Abstract
Ethics are considered a basic aptitude in healthcare, and the capacity to handle ethical dilemmas in tough times calls for an adequate, responsible, and blame-free environment. While do-not-resuscitate (DNR) decisions are made in advance in certain medical situations, in particular in the setting of poor prognosis like in advanced oncology, the discussion of DNR in relation to acute medical conditions, the COVID-19 pandemic in this example, might impose ethical dilemmas to the patient and family, healthcare providers (HCPs) including physicians and nurses, and to the institution. The literature on DNR decisions in the more recent pandemics and outbreaks is scarce. DNR was only discussed amid the H1N1 influenza pandemic in 2009, with clear global recommendations. The unprecedented condition of the COVID-19 pandemic leaves healthcare systems worldwide confronting tough decisions. DNR has been implemented in some countries where the healthcare system is limited in capacity to admit, and thus intubating and resuscitating patients when needed is jeopardized. Some countries were forced to adopt a unilateral DNR policy for certain patient groups. Younger age was used as a discriminator in some, while general medical condition with anticipated good outcome was used in others. The ethical challenge of how to balance patient autonomy vs. beneficence, equality vs. equity, is a pressing concern. In the current difficult situation, when cases top 100 million globally and the death toll surges past 2.7 million, difficult decisions are to be made. Societal rather than individual benefits might prevail. Pre-hospital triaging of cases, engagement of other sectors including mental health specialists and religious scholars to support patients, families, and HCPs in the frontline might help in addressing the psychological stress these groups might encounter in addressing DNR in the current situation.
Highlights
Cardiopulmonary resuscitation (CPR) was first devised in 1530 [1]
Triaging patients including COVID-19 patients, those with acute conditions like cardiopulmonary cases, those with emergency surgical intervention as well as cancer patients planned for elective surgeries which can be postponed for a maximum of a few weeks, but no longer, would be an important ethical consideration when addressing the potential of limited resources should intensive care unit (ICU) and ventilators be needed
In Italy, around 50% of hospital beds in a 1,000-bed hospital in Northern Italy were occupied by COVID-19 patients [32], leaving the other half to deal with the rest of the other medical conditions, which might be sub-optimal to say the least
Summary
Cardiopulmonary resuscitation (CPR) was first devised in 1530 [1]. it was only in 1956 that CPR was reinvented and refined into the currently known and performed technique [2]. How ethical is it to consider unilateral (i.e., without prior consent of patient) DNR orders for COVID19 infected patients in the face of limited resources? An exhaustive literature review using PubMed, Medline, Science Direct, and online news sites was undertaken to gather evidence and summarize the local, regional, and international recommendations How ethical is it to consider unilateral DNR orders for COVID-19 patients in the face of limited resources?. Triaging patients including COVID-19 patients, those with acute conditions like cardiopulmonary cases, those with emergency surgical intervention as well as cancer patients planned for elective surgeries which can be postponed for a maximum of a few weeks, but no longer, would be an important ethical consideration when addressing the potential of limited resources should ICUs and ventilators be needed. This could compromise the small windows cancer patients might have, difficult decisions are made in anticipation of the worst (Ethical Considerations for Treating Cancer Patients during the SARS-COV-2 Virus Crisis: To Treat or Not to Treat? A Cancer Center in Low-Middle Income Country)
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