Ventilator Triage Policies During the COVID-19 Pandemic at U.S. Hospitals Associated With Members of the Association of Bioethics Program Directors.

BACKGROUND: The coronavirus disease 2019 pandemic has or threatens to overwhelm health care systems. Many institutions are developing ventilator triage policies. OBJECTIVE: To characterize the development of ventilator triage policies and compare policy content. DESIGN: Survey and mixed-methods content analysis. SETTING: North American hospitals associated with members of the Association of Bioethics Program Directors. PARTICIPANTS: Program directors. MEASUREMENTS: Characteristics of institutions and policies, including triage criteria and triage committee membership. RESULTS: Sixty-seven program directors responded (response rate, 91.8%); 36 (53.7%) hospitals did not yet have a policy, and 7 (10.4%) hospitals' policies could not be shared. The 29 institutions providing policies were relatively evenly distributed among the 4 U.S. geographic regions (range, 5 to 9 policies per region). Among the 26 unique policies analyzed, 3 (11.3%) were produced by state health departments. The most frequently cited triage criteria were benefit (25 policies [96.2%]), need (14 [53.8%]), age (13 [50.0%]), conservation of resources (10 [38.5%]), and lottery (9 [34.6%]). Twenty-one (80.8%) policies use scoring systems, and 20 of these (95.2%) use a version of the Sequential Organ Failure Assessment score. Among the policies that specify the triage team's composition (23 [88.5%]), all require or recommend a physician member, 20 (87.0%) a nurse, 16 (69.6%) an ethicist, 8 (34.8%) a chaplain, and 8 (34.8%) a respiratory therapist. Thirteen (50.0% of all policies) require or recommend that those making triage decisions not be involved in direct patient care, but only 2 (7.7%) require that their decisions be blinded to ethically irrelevant considerations. LIMITATION: The results may not be generalizable to institutions without academic bioethics programs. CONCLUSION: Over one half of respondents did not have ventilator triage policies. Policies have substantial heterogeneity, and many omit guidance on fair implementation. PRIMARY FUNDING SOURCE: None.

Parents Refusing Dialysis for a 3-Month-Old With Renal Failure.

A 3-month-old boy with failure to thrive was referred to a nephrology clinic after a diagnostic workup for failure to thrive revealed a serum urea nitrogen level of 95 mg/dL and creatinine level of 3.6 mg/dL. A renal ultrasound revealed marked bilateral hydronephrosis with little remaining renal cortex in either kidney. A voiding cystourethrogram revealed evidence of posterior urethral valves. The child had no evident comorbidities. Fulguration of the valves was successfully performed but did not lead to improvement in kidney function. The nephrologists recommended the initiation of dialysis with the hope that the child would be able to receive a kidney transplant in the future. After careful consideration, the family stated that they did not want this child to suffer with a lifetime of dialysis and transplant care. They were also concerned about the impact of this child's illness on their other 2 children and their family. They requested that their son be provided with palliative care only. Experts in nephrology, bioethics, and critical care discuss the ethical issues raised by this parental request.

A Conceptual Model for the Translation of Bioethics Research and Scholarship.

While the bioethics literature demonstrates that the field has spent substantial time and thought over the last four decades on the goals, methods, and desired outcomes for service and training in bioethics, there has been less progress defining the nature and goals of bioethics research and scholarship. This gap makes it difficult both to describe the breadth and depth of these areas of bioethics and, importantly, to gauge their success. However, the gap also presents us with an opportunity to define this scope of work for ourselves and to help shape the broader conversation about the impact of academic research. Because of growing constraints on academic funding, researchers and scholars in many fields are being asked to demonstrate and also forecast the value and impact of their work. To do that, and also to satisfy ourselves that our work has meaningful effect, we must understand how our work can motivate change and how that change can be meaningfully measured. In a field as diverse as bioethics, the pathways to and metrics of change will likewise be diverse. It is therefore critical that any assessment of the impact of bioethics research and scholarship be informed by an understanding of the nature of the work, its goals, and how those goals can and ought to be furthered. In this paper, we propose a conceptual model that connects individual bioethics projects to the broader goals of scholarship, describing the translation of research and scholarly output into changes in thinking, practice, and policy. One of the key implications of the model is that impact in bioethics is generally the result of a collection of projects rather than of any single piece of research or scholarship. Our goal is to lay the groundwork for a thoroughgoing conversation about bioethics research and scholarship that will advance and shape the important conversation about their impact.

When Rights Just Won't Do: Ethical Considerations When Making Decisions for Severely Disabled Newborns.

Children born with severe handicapping conditions, where survival and quality of survival is indeterminate, present special challenges for families and health-care professionals tasked with deciding the best courses of treatment and care. The case of Baby G presents an opportunity to compare the relative effectiveness of ethical versus rights theories in providing guidance about what obligations are owed to such children at bedside and how those obligations pertain to broader societal duties in a rights framework. We review common theories of determining the "best interests standard" of newborn decision-making and the priority of families to decide on behalf of their children. We then discuss what support the rights framework of the U.N. Convention on the Rights of the Child (CRC) might lend to the best implementation of clinical ethics decision-making. Finally, we conclude that the universal nature of rights theory does not provide the particular, specific guidance needed at the bedside of the critically ill infant.

Networking Ethics: A Survey of Bioethics Networks Across the U.S.

Ethics networks have emerged over the last few decades as a mechanism for individuals and institutions over various regions, cities and states to converge on healthcare-related ethical issues. However, little is known about the development and nature of such networks. In an effort to fill the gap in the knowledge about such networks, a survey was conducted that evaluated the organizational structure, missions and functions, as well as the outcomes/products of ethics networks across the country. Eighteen established bioethics networks were identified via consensus of three search processes and were approached for participation. The participants completed a survey developed for the purposes of this study and distributed via SurveyMonkey. Responses were obtained from 10 of the 18 identified and approached networks regarding topic areas of: Network Composition and Catchment Areas; Network Funding and Expenses; Personnel; Services; and Missions and Accomplishments. Bioethics networks are designed primarily to bring ethics education and support to professionals and hospitals. They do so over specifically defined areas-states, regions, or communities-and each is concerned about how to stay financially healthy. At the same time, the networks work off different organizational models, either as stand-alone organizations or as entities within existing organizational structures.

Why we must leave our organs to others.

Organ procurement presents several ethical concerns (from what constitutes acceptable criteria for death to issues involved in specifically designating to whom an organ can be given), but none is more central than the concern for what are appropriate means for acquiring organs. The following discussion attempts a different perspective on the issue of organ procurement by arguing that, rather than appealing to our charitable consciences or our pocketbooks, relinquishing our organs after death in this day and age is, in fact, obligatory for most people. Each of us is pressed by the growing demand for our organs should we die "rightly," and that desperate need has risen to such a level that not to release our organs for transplantation would constitute a serious moral wrong.

Age and the allocation of organs for transplantation: a case study.

What role should age play in the allocation of organs for transplantation? Historically, older patients have not been listed as candidates for transplantation on the assumption that greater benefit could be obtained by favoring younger candidates, raising questions of equity and age discrimination. At the same time, organs offered for donation by the very old are frequently rejected because of concerns about length of viability. We examine a local case that challenges these practices: the liver from an elderly donor was successfully transplanted into an older patient. After exploring some of the potential problems with such a solution, we propose creating a second pool of organs from the very old for transplantation into older candidates, thus expanding the number of organs available, saving additional lives, and including the elderly more visibly in our transplant system.