Racial Equity, Diversity and Inclusion in Bioethics: Recommendations from the Association of Bioethics Program Directors Presidential Task Force.

Recent calls to address racism in bioethics reflect a sense of urgency to mitigate the lethal effects of a lack of action. While the field was catalyzed largely in response to pivotal events deeply rooted in racism and other structures of oppression embedded in research and health care, it has failed to center racial justice in its scholarship, pedagogy, advocacy, and practice, and neglected to integrate anti-racism as a central consideration. Academic bioethics programs play a key role in determining the field's norms and practices, including methodologies, funding priorities, and professional networks that bear on equity, inclusion, and epistemic justice. This article describes recommendations from the Racial Equity, Diversity, and Inclusion (REDI) Task Force commissioned by the Association of Bioethics Program Directors to prioritize and strengthen anti-racist practices in bioethics programmatic endeavors and to evaluate and develop specific goals to advance REDI.

Acknowledging the Burdens of 'Blackness'.

The novel coronavirus of 2019 exposed, in an undeniable way, the severity of racial inequities in America's healthcare system. As the urgency of the pandemic grew, administrators, clinicians, and ethicists became concerned with upholding the ethical principle of "most lives saved" by re-visiting crisis standards of care and triage protocols. Yet a colorblind, race-neutral approach to "most lives saved" is inherently inequitable because it reflects the normality and invisibility of 'whiteness' while simultaneously disregarding the burdens of 'Blackness'. As written, the crisis standards of care (CSC) adopted by States are racist policies because they contribute to a history that treats Black Americans are inherently less than. This paper will unpack the idealized fairness and equity pursued by CSC, while also considering the use of modified Sequential Organ Failure Assessment (mSOFA) as a measure of objective equality in the context of a healthcare system that is built on systemic racism and the potential dangers this can have on Black Americans with COVID-19.

A Fate Worse Than Death: Prognostication of Devastating Brain Injury.

OBJECTIVES: To describe the sources of uncertainty in prognosticating devastating brain injury, the role of the intensivist in prognostication, and ethical considerations in prognosticating devastating brain injury in the ICU. DATA SOURCES: A PubMed literature review was performed. STUDY SELECTION: Articles relevant to prognosis in intracerebral hemorrhage, acute ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, and postcardiac arrest anoxic encephalopathy were selected. DATA EXTRACTION: Data regarding definition and prognosis of devastating brain injury were extracted. Themes related to how clinicians perform prognostication and their accuracy were reviewed and extracted. DATA SYNTHESIS: Although there are differences in pathophysiology and therefore prognosis in the various etiologies of devastating brain injury, some common themes emerge. Physicians tend to have fairly good prognostic accuracy, especially in severe cases with poor prognosis. Full supportive care is recommended for at least 72 hours from initial presentation to maximize the potential for recovery and minimize secondary injury. However, physician approaches to the timing of and recommendations for withdrawal of life-sustaining therapy have a significant impact on mortality from devastating brain injury. CONCLUSIONS: Intensivists should consider the modern literature describing prognosis for devastating brain injury and provide appropriate time for patient recovery and for discussions with the patient's surrogates. Surrogates wish to have a prognosis enumerated even when uncertainty exists. These discussions must be handled with care and include admission of uncertainty when it exists. Respect for patient autonomy remains paramount, although physicians are not required to provide inappropriate medical therapies.

Pediatric Ethics Consultation: Practical Considerations for the Clinical Ethics Consultant.

Clinical ethics consultants face a wide range of ethical dilemmas that require broad knowledge and skills. Although there is considerable overlap with the approach to adult consultation, ethics consultants must be aware of differences when they work with infant, pediatric, and adolescent cases. This article addresses unique considerations in the pediatric setting, reviews foundational theories on parental authority, suggests practical approaches to pediatric consultation, and outlines current available resources for clinical ethics consultants who wish to deepen their skills in this area.

Technical Considerations for Implementation of Tele-Ethics Consultation in the Intensive Care Unit.

BACKGROUND: Robust ethics consultation services cannot be sustained by all hospitals; consultative service from a high-volume center via teleconferencing is an attractive alternative. This pilot study was conceived to explore the feasibility and understand the practical implications of offering such a service. METHODS: High-definition videoconferencing was used to provide real-time interaction between the rounding clinicians and a remote clinical ethicist. Data collection included: (1) evaluation of the hardware and software required for teleconferencing, and (2) comparison of ethics trigger counts between the remote and on-site ethicist during rounds. RESULTS: Issues with audio represented the majority of technical problems. Once technical difficulties were addressed, the on-site ethicist's count of "triggers" was not statistically different from the count of the remote ethicist. CONCLUSION: Remote clinical ethics rounding is feasible when the equipment is optimized. Remote ethicists can identify similar numbers of "triggers" for possible ethical issues when compared to on-site ethicist numbers.

Defining Futile and Potentially Inappropriate Interventions: A Policy Statement From the Society of Critical Care Medicine Ethics Committee.

OBJECTIVES: The Society of Critical Care Medicine and four other major critical care organizations have endorsed a seven-step process to resolve disagreements about potentially inappropriate treatments. The multiorganization statement (entitled: An official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units) provides examples of potentially inappropriate treatments; however, no clear definition is provided. This statement was developed to provide a clear definition of inappropriate interventions in the ICU environment. DESIGN: A subcommittee of the Society of Critical Care Medicine Ethics Committee performed a systematic review of empirical research published in peer-reviewed journals as well as professional organization position statements to generate recommendations. Recommendations approved by consensus of the full Society of Critical Care Medicine Ethics Committees and the Society of Critical Care Medicine Council were included in the statement. MEASUREMENTS AND MAIN RESULTS: ICU interventions should generally be considered inappropriate when there is no reasonable expectation that the patient will improve sufficiently to survive outside the acute care setting, or when there is no reasonable expectation that the patient's neurologic function will improve sufficiently to allow the patient to perceive the benefits of treatment. This definition should not be considered exhaustive; there will be cases in which life-prolonging interventions may reasonably be considered inappropriate even when the patient would survive outside the acute care setting with sufficient cognitive ability to perceive the benefits of treatment. When patients or surrogate decision makers demand interventions that the clinician believes are potentially inappropriate, the seven-step process presented in the multiorganization statement should be followed. Clinicians should recognize the limits of prognostication when evaluating potential neurologic outcome and terminal cases. At times, it may be appropriate to provide time-limited ICU interventions to patients if doing so furthers the patient's reasonable goals of care. If the patient is experiencing pain or suffering, treatment to relieve pain and suffering is always appropriate. CONCLUSIONS: The Society of Critical Care Medicine supports the seven-step process presented in the multiorganization statement. This statement provides added guidance to clinicians in the ICU environment.

Effect of Race and Ethnicity on Pulmonary Function Testing Interpretation: An American College of Chest Physicians (CHEST), American Association for Respiratory Care (AARC), American Thoracic Society (ATS), and Canadian Thoracic Society (CTS) Evidence Review and Research Statement.

BACKGROUND: Calls have been made to discontinue the routine use of race and ethnicity in medicine. Specific to respiratory medicine, the use of race- and ethnicity-specific reference equations for the interpretation of pulmonary function test (PFT) results has been questioned. RESEARCH QUESTIONS: Three key questions were addressed: (1) What is the current evidence supporting the use of race- and ethnicity-specific reference equations for the interpretation of PFTs? (2) What are the potential clinical implications of the use or nonuse of race and ethnicity in interpreting PFT results? and (3) What research gaps and questions must be addressed and answered to understand better the effect of race and ethnicity on PFT results interpretation and potential clinical and occupational health implications? STUDY DESIGN AND METHODS: A joint multisociety (American College of Chest Physicians, American Association for Respiratory Care, American Thoracic Society, and Canadian Thoracic Society) expert panel was formed to undertake a comprehensive evidence review and to develop a statement with recommendations to address the research questions. RESULTS: Several assumptions and gaps, both in the published literature and in our evolving understanding of lung health, were identified. It seems that many past perceptions and practices regarding the effect of race and ethnicity on PFT results interpretation are based on limited scientific evidence and measures that lack reliability. INTERPRETATION: A need exists for more and better research that will inform our field about these many uncertainties and will serve as a foundation for future recommendations in this area. The identified shortcomings should not be discounted or dismissed because they may enable flawed conclusions, unintended consequences, or both. Addressing the identified research gaps and needs would allow a better-a more informed-understanding of the effects of race and ethnicity on PFT results interpretation.

Anti-Black Racism as a Chronic Condition.

Because America has a foundation of anti-Black racism, being born Black in this nation yields an identity that breeds the consequences of a chronic condition. This article highlights several ways in which medicine and clinical ethics, despite the former's emphasis on doing no harm and the latter's emphasis on nonmaleficence, fail to address or acknowledge some of the key ways in which physicians can-and do-harm patients of color. To understand harm in a way that can provide real substance for ethical standards in the practice of medicine, physicians need to think about how treatment decisions are constrained by a patient's race. The color of one's skin can and does negatively affect the quality of a person's diagnosis, promoted care plan, and prognosis. Yet racism in medicine and bioethics persist-because a racist system serves the interests of the dominant caste, White people. As correctives to this system, the authors propose several antiracist commitments physicians or ethicists can make.

Treating Workers as Essential Too: An Ethical Framework for Public Health Interventions to Prevent and Control COVID-19 Infections among Meat-processing Facility Workers and Their Communities in the United States.

Meat is a multi-billion-dollar industry that relies on people performing risky physical work inside meat-processing facilities over long shifts in close proximity. These workers are socially disempowered, and many are members of groups beset by historic and ongoing structural discrimination. The combination of working conditions and worker characteristics facilitate the spread of SARS-CoV-2, the virus that causes COVID-19. Workers have been expected to put their health and lives at risk during the pandemic because of government and industry pressures to keep this "essential industry" producing. Numerous interventions can significantly reduce the risks to workers and their communities; however, the industry's implementation has been sporadic and inconsistent. With a focus on the U.S. context, this paper offers an ethical framework for infection prevention and control recommendations grounded in public health values of health and safety, interdependence and solidarity, and health equity and justice, with particular attention to considerations of reciprocity, equitable burden sharing, harm reduction, and health promotion. Meat-processing workers are owed an approach that protects their health relative to the risks of harms to them, their families, and their communities. Sacrifices from businesses benefitting financially from essential industry status are ethically warranted and should acknowledge the risks assumed by workers in the context of existing structural inequities.

The Future of Critical Care: Optimizing Technologies and a Learning Healthcare System to Potentiate a More Humanistic Approach to Critical Care.

While technological innovations are the invariable crux of speculation about the future of critical care, they cannot replace the clinician at the bedside. This article summarizes the work of the Society of Critical Care Medicine-appointed multiprofessional task for the Future of Critical Care. The Task Force notes that critical care practice will be transformed by novel technologies, integration of artificial intelligence decision support algorithms, and advances in seamless data operationalization across diverse healthcare systems and geographic regions and within federated datasets. Yet, new technologies will be relevant and meaningful only if they improve the very human endeavor of caring for someone who is critically ill.

Professional Societies' Role in Addressing Member Burnout and Promoting Well-Being.

Rationale: Critical care clinicians have high burnout rates. Previous studies have explored individual and organizational solutions to address burnout, but existing literature has not considered how professional societies can prevent burnout and promote member well-being. Objectives: The Critical Care Society Collaborative convened a task force to document professional society initiatives to address burnout, explore perspectives on the role of societies to address burnout, and develop recommendations that could guide critical care societies' efforts to promote well-being. Methods: We conducted a multiphase evaluation of 17 major U.S. professional societies whose members regularly work in critical care settings. We asked representatives from each society to document their existing well-being initiatives, and we conducted semistructured interviews to explore perspectives on the role of professional societies to address burnout. The task force members then met to discuss phase one and two findings to develop recommendations that could act as a roadmap to guide future society efforts. Results: All society representatives agreed that professional societies have a responsibility to address burnout, and they described various well-being initiatives that could act as examples for future efforts. We developed a roadmap with the following recommendations: 1) Acknowledge the problem of burnout; 2) Commit to supporting member well-being; 3) Create collaborations to promote well-being; 4) Educate and advocate for change; 5) Foster innovation through research; and 6) Support organizational and individual solutions. Conclusions: Our findings highlight a clear role for professional societies to address burnout and promote members' well-being.

Developing an Ethics Framework for Allocating Remdesivir in the COVID-19 Pandemic.

On May 1, 2020, the US Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) to allow use of the antiviral drug remdesivir to treat patients with severe coronavirus disease-2019 (COVID-19). Remdesivir is an investigational drug studied in clinical trials for COVID-19 and is available to children and pregnant women through compassionate-use access but is not yet FDA approved. In early May, the US Department of Health and Human Services began to distribute remdesivir, donated by Gilead Sciences, Inc., to hospitals and state health departments for emergency use; multiple shipments have since been distributed. This process has raised questions of how remdesivir should be allocated. The Minnesota Department of Health has collaborated with the Minnesota COVID Ethics Collaborative and multiple clinical experts to issue an Ethical Framework for May 2020 Allocation of Remdesivir in the COVID-19 Pandemic. The framework builds on extensive ethical guidance developed for public health emergencies in Minnesota before the COVID-19 crisis. The Minnesota remdesivir allocation framework specifies an ethical approach to distributing the drug to facilities across the state and then among COVID-19 patients within each facility. This article describes the process of developing the framework and adjustments in the framework over time with emergence of new data, analyzes key issues addressed, and suggests next steps. Sharing this framework and the development process can encourage transparency and may be useful to other states formulating and refining their approach to remdesivir EUA allocation.

Therapy for Pulmonary Arterial Hypertension in Adults: Update of the CHEST Guideline and Expert Panel Report.

BACKGROUND: Pulmonary arterial hypertension (PAH) carries a poor prognosis if not promptly diagnosed and appropriately treated. The development and approval of 14 medications over the last several decades have led to a rapidly evolving approach to therapy, and have necessitated periodic updating of evidence-based treatment guidelines. This guideline statement, which now includes a visual algorithm to enhance its clinical utility, represents the fourth iteration of the American College of Chest Physicians Guideline and Expert Panel Report on Pharmacotherapy for PAH. METHODS: The guideline panel conducted an updated systematic review to identify studies published after those included in the 2014 guideline. A systematic literature search was conducted using MEDLINE via PubMed and the Cochrane Library. The quality of the body of evidence was assessed for each critical or important outcome of interest using the Grading of Recommendations Assessment, Development and Evaluation approach. Graded recommendations and ungraded consensus-based statements were developed and voted on using a modified Delphi technique to achieve consensus. RESULTS: Two new recommendations on combination therapy and two ungraded consensus-based statements on palliative care were developed. An evidence-based and consensus-driven treatment algorithm was created to guide the clinician through an organized approach to management, and to direct readers to the appropriate area of the document for more detailed information. CONCLUSIONS: Therapeutic options for the patient with PAH continue to expand through basic discovery, translational science, and clinical trials. Optimal use of new treatment options requires prompt evaluation at an expert center, utilization of current evidence-based guidelines, and collaborative care using sound clinical judgment.