and dying should inform operationalization of the framework, and could lead to innovative adaptations to care, such as homebased hospice care or support from spiritual leaders or traditional healers.

Broadly, ethical standards for clinical decision-making palliative care in COVID-19 should take into consideration the following elements:

 Shared decision-making between two or more experienced clinicians;  Consideration of the patient's and/or the family's stated wishes;  Standardized evaluation of medical urgency, risk factors and clinical frailty of each patient;  Ongoing analysis of available clinical resources;  Evaluation of current and projected demand on clinical resources;  Standardized record-keeping of decision-making processes;  Availability of psychological support for clinical staff.

Shared decision-making attempts to blunt the potential for moral distress or injury and severe mental health consequences when the responsibility is placed on a sole clinical provider. Standardization of patient evaluation criteria is also an essential component of ethical decision-making processes in order to mitigate implicit or overt bias. Decisions about the clinical care appropriate for COVID-19 patients should be guided primarily by transparent and objective assessments of disease severity, co-morbid states, and clinical frailty or prognosis. Priorities of care should include end-of-life symptom management and attendance to the psychosocial and spiritual needs of patients and their families.

Communication Script 

Fair Allocation of Scarce Medical Resources in the Time of Covid-19

Ethical Framework for Health Care Institutions Responding to Novel Coronavirus SARS-CoV-2 (COVID-19) Guidelines for Institutional Ethics Services Responding to COVID-19 Managing Uncertainty, Safeguarding Communities, Guiding Practice

Alleviating suffering and upholding dignity in the midst of CoViD-19 response: A place for palliative care

Integrating palliative care and symptom relief into the response to humanitarian emergencies and crises: A WHO guide

This figure illustrates the granular nature of care quality as it gradually degrades from usual care through contingency and then crisis operations, with illustrative examples of strategies used by organizations to maintain optimal quality of care at each stage despite increasingly severe shortages of staff, space, and supplies. Note that resource categories are interrelated, so shortages in one category affect other categories. For example, there may be adequate numbers of oxygen stations but not enough trained personnel to use them. There may be a need to use crisis standards of care for some resources but not others.