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The Ethics of Unilateral Do-Not-Resuscitate Orders for COVID-19 Patients

Published online by Cambridge University Press:  10 January 2022

Abstract

This paper examines several decision-making models that have been proposed to limit the use of CPR for COVID-19 patients. My main concern will be to assess proposals for the implementation of unilateral DNRs — i.e., orders to withhold CPR without the agreement of patients or their surrogates.

Type
Independent Articles
Copyright
© 2021 The Author(s)

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References

Hick, J.L. et al., “Duty to Plan: Health Care, Crisis Standards of Care, and Novel Coronavirus SARS-CoV-2,” National Academy of Medicine Perspectives, March 5, 2020, available at < https://nam.edu/duty-to-plan-health-care-crisis-standards-of-care-and-novel-coronavirus-sars-cov-2/> (last visited November 9, 2020).Google ScholarPubMed
For a good example, see Zitter, J., Extreme Measures: Finding a Better Path to the End of Life (New York: Avery, 2017).Google Scholar
Zhou, F. et al., “Clinical Course and Risk Factors for Mortality of Adult Inpatients with COVID-19 in Wuhan, China: A Retrospective Cohort Study,” The Lancet 395, no. 10229 (2020): 10541062.CrossRefGoogle ScholarPubMed
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. Minnesota emphasizes that “proactive” triage is justified only when resources remain critically limited despite maximum efforts to conserve and adapt (“Crisis Standards”: 14-15). A key assumption reiterated throughout Washington’s “Scarce Resource Management” is that triage algorithms should be used only when “Healthcare systems are overwhelmed despite maximizing all surge and mitigation strategies impacting the space and/or staff and/or supplies needed to deliver usual levels of care.”Google Scholar
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Halpern and White, “Guidance for Decisions Regarding Cardiopulmonary Resuscitation.”Google Scholar
For an example of the ethical pitfalls and disparities that can arise when potentially life-sustaining interventions are withheld without sufficient clarity and transparency, see A. Waldman and J. Kaplan, “Sent Home to Die,” ProPublica, September 2, 2020, available at <https://www.propublica.org/article/sent-home-to-die> (last visited October 22, 2021). In this case, numerous patients (all of whom were African American) were discharged from or denied admission to Ochsner Medical Center in New Orleans, Louisiana after being told that nothing more could be done for them. While Ochsner denies any wrongdoing or deviation from standard protocols, confusion persists about whether these decisions were based on resource scarcity, and about whether some patients could have indeed benefitted from continued care in the hospital. There was, in addition, a perception of discrimination among some families.+(last+visited+October+22,+2021).+In+this+case,+numerous+patients+(all+of+whom+were+African+American)+were+discharged+from+or+denied+admission+to+Ochsner+Medical+Center+in+New+Orleans,+Louisiana+after+being+told+that+nothing+more+could+be+done+for+them.+While+Ochsner+denies+any+wrongdoing+or+deviation+from+standard+protocols,+confusion+persists+about+whether+these+decisions+were+based+on+resource+scarcity,+and+about+whether+some+patients+could+have+indeed+benefitted+from+continued+care+in+the+hospital.+There+was,+in+addition,+a+perception+of+discrimination+among+some+families.>Google Scholar

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