Code Blue During the COVID-19 Pandemic

Abstract

The surging COVID-19 pandemic has raised ethical and moral dilemmas that Western nations with first-rate medical care facilities rarely confront—how to best allocate standard life-saving medical resources when escalating demand outstrips supply. Sadly, these quandaries are familiar challenges in resource-poor countries. What makes this pandemic notable is that the scope and number of reported cases have been primarily in First World nations, raising questions in some settings about the use of emergency treatments like resuscitation care for in-hospital cardiac arrest (IHCA). This perspective reviews the debate around these ethical and moral dilemmas more broadly but focuses specifically on IHCA and the response of the medical community.

To date, the impact of the COVID-19 pandemic in the U.S. has varied widely by region. Already in certain areas of the U.S., hospitals have run out of intensive care unit (ICU) beds and mechanical ventilators for patients and personal protective equipment (PPE) for healthcare providers. Like Italian physicians in Lombardy before them, physicians are faced with decisions about rationing of healthcare resources. Deontological ethics emphasize that each person is valuable and should have an equal chance of receiving life-saving care (i.e., “first-come, first-served”). However, this framework in some instances is becoming an exercise of abstract argumentation as clinicians may be forced to apply utilitarian ethics to prioritize saving the most lives in settings with extremely limited resources.

But the disconnect is that, to date, physicians in the U.S. have had the luxury to practice medicine with an individual rather than a societal perspective. We have learned from and coveted our caring relationships with fellow human beings, and we have been largely spared from confronting medical scarcity at the bedside. By nature, training, and experience, we practice medicine in an ethical framework of deontology and not utilitarianism. Yet that equation changes when facing two patients with equal need but insufficient resources to care for both. Choosing between which patient receives life-saving care when the alternative outcome is certain death presents a situation of imminent moral distress.

Utilitarian decision-making has been the foundation with which some regions in Italy have handled medical personnel and extreme resource scarcity. In their document, “Clinical Ethics Recommendations for Allocation of Care in Resource-Limited Circumstances”,¹ the Italian Scientific Society of Anesthesiologists, Intensivists, and Pain Therapists recommend setting an age limit during this pandemic by which to deny a patient a ventilator and an ICU bed so as to maximize the benefit of limited intensive care resources for the greatest number of patients. Others in the U.S. have also advocated for a rationing approach in the setting of ventilator and ICU bed scarcity.^2–4 Critical to these policies is that these guidelines are set by ethics teams and provide a framework by which physicians abide. Such guiding principles permit physicians during this pandemic to exit the deontological framework by which they have always practiced and provide them some protection from the moral anguish in the impossible treatment decisions to be made.

In this ethical context, the management of IHCA, which affects an estimated 300,000 hospitalized patients in the U.S. annually in a non-pandemic year, is ever more important to address. IHCA is a medical emergency where prompt response and treatment are critical. In normal times, more than 1 in 5 patients with an IHCA survive to hospital discharge—a marked improvement from just two decades ago when 1 in 8 survived to discharge.⁵ During the COVID-19 pandemic, survival is expected to be much lower as there will be substantial delays in delivering potentially life-saving CPR during the first minutes after IHCA as healthcare providers don PPE prior to initiating resuscitations. Given the expected shortage of ventilators and ICU beds for patients and PPE for providers in some U.S. regions, some have even advocated Do-Not-Attempt-Resuscitate (DNAR)/Allow Natural Death (AND) orders for all COVID-19 patients irrespective of patient preferences or progniosis.⁶ Other hospitals have instituted policies delaying initiation of critical chest compressions until a patient with IHCA has been intubated because of the concern that CPR is an aerosol generating procedure and thus may endanger the health care provider. The time necessary for arrival at a patient’s room, donning PPE and securing an invasive airway may delay CPR by up to 10 minutes. Based on data from delays in CPR initiation for out-of-hospital cardiac arrests, deferring initiation of CPR for 10 minutes may decrease IHCA survival to far below 10% for all patients irrespective of COVID-19 status.

As leaders in resuscitation science, we understand and appreciate concerns with resuscitation care during the COVID-19 pandemic. Yet we believe there is a way to implement a more nuanced and contextualized approach to Code Blue responses for IHCA in order to balance ethics, healthcare provider safety, and scarce resources. To start, we believe hospitals should implement policies to clarify patients’ advanced directives and their COVID-19 status as soon as possible. All admitted patients regardless of COVID-19 status should have meaningful discussions about goals of care and DNAR/AND status on admission.

Next, resource management during an IHCA will vary depending on whether one’s hospital is confronted with imminent and extreme resource scarcity. For hospitals not in an extreme COVID-19 case surge but with moderate to high COVID-19 prevalence in the community and that have adequate ventilator and ICU bed capacity and PPE for the foreseeable future, a reasonable approach for IHCA resuscitations can be as follows. Among patients with suspected or confirmed COVID-19 disease, medical providers should don PPE prior to resuscitations. This is to protect healthcare providers as the Italian experience has shown that 1 in 6 hospitalized patients with COVID-19 are healthcare workers.⁷ However, initiation of CPR—an aerosolizing procedure—should not be delayed before securing an invasive airway, as this will unnecessarily deprive the patient of life-saving CPR as medical providers will already be in PPE. PPE, however, should be conserved; thus, the total number of providers in the resuscitation room should be limited to essential individuals for delivering CPR, securing an airway, administering intravenous drugs, and obtaining central venous access if needed. For patients whose COVID-19 status is unknown, resuscitation team members should still don PPE to protect themselves given that COVID-19 transmission can occur from asymptomatic patients.

For hospitals in the midst of an overwhelming COVID-19 surge with an existing or imminent shortage of ventilators, ICU beds, and PPE, we expect systems to consider instituting a utilitarian approach to guide whether or not to resuscitate any patient with IHCA, irrespective of COVID-19 status. To accomplish this, each hospital may need to organize an ethics team comprised of a physician, nurse, respiratory therapist, and ethicist to develop written protocols and review all admitted patients who are not DNAR/AND during a hospitalization and determine whether, in the event of cardiac arrest, the patient should undergo resuscitation efforts or be made DNAR/AND. If the latter, the patient would be informed as to the decision and the rationale. Allocation criteria could include evidence-based criteria such as age and comorbidities and evolve as epidemiology and outcomes data emerge. Such allocation criteria would be based on a patient’s expected number of years of life left to be lived and should be agnostic to race, sex, income, and position in society. The criteria ought to be reviewed regularly as treatment and knowledge about COVID-19 evolves and as hospital resources change. And if resources do not allow for this to occur for each admitted patient, a hospital’s ethics team may choose to focus on patients at highest risk for clinical decline and IHCA–e.g., patients who are ventilated and on intravenous vasopressors. In so doing, the ethics team will relieve individual responding healthcare providers of the responsibility in making rationing decisions—rationing decisions which will nonetheless occur when scarce resources in these settings are allocated on a first-come, first-served deontological framework. Unfortunately, in some settings, the already dire circumstances may preclude such an approach due to manpower.

Even for patients who are already on a ventilator, hospitals’ allocation criteria in areas with extreme resource scarcity could also recommend no resuscitative efforts if the likelihood of survival is expected to be extremely low to make available resources for others. Within GWTG-Resuscitation, we know that patients 80 years of age or older who have an IHCA while on a ventilator with an initial rhythm or asystole or pulseless electrical activity and concurrent pneumonia or sepsis have only a 3.7% likelihood of survival without severe neurological disability. If they are also on an intravenous vasopressor, that likelihood decreases to 2.7%. That translates to a number needed to resuscitate of 27 and 37, respectively. And in patients with COVID-19, these rates are expected to be lower as significant delays in initiating CPR are likely. Such considerations in a setting of extreme resource scarcity during a COVID-19 surge will ensure what limited ICU resources exist are maximized for the greatest societal benefit.

These are unprecedented times and we must plan for the challenges ahead. When confronted with extreme resource scarcity, rationing will occur regardless of whether one approaches the current COVID-19 crisis with a deontological or a utilitarian ethics framework. We are hopeful that hospitals can avoid the extreme policy of not performing resuscitations on any patient with IHCA regardless of prognosis, as some hospitals are envisioning. In any case, the lack of a systematic approach with clearly defined allocation criteria at hospitals with extreme resource scarcity will lead to inefficient use of medical therapies and deplete PPE, putting both patients’ and providers’ lives on the line.