key: cord-1055565-k6ulikqa authors: Lockey, Stephen D.; Nelson, Philip C.; Kessler, Michael J.; Kessler, Michael W. title: Approaching “Elective” Surgery in the Era of COVID-19 date: 2020-09-29 journal: J Hand Surg Am DOI: 10.1016/j.jhsa.2020.09.006 sha: b610bed0bbe5901b15a7e07cf86f40720bfe2d7b doc_id: 1055565 cord_uid: k6ulikqa The COVID-19 pandemic created unprecedented challenges for the healthcare system. In order to meet capacity demands, hospitals around the world suspended surgeries deemed to be “elective.” In hand surgery, there are numerous pathologies treated on an elective basis, but a delay or absence of care may result in poorer outcomes. We present here an ethical framework for prioritizing elective surgery during a period of resource scarcity. Instead of using the term elective, we define procedures that can be safely delayed based on three considerations. First, a safe delay is only possible if deferral will not result in permanent injury. Second, a delay in care will come with tolerable costs and impositions that can be appropriately managed in the future. Third, a safe delay will preserve the bioethical principle of patient autonomy. In considering these criteria, three case examples are discussed taking into account individual patient characteristics and the pathophysiology of the condition. This framework design is applicable to ambulatory surgery in any period of crises that may strain resources, but further considerations may be important if an operation requires hospital admission. The COVID-19 pandemic resulted in unprecedented challenges for our healthcare 23 system. Many hospital systems shifted to a model of "crisis standards of care" which set 24 standards for the "optimal level of care that can be delivered during a catastrophic event, 25 requiring substantial change in usual health care operations." In an effort to conserve resources 26 for treating expected surges of COVID-19 patients and reduce the risk of exposure to COVID-19 27 between patients and providers, hospitals cancelled procedures determined to be elective. In the 28 federal and state level guidance, however, the definition of elective procedures was less specific 29 and left many judgments to regional public health officials and local practitioners. Conditions 30 that are life or limb threatening or if a delay in surgery will negatively impact outcome are treated 31 as "non-elective" cases, but this definition is subject to interpretation and abuse. Many hospitals 32 implemented sweeping halts on elective surgeries, raising concerns about how long a case 33 should be delayed before there is a significant risk of harm. The uncertainty regarding the length 34 of delay due to the pandemic raised unprecedented challenges in how to triage and schedule 35 cases that were postponed. We propose to use "safely-delayed" as the preferred term for 36 identifying procedures in orthopedic hand surgery which can be deferred in a way that does not 37 negatively impact clinical outcome and avoids sub-optimal results or even permanent injury. We 38 propose a medical and bioethical framework for judging these conditions that can guide case-39 by-case decisions in the context of an individual patient's disability, local medical resource 40 scarcity and case density, and the success of surgery in providing relief. A safe delay is possible 41 when three fundamental bioethics principles, tailored to the specific situation in hand surgery, 42 are satisfied: 1 43 Principle of Non-maleficence: surgical deferral may be safely delayed only when the 44 time duration of the delay will not cause permanent harm or irreparability. 45 J o u r n a l P r e -p r o o f clinical outcome, imposing only tolerable impositions that can be appropriately managed, 47 such as pain and short-term functional limitations. 48 Principle of Justice: a safe delay will balance physician-guided patient autonomy and 49 decision-making with the public health need to preserve scarce resources, in a way that 50 minimizes unjust or privileged distribution of medical resources. 51 Using this framework, we can consider a spectrum of scenarios in which surgeries are 52 classified as safely-delayed, or not. 53 We propose a medical and moral framework for identifying urgent or necessary as 55 opposed to safely delayed surgeries that can be derived from the principles of respect for 56 autonomy, nonmaleficence, beneficence, and justice. 2 57 When considering whether a surgical procedure can be safely-delayed, a primary 58 consideration is the principle of nonmaleficence, which requires that caregivers do not 59 intentionally create harm or injury to the patient, either by direct action or by omission of an 60 action. A delay of a surgical procedure that results in a clinical outcome different from a non-61 delayed procedure, such as permanent or irreparable damage, would likely violate this principle. 62 This consideration is both medical and moral in nature. As a medical consideration, evidence-63 based judgments about the risks of the delay and costs to a successful surgical outcome will 64 factor into whether or not the delay can be considered safe. The moral consideration builds on 65 the medical judgment: if long term outcomes are diminished or put at significant risk due to the 66 possible delay, the moral principle is violated since harm ensues and the surgery ought not be 67 delayed. The principle of nonmaleficence also requires the clinician to consider the risk of 68 J o u r n a l P r e -p r o o f medical conditions or advanced age, the potential for a suboptimal clinical outcome due to delay 70 must be weighed against the risks to a patient's overall health. Therefore, to truly minimize the 71 chances of harm, surgeons must determine the balance of risks based on a patient's specific 72 circumstances and the burden of infection within the region. 73 The principle of beneficence, at the heart of medical care, sets a duty to provide care for younger patients susceptible to a lifetime of disability. 9,10 It is therefore not surprising that the 117 take age, occupation, and handedness into consideration when approaching treatment. 11 119 Additionally, those with a symptomatic malunion may require a corrective osteotomy, which has 120 a reported complication rate of 50% and is associated with significant morbidity. 12,13 This 121 example demonstrates the potential dilemma in approaching treatment at a time when 122 conservative management may be incentivized. The COVID-19 pandemic brought unprecedented challenges across healthcare fields. 184 The presence of disease in our communities does not eliminate the surgical needs seen in 185 emergency rooms and clinics each and every day. While surgeons must certainly be available 186 to help in the direct care of COVID-19 patients or those affected by future pandemics, it is 187 equally important that we treat those who require our surgical intervention. This task is 188 challenging as it requires each patient to be considered on a case-by-case basis in the context 189 of the availability of resources in the community and the prevalence of disease. that this pandemic is unlikely to be the last. The framework outlined here can be applied in 192 similar circumstances of resource scarcity. One limitation of this discussion is that we consider 193 strictly outpatient procedures, but cases that require hospital admission (e.g. spine surgery, 194 adult reconstruction, bariatric surgery, etc.) face additional challenges. 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