TROUBLE ON THE FRONTLINES: ETHICS OF CPR

TROUBLE ON THE FRONTLINES

THE ETHICS OF CARDIOPULMONARY RESUSCITATION DURING COVID-19

By Shayna Cohen Riley Hurr

Eight months after the World Health Organization (WHO) officially declared the COVID19 outbreak as a pandemic, the impact COVID-19 has had on the lives of physicians, patients, and their families has been immense and profoundly tragic. As of November 10th, there have been over 240,000 deaths from COVID19 in the United States alone, which comes along with another sobering statistic: 1,361 US healthcare providers (HCPs) caring for COVID-19 patients have died. With national PPE shortages and COVID-19 cases continuing to surge in many places, putting stress on critical care resources, the ability for frontline workers to protect themselves while adequately serving patients seems more and more difficult. Along with potentially exposing themselves and their families to an incredibly infectious virus, HCPs are also evidently struggling with seeing the harsh realities of the pandemic firsthand, and as a result some have experienced significant struggles with their own mental health. Broadly, the COVID-19 pandemic is forcing HCPs and their institutions to radically redefine what it means to provide treatment in a time of crisis. Specifically, withholding cardiopulmonary resuscitation (CPR) from COVID-19 patients has been up for discussion in some hospitals since CPR requires close proximity to a patient and can lead to more airborne transmission.

For the hospitals considering policies like withholding CPR, there are a number of reasons why this could be advantageous. Primarily, withholding CPR from COVID-19 patients seems to be

the way to objectively save the most lives. If a HCP gets COVID19 from a patient, they would be unable to take care of other patients for an absolute minimum of 14 days. If life-saving measures are not performed on COVID-19 patients, it would be less likely for an HCP to contract it from the patient in the first place. Additionally, CPR can also cause sputum and other bodily fluids to escape, since oftentimes recovery after being resuscitated involves coughing and possibly even throwing up. Even with all the precautions taken, there is still a risk that the SARS-CoV-2 virus could be airborne and transmitted not just to frontline workers but to other patients in the hospital, especially if there aren’t enough ICU beds or negative pressure rooms to effectively isolate COVID-19 patients. Outside of the sheer number of lives saved, resuscitation efforts do not seem to be all that successful at saving the lives of the COVID-19 patients themselves. It has been reported out of Wuhan, China that, of the COVID-19 patients who experienced cardiac arrest and needed CPR, there was only a 2.9% survival rate after resuscitation measures were performed. Finally, although frontline workers surely have some kind of obligation to help those seeking treatment, it is worth saying that it seems unreasonable to expect or mandate physicians to put their own lives at risk to treat anyone else.

On the other hand, there are a number of ethical problems that come about with refusal to resuscitate any COVID-19 patient. Namely, COVID-19 is by no means a monolithic disease, and individuals who become sick with COVID-19 and may need to be hospitalized can be from a wide range of demographics with a variety of possible comorbidities. As a result, there are a number of considerations that would likely need to go into determining who should and shouldn't be eligible to receive resuscitation efforts, and there is the possibility that such policies could unintentionally lead to ageism and ableism in medical care. These disparities in treatment already exist to some degree due to limited ventilators and the very nature of COVID-19 but would likely be even further exacerbated by institutional policies on resuscitation. Additionally, there are many questions related to the autonomy of patients and their families. While some patients may opt for a do-not-resuscitate (DNR) order, there are undoubtedly many patients who would want to receive CPR and other life-saving measures. Is it unjust for HCPs to deny care to someone who actively seeks it, regardless of the risk to themselves or others?

With all of these considerations in mind, it seems that the best course of action for frontline workers and their patients is for CPR to be given to COVID-19 patients only after the code team has donned appropriate PPE. If appropriate PPE is not available, hospitals and clinics should not require frontline workers to administer CPR without the proper protection. This framework accomplishes two key things: 1) it protects the autonomy and safety of the frontline workers treating COVID-19 patients, and 2) it allows for COVID-19 patients to be treated by all HCPs when PPE is available or perhaps by some HCPs who still wish to offer CPR even without proper PPE. Ultimately, autonomy of frontline workers and their patients ought to be prioritized above all else. Respecting the autonomy of healthcare workers means that they should not be forced to provide close-contact care without proper PPE, but at the same time, no one should actively prevent them from providing that care if

they wish to do so and understand the risks. This allows the HCPs to make the decision based on what they feel most comfortable with while still ensuring that COVID19 patients may still receive CPR under the right conditions. In a situation as complex and sobering as the COVID-19 pandemic, it is incredibly important that all those directly involved have a say in the prescription of treatment protocols, especially protocols like CPR. By honoring the autonomy of both the HCPs and the patients, healthcare institutions may be able to reconcile competing wishes into a situation that respects everyone’s boundaries while still fulfilling the mission of providing as high quality care as possible.

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