This article assesses ethical challenges during a public health emergency that necessitates shifting from optimizing care for every individual to care that saves the most lives. The article focuses on three ethical problems from the perspective of cardiovascular care: halting non-emergent clinical care, developing fair triage approaches, and counseling patients and families when treatments cannot be provided due to scarcity.
Halting non-emergent care requires cardiologists to make complex determinations regarding the urgency of care and to make many of these assessments via telemedicine without the benefit of physical exams or diagnostic tools. Additionally, clinicians must consider the risk of patients acquiring COVID-19 in clinical settings, as well as allocation of limited supplies of PPE and clinician and staff time. The authors note that these decisions are more common than rationing or triage decisions that have received greater attention, such as potential ventilator or ICU triage, but may be left to individual clinicians operating with little guidance.
Crisis standards of care (CSC) frameworks for ethically allocating scarce resources aim to uphold core ethical principles of fairness, duty to care, resource stewardship, transparency, consistency, proportionality, and accountability. Most CSC allocation systems prioritize saving the most lives and include assessment of patients’ likelihood of survival to discharge and near-term life expectancy. The authors note that these assessments are particularly complex for cardiac patients and that some commonly used tools (e.g., SOFA score) are poor predictors for cardiovascular diseases and associated mortality; however, balancing difficult ethical issues is a challenge commonly faced by advanced heart failure cardiologists regarding transplant allocation.
Communicating forced choices regarding care to patients and their families (e.g., limited resuscitation efforts or denial of ICU care due to scarcity) requires recognition that not providing usual care in an unusual situation is not unethical and does not reflect a judgment of the patient’s worth or a determination of futility. Such decisions should be made to maximize benefits and minimize harms as a function of external constraints, and the decisions should be made transparently and communicated honestly. Additionally, patients who are denied critical resources should continue to receive ongoing care and support.