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Med Decis Making ; 41(4): 408-418, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33660540


OBJECTIVE: To explore the key patient attributes important to members of the Australian general population when prioritizing patients for the final intensive care unit (ICU) bed in a pandemic over-capacity scenario. METHODS: A discrete-choice experiment administered online asked respondents (N = 306) to imagine the COVID-19 caseload had surged and that they were lay members of a panel tasked to allocate the final ICU bed. They had to decide which patient was more deserving for each of 14 patient pairs. Patients were characterized by 5 attributes: age, occupation, caregiver status, health prior to being infected, and prognosis. Respondents were randomly allocated to one of 7 sets of 14 pairs. Multinomial, mixed logit, and latent class models were used to model the observed choice behavior. RESULTS: A latent class model with 3 classes was found to be the most informative. Two classes valued active decision making and were slightly more likely to choose patients with caregiving responsibilities over those without. One of these classes valued prognosis most strongly, with a decreasing probability of bed allocation for those 65 y and older. The other valued both prognosis and age highly, with decreasing probability of bed allocation for those 45 y and older and a slight preference in favor of frontline health care workers. The third class preferred more random decision-making strategies. CONCLUSIONS: For two-thirds of those sampled, prognosis, age, and caregiving responsibilities were the important features when making allocation decisions, although the emphasis varies. The remainder appeared to choose randomly.

Atitude Frente a Saúde , Cuidados Críticos , Tomada de Decisões/ética , Alocação de Recursos para a Atenção à Saúde , Unidades de Terapia Intensiva , Pandemias , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Austrália , Ética Clínica , Feminino , Alocação de Recursos para a Atenção à Saúde/ética , Alocação de Recursos para a Atenção à Saúde/métodos , Humanos , Análise de Classes Latentes , Masculino , Pessoa de Meia-Idade , Admissão do Paciente , Opinião Pública , Inquéritos e Questionários , Triagem , Adulto Jovem
J Med Internet Res ; 23(3): e24883, 2021 03 11.
Artigo em Inglês | MEDLINE | ID: mdl-33651705


BACKGROUND: Effective communication during a health crisis can ease public concerns and promote the adoption of important risk-mitigating behaviors. Public health agencies and leaders have served as the primary communicators of information related to COVID-19, and a key part of their public outreach has taken place on social media platforms. OBJECTIVE: This study examined the content and engagement of COVID-19 tweets authored by Canadian public health agencies and decision makers. We propose ways for public health accounts to adjust their tweeting practices during public health crises to improve risk communication and maximize engagement. METHODS: We retrieved data from tweets by Canadian public health agencies and decision makers from January 1, 2020, to June 30, 2020. The Twitter accounts were categorized as belonging to either a public health agency, regional or local health department, provincial health authority, medical health officer, or minister of health. We analyzed trends in COVID-19 tweet engagement and conducted a content analysis on a stratified random sample of 485 tweets to examine the message functions and risk communication strategies used by each account type. RESULTS: We analyzed 32,737 tweets authored by 118 Canadian public health Twitter accounts, of which 6982 tweets were related to COVID-19. Medical health officers authored the largest percentage of COVID-19-related tweets (n=1337, 35%) relative to their total number of tweets and averaged the highest number of retweets per COVID-19 tweet (112 retweets per tweet). Public health agencies had the highest frequency of daily tweets about COVID-19 throughout the study period. Compared to tweets containing media and user mentions, hashtags and URLs were used in tweets more frequently by all account types, appearing in 69% (n=4798 tweets) and 68% (n=4781 tweets) of COVID-19-related tweets, respectively. Tweets containing hashtags also received the highest average retweets (47 retweets per tweet). Our content analysis revealed that of the three tweet message functions analyzed (information, action, community), tweets providing information were the most commonly used across most account types, constituting 39% (n=181) of all tweets; however, tweets promoting actions from users received higher than average retweets (55 retweets per tweet). When examining tweets that received one or more retweet (n=359), the difference between mean retweets across the message functions was statistically significant (P<.001). The risk communication strategies that we examined were not widely used by any account type, appearing in only 262 out of 485 tweets. However, when these strategies were used, these tweets received more retweets compared to tweets that did not use any risk communication strategies (P<.001) (61 retweets versus 13 retweets on average). CONCLUSIONS: Public health agencies and decision makers should examine what messaging best meets the needs of their Twitter audiences to maximize sharing of their communications. Public health accounts that do not currently employ risk communication strategies in their tweets may be missing an important opportunity to engage with users about the mitigation of health risks related to COVID-19.

/epidemiologia , Tomada de Decisões/ética , Saúde Pública , Mídias Sociais/tendências , Canadá/epidemiologia , Humanos , /isolamento & purificação
J Clin Ethics ; 32(1): 61-68, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33656457


This article addresses a common yet rarely discussed aspect of hospital care-a pro-active approach to ethical dilemmas. Potential ethical conflicts often present warning signs to clinicians, analogous to the warning lights on a car's dashboard. Using a recent case study, a commonly encountered clinical decision-a conflict about whether to terminally extubate a critically ill patient versus whether to offer a tracheostomy-we describe a pro-active approach to ethical conflicts and outline three learning objectives: (1) the need for a robust understanding of the term "futility," (2) the need for an appreciation the various and often conflicting interpretations of "improved/improving," and (3) the need to understand the challenges of surrogate decision making.

Tomada de Decisões/ética , Futilidade Médica , Princípios Morais , Médicos , Humanos
BMC Med Ethics ; 22(1): 28, 2021 03 22.
Artigo em Inglês | MEDLINE | ID: mdl-33752662


BACKGROUND: The worsening COVID-19 pandemic in South Africa poses multiple challenges for clinical decision making in the context of already-scarce ICU resources. Data from national government and the last published national audit of ICU resources indicate gross shortages. While the Critical Care Society of Southern Africa (CCSSA) guidelines provide a comprehensive guideline for triage in the face of overwhelmed ICU resources, such decisions present massive ethical and moral dilemmas for triage teams. It is therefore important for the health system to provide clinicians and critical care facilities with as much support and resources as possible in the face of impending pandemic demand. Following a discussion of the ethical considerations and potential challenges in applying the CCSSA guidelines, the authors propose a framework for regional triage committees adapted to the South African context. DISCUSSION: Beyond the national CCSSA guidelines, the clinician has many additional ethical and clinical considerations. No single ethical approach to decision-making is sufficient, instead one which considers multiple contextual factors is necessary. Scores such as the Clinical Frailty Score and Sequential Organ Failure Assessment are of limited use in patients with COVID-19. Furthermore, the clinician is fully justified in withdrawing ICU care based on medical futility decisions and to reallocate this resource to a patient with a better prognosis. However, these decisions bear heavy emotional and moral burden compounded by the volume of clinical work and a fear of litigation. CONCLUSION: We propose the formation of Provincial multi-disciplinary Critical Care Triage Committees to alleviate the emotional, moral and legal burden on individual ICU teams and co-ordinate inter-facility collaboration using an adapted framework. The committee would provide an impartial, broader and ethically-sound viewpoint which has time to consider broader contextual factors such as adjusting rationing criteria according to different levels of pandemic demand and the latest clinical evidence. Their functioning will be strengthened by direct feedback to national level and accountability to a national monitoring committee. The potential applications of these committees are far-reaching and have the potential to enable a more effective COVID-19 health systems response in South Africa.

Cuidados Críticos/ética , Tomada de Decisões/ética , Alocação de Recursos para a Atenção à Saúde/ética , Unidades de Terapia Intensiva , Pandemias , Triagem/métodos , Comportamento Cooperativo , Emoções , Ética Médica , Recursos em Saúde , Humanos , Futilidade Médica , Prognóstico , África do Sul , Triagem/ética
Acad Med ; 96(6): 798-801, 2021 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-33637659


The glaring racial inequities in the impact of the COVID-19 pandemic and the devastating loss of Black lives at the hands of police and racist vigilantes have catalyzed a global reckoning about deeply rooted systemic racism in society. Many medical training institutions in the United States have participated in this discourse by denouncing racism, expressing solidarity with people of color, and reexamining their diversity and inclusion efforts. Yet, the stagnant progress in recruiting, retaining, and supporting racial/ethnic minority trainees and faculty at medical training institutions is well documented and reflects unaddressed systemic racism along the academic pipeline. In this article, the authors draw upon their experiences as early-career physicians of color who have led and supported antiracism efforts within their institutions to highlight key barriers to achieving meaningful progress. They describe common pitfalls of diversity and inclusion initiatives and call for an antiracist approach to systems change. The authors then offer 9 recommendations that medical training institutions can implement to critically examine and address racist structures within their organizations to actualize racial equity and justice.

Afro-Americanos/psicologia , Preceptoria/métodos , Racismo/prevenção & controle , Afro-Americanos/etnologia , /epidemiologia , Diversidade Cultural , Tomada de Decisões/ética , Grupos Étnicos/psicologia , Humanos , Grupos Minoritários/psicologia , Preceptoria/estatística & dados numéricos , Justiça Social , Estados Unidos/etnologia
Int Nurs Rev ; 68(2): 181-188, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-33615479


AIM: To identify factors underlying ethical conflict occurring during the current COVID-19 pandemic in the critical care setting. BACKGROUND: During the first wave of the COVID-19 outbreak, Spanish and Italian intensive care units were overwhelmed by the demand for admissions. This fact revealed a crucial problem of shortage of health resources and rendered that decision-making was highly complex. SOURCES OF EVIDENCE: Applying a nominal group technique this manuscript identifies a series of factors that may have played a role in the emergence of the ethical conflicts in critical care units during the COVID-19 pandemic, considering ethical principles and responsibilities included in the International Council of Nurses Code of Ethics. The five factors identified were the availability of resources; the protection of healthcare workers; the circumstances surrounding decision-making, end-of-life care, and communication. DISCUSSION: The impact of COVID-19 on health care will be long-lasting and nurses are playing a central role in overcoming this crisis. Identifying these five factors and the conflicts that have arisen during the COVID-19 pandemic can help to guide future policies and research. CONCLUSIONS: Understanding these five factors and recognizing the conflicts, they may create can help to focus our efforts on minimizing the impact of the ethical consequences of a crisis of this magnitude and on developing new plans and guidelines for future pandemics. IMPLICATIONS FOR NURSING PRACTICE AND POLICY: Learning more about these factors can help nurses, other health professionals, and policymakers to focus their efforts on minimizing the impact of the ethical consequences of a crisis of this scale. This will enable changes in organizational policies, improvement in clinical competencies, and development of the scope of practice.

/terapia , Tomada de Decisões/ética , Ética Institucional , Unidades de Terapia Intensiva/ética , Pneumonia Viral/terapia , Assistência Terminal/ética , /epidemiologia , Humanos , Itália/epidemiologia , Pandemias , Pneumonia Viral/epidemiologia , Pneumonia Viral/virologia , Espanha/epidemiologia
HEC Forum ; 33(1-2): 73-90, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-33587216


The Covid-19 pandemic has presented major challenges to society, exposing preexisting ethical weaknesses in the modern social fabric's ability to respond. Distrust in government and a lessened authority of science to determine facts have both been exacerbated by the polarization and disinformation enhanced by social media. These have impaired society's willingness to comply with and persevere with social distancing, which has been the most powerful initial response to mitigate the pandemic. These preexisting weaknesses also threaten the future acceptance of vaccination and contact tracing, two other tools needed to combat epidemics. Medical ethicists might best help in this situation by promoting truth-telling, encouraging the rational adjudication of facts, providing transparent decision-making and advocating the virtue of cooperation to maximize the common good. Those interventions should be aimed at the social level. The same elements of emphasizing cooperation and beneficence also apply to the design of triage protocols for when resources are overwhelmed. A life-stages approach increases beneficence and reduces harms. Triage should be kept as simple and straightforward as reasonably possible to avoid unwieldly application during a pandemic.

/prevenção & controle , Eticistas , Pandemias/prevenção & controle , Papel Profissional , Comportamento Cooperativo , Tomada de Decisões/ética , Humanos , Alocação de Recursos/ética , Triagem/ética , Revelação da Verdade/ética
Clin J Oncol Nurs ; 25(1): 61-68, 2021 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-33480884


BACKGROUND: The disruption in the supply chain of resources and interruptions in cancer treatments caused by the pandemic presented tremendous challenges to the healthcare system. OBJECTIVES: This article describes the National Academy of Medicine-defined states of medical and nursing care delivery for which local plans should be drawn and the shifting and evolving systems framework that can guide decisions to optimize the crisis standards of care. METHODS: A case study is presented to describe the process of shifting the state of medical and nursing care delivery and bioethical nursing considerations during the pandemic and beyond. FINDINGS: An evolving and shifting systems framework for crises rooted in deontology, principlism, and the ethics of care model provide meaningful guidance for establishing priorities for patient care.

/enfermagem , Tomada de Decisões/ética , Assistência à Saúde/ética , Neoplasias/enfermagem , Enfermagem Oncológica/ética , Enfermagem Oncológica/normas , Pandemias/ética , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias/prevenção & controle , Guias de Prática Clínica como Assunto
Healthc Manage Forum ; 34(3): 193-195, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33353414


The COVID-19 pandemic has required healthcare organizations to introduce risk mitigation strategies that challenge usual family presence (visitor) policies. Policies within healthcare must be viewed from an ethical lens, which includes ensuring that the patient voice helps guide decision-making. In considering pandemic-specific family presence policies, Kingston Health Sciences Centre, an academic tertiary care hospital in Southeastern Ontario, applied an ethical framework for decision-making. The various tensions between the values of duty to provide care, protection of the public from harm, transparency, proportionality, and patient-centred care are highlighted in a discussion of how patient partners contributed to decision-making about family presence in the first 9 months of the COVID-19 pandemic.

/epidemiologia , Tomada de Decisões/ética , Instalações de Saúde/ética , Controle de Infecções , Política Organizacional , Visitas a Pacientes , Humanos , Ontário/epidemiologia , Pandemias
J Med Ethics ; 47(2): 108-112, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33335068


One prominent view in recent literature on resource allocation is Persad, Emanuel and Wertheimer's complete lives framework for the rationing of lifesaving healthcare interventions (CLF). CLF states that we should prioritise the needs of individuals who have had less opportunity to experience the events that characterise a complete life. Persad et al argue that their system is the product of a successful process of reflective equilibrium-a philosophical methodology whereby theories, principles and considered judgements are balanced with each other and revised until we achieve an acceptable coherence between our various beliefs. Yet I argue that many of the principles and intuitions underpinning CLF conflict with each other, and that Persad et al have failed to achieve an acceptable coherence between them. I focus on three tensions in particular: the conflict between the youngest first principle and Persad et al's investment refinement; the conflict between current medical need and a concern for lifetime equality; and the tension between adopting an objective measure of complete lives and accommodating for differences in life narratives.

Tomada de Decisões/ética , Ética Clínica , Alocação de Recursos para a Atenção à Saúde/ética , Equidade em Saúde/ética , Justiça Social , Triagem/ética , Assistência à Saúde/ética , Análise Ética , Prioridades em Saúde/ética , Nível de Saúde , Humanos , Princípios Morais
Rev. bioét. derecho ; (50): 37-61, nov. 2020.
Artigo em Espanhol | IBECS | ID: ibc-191345


Este documento ofrece una propuesta desde la perspectiva de la bioética para la elaboración de un protocolo de triaje en el contexto de la pandemia de COVID-19. Dicha propuesta incluye recomendaciones sobre las normas procedimentales y normas sustantivas que deben regir la asignación y reasignación de recursos terapéuticos en condiciones de escasez extrema

This document offers a proposal for the elaboration of a triage guideline in the context of the COVID-19 pandemic. This proposal includes recommendations on the procedural norms and substantive norms that should govern the allocation and reallocation of therapeutic resources in conditions of extreme scarcity

Aquest document ofereix una proposta des de la perspectiva de la bioètica per a l'elaboració d'un protocol de triatge en el context de la pandèmia de COVID-19. L'esmentada proposta inclou recomanacions sobre les normes procedimentals I normes substantives que han de regir l'assignació I reassignació de recursos terapèutics en condicions d'escassetat extrema

Infecções por Coronavirus/epidemiologia , Pneumonia Viral/epidemiologia , Pandemias/ética , Protocolos Clínicos , Triagem/ética , Tomada de Decisões/ética
Rev. bioét. derecho ; (50): 189-203, nov. 2020.
Artigo em Espanhol | IBECS | ID: ibc-191353


La actual pandemia por la COVID-19 está ocasionado serias amenazas para la salud pública a nivel mundial, especialmente para los grupos de población más vulnerables. Los casos más graves de la enfermedad han sido primeramente atendidos por los profesionales de urgencias y emergencias, los cuales han tenido que tomar decisiones en contextos altamente complejos donde la priorización en la asignación de los recursos sanitarios disponibles les ha generado situaciones éticamente conflictivas. El objetivo del presente artículo es analizar la importancia de implantar la PDA en los servicios de urgencias y emergencias como herramienta de consulta en la resolución de los problemas éticos surgidos durante la pandemia por COVID-19, concretamente, en la atención al paciente crónico complejo o con enfermedad crónica avanzada

The events of the present CoVID-19 pandemic are causing serious threats to Public Health worldwide, specifically at the most vulnerable population groups. Emergency professionals have served as the first responders for the most serious cases of this disease. At the same time, they have made decisions in highly complex contexts where the prioritization of allocated care resources has generated ethically conflictive situations. The aim of this article is to analyze the importance of implementing the ACP as a tool in the emergency services to solve ethical problems that have arisen during the COVID-19 pandemic, particularly in the care of complex chronic patients or those with advanced chronic disease

L'actual pandèmia per la COVID-19 està ocasionat serioses amenaces a la salut pública a nivell mundial, especialment als grups de població més vulnerables. Els casos més greus de la malaltia han estat primerament atesos pels professionals d'urgències I emergències, els quals han hagut de prendre decisions en contextos altament complexos on la priorització en l'assignació dels recursos sanitaris disponibles els ha generat situacions èticament conflictives. L'objectiu d'aquest article va ser analitzar la importància d'implantar la PDA en els serveis d'urgències I emergències com a eina de consulta a la resolució dels problemes ètics sorgits durant la pandèmia per COVID-19, concretament, en l'atenció al pacient crònic complex o amb malaltia crònica avançada

Humanos , Prioridades em Saúde/ética , Prioridades em Saúde/organização & administração , Planejamento de Assistência ao Paciente , Tomada de Decisões/ética , Conflito de Interesses , Serviços Médicos de Emergência/ética , Infecções por Coronavirus/epidemiologia , Pneumonia Viral/epidemiologia , Pandemias , Doença Crônica
J Med Ethics ; 46(11): 726-731, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32913116


It has recently been reported that some hospitals in the UK have placed a blanket restriction on the provision of maternal request caesarean sections (MRCS) as a result of the COVID-19 pandemic. Pregnancy and birthing services are obviously facing challenges during the current emergency, but we argue that a blanket ban on MRCS is both inappropriate and disproportionate. In this paper, we highlight the importance of MRCS for pregnant people's health and autonomy in childbirth and argue that this remains crucial during the current emergency. We consider some potential arguments-based on pregnant people's health and resource allocation-that might be considered justification for the limitation of such services. We demonstrate, however, that these arguments are not as persuasive as they might appear because there is limited evidence to indicate either that provision of MRCS is always dangerous for pregnant people in the circumstances or would be a substantial burden on a hospital's ability to respond to the pandemic. Furthermore, we argue that even if MRCS was not a service that hospitals are equipped to offer to all pregnant persons who seek it, the current circumstances cannot justify a blanket ban on an important service and due attention must be paid to individual circumstances.

Cesárea/ética , Tomada de Decisões/ética , Alocação de Recursos para a Atenção à Saúde/ética , Direitos Humanos , Pandemias/ética , Complicações Infecciosas na Gravidez/prevenção & controle , Betacoronavirus , Cesárea/efeitos adversos , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/virologia , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Procedimentos Cirúrgicos Eletivos/ética , Feminino , Saúde , Hospitais , Humanos , Mães , Pandemias/prevenção & controle , Autonomia Pessoal , Pneumonia Viral/epidemiologia , Pneumonia Viral/prevenção & controle , Pneumonia Viral/virologia , Gravidez , Complicações Infecciosas na Gravidez/epidemiologia , Complicações Infecciosas na Gravidez/etiologia , Complicações Infecciosas na Gravidez/virologia , Gestantes , Reino Unido
Rev. bioét. (Impr.) ; 28(3): 410-417, jul.-set. 2020.
Artigo em Português | LILACS | ID: biblio-1137123


Resumo Este artigo busca identificar contribuições da bioética para enfrentar conflitos relacionados à tomada de decisão em tempos de pandemia. Trata-se de texto elaborado a partir de reflexões pessoais dos autores em diálogo com a literatura de diferentes perspectivas da bioética. Com fundamento em relatos históricos, argumenta-se que, durante epidemias, a sociedade passa a atuar em modo de excepcionalidade, o que exige argumentação mais apurada para se posicionar ante os conflitos que surgem. Analisam-se então diferentes vertentes teóricas - principialismo, personalismo, utilitarismo e bioética social -, recolhendo de cada uma elementos que podem nortear a tomada de decisão. Com base nessas contribuições, propõem-se parâmetros para a atuação dos profissionais da saúde, reconhecendo igual valor em cada vida humana, com o propósito de salvar o maior número de pessoas possível. Por fim, aponta-se para a responsabilidade de agentes políticos.

Abstract This article aims to identify the contribution of bioethics to resolve decision-making conflicts in healthcare in times of pandemic. The research was based on the authors' personal reflections in a dialogue with the literature and different bioethical perspectives. Historical accounts show that when a society is experiencing an epidemic it starts to function in a mode of social exceptionality, reinforcing the need for a more appropriate form of reasoning before the ethical conflicts that may arise from this situation. Some approaches to bioethics - principlism, personalism, utilitarianism and social bioethics - are briefly examined in order to obtain the elements for guiding the decision-making process. Finally, we suggest some parameters for health professionals, recognizing the value of all human lives, to save as many lives as possible.

Resumen Este artículo tiene como objetivo identificar la contribución de la bioética para hacer frente a los conflictos relacionados con la toma de decisiones en tiempos de pandemia. Se trata de un texto elaborado con base en las reflexiones personales de los autores en diálogo con la literatura de diferentes perspectivas de la bioética. Con base en los relatos históricos, se argumenta que, durante epidemias, la sociedad pasa a actuar en modo de excepcionalidad, lo que requiere una argumentación más precisa para posicionarse ante los conflictos que surgen. Se analizan entonces diferentes vertientes teóricas -el principialismo, el personalismo, el utilitarismo y la bioética social-, recogiendo de cada una los elementos que pueden orientar la toma de decisiones. Con base en dichas contribuciones, se proponen parámetros para la actuación de los profesionales de la salud, reconociendo el mismo valor en cada vida humana, con el propósito de salvar al mayor número posible de personas. Por fin, se apunta hacia la responsabilidad de los agentes políticos.

Grupos de Risco , Bioética , Infecções por Coronavirus , Teoria Ética , Pessoalidade , Tomada de Decisões/ética , Pandemias