COVID-19 crisis standards of care necessarily have ill effects on patients, but the health professionals who implement them suffer too.
An “Ethics Talk” video podcast from the AMA Journal of Ethics® (@JournalofEthics) features an interview with Matthew Wynia, MD, MPH, professor of medicine and public health and director of the Center for Bioethics and Humanities at the University of Colorado in Denver. Dr. Wynia outlined the tough decisions administrators and physicians face when confronted with rapidly dwindling resources.
Dr. Wynia also serves on the Forum on Medical and Public Health Preparedness for Disasters and Emergencies of the National Academies of Sciences, Engineering and Medicine. Last year, he co-wrote a National Academy of Medicine discussion paper on COVID-19 crisis standards of care.
No blame or shame
State officials often don’t want to take responsibility for activating crisis standards of care because doing so “implies that their planning to avoid crisis standards of care didn't work,” Dr. Wynia said.
"I understand why a governor would not want to acknowledge the reality of their situation. It feels bad. It looks bad. It is bad,” he said. “But failure to acknowledge the reality of a situation does not change the reality of the situation. And that’s unfortunately where some localities and states are at right now.”
The message needs to be that “red states, blue states, they’re all seeing this right now,” Dr. Wynia said. “Implementation of crisis standards of care—when that is necessary—is appropriate and will, in fact, improve the quality of care that you’re able to deliver to the largest number of people.”
Federal support needed
Another core issue is that the U.S. health care system is fragmented, Dr. Wynia noted. In particular, there’s a disconnect—and even a conflict—between federal laws and state responsibilities.
“Many of the things that we usually talk about in terms of crisis standards of care—allowing folks to operate outside of their usual scope of practice, for example—is not a federal issue,” he said. “That’s a state issue.”
But there are regulatory steps that the federal government could take to alleviate stress on hospitals and health systems. Reducing documentation requirements is one example.
“That would alleviate some of the stress that is arising on the staff and on doctors and nurses who are actually struggling to keep up with caseloads right now,” he said.
Help with payroll is another.
“We have health care professionals who are out of work or underemployed right now. And simultaneously, we have hospitals and health systems that are completely swamped. And that’s just nuts,” Dr. Wynia said.
“It reflects a lack of coordination and a lack of funding,” he noted, adding that states can’t run deficits but the federal government can.
“Funding could come from the federal level to help states with the fiscal implications … of having to operate under crisis standards of care and allow them to hire up in situations where staffing shortages are a real problem,” he said.
Worker well-being at stake too
Health care equipment is often seen as a limited resource, yet staff are assumed to be an infinitely flexible resource, Dr. Wynia noted.
“What we are learning is that’s not true,” he said. “At some point, staff have been stretched and expanded and asked to do more and work longer hours and take care of more patients to the point where not only do you start to see staff who ... burn out and can’t do it anymore, but you see staff getting sick and can’t come to work anymore."
Recognizing this reality, some employers are now offering free meals, free child care and even free car care to employees—anything to enable them to work longer hours without losing control of the rest of their lives. Providing opportunities to talk about the stress and distress of working under crisis standards of care that can lead to poorer-quality care is also important.
“Even if you are being forced into that circumstance,” Dr. Wynia said, “it still feels terrible.”
More on crisis standards of care
The AMA and seven other national organizations recently issued a joint statement calling for readiness to quickly implement crisis standards of care to meet the surge and protect the health care system from functional collapse. Learn more about why the horrific COVID-19 surge demands readiness on crisis standards of care.
Earlier in the COVID-19 pandemic, Dr. Wynia discussed the ethics of triaging critically ill patients and how to involve the public in creating decision-making protocols.
Listen to previous episodes of the “Ethics Talk” podcast or subscribe in iTunes or other services.
