The current COVID-19 pandemic raises important questions about the role of emergency physicians in making decisions about CPR and allocation of scarce resources.

Follow Guidelines

CPR efforts expend significant human and material resources, and they are associated with poor outcomes. Emergency physicians caring for patients with critical illness should help those patients understand their treatment alternatives and encourage them to reflect on and communicate their goals of care. Information about prognosis, including published data indicating that a high percentage of elderly COVID-19 patients with respiratory failure do not survive despite ventilator therapy, can enable patients to make more informed decisions about accepting or forgoing certain treatment options.¹

Treating physicians routinely ask about preferences regarding CPR, but physicians also make some decisions about whether and how to do CPR. When physicians are making such decisions, they should consider the likelihood of benefit (ie, survival to discharge), as well as the risks to providers (disease transmission despite appropriate personal protective equipment [PPE]), and other patients (diversion of resources from the care of other patients). According to American Heart Association guidelines, when CPR is performed on patients with known or suspected COVID-19, treatment priorities include:²

• Reduce provider exposure (appropriate PPE, limit number of persons in the room).
• Prioritize oxygenation and ventilation strategies with lower aerosolization risk.
• Consider the appropriateness of starting and continuing resuscitation.

In its policy on non-beneficial (“futile”) emergency medical interventions, ACEP offers additional guidance:³

• Physicians are under no ethical obligation to render interventions that they judge to have no realistic likelihood of benefit to the patient.
• An emergency physician’s judgments to withhold or withdraw requested interventions should be unbiased and should be based on available scientific evidence and societal and professional standards.

Delegate Allocation Decisions

The COVID-19 pandemic has produced a major surge of critically ill patients in several nations. When such a surge of patients exceeds the critical care capacity of a hospital or health system, physicians must decide how to allocate scarce resources, such as ventilators, ICU beds, and even general hospital beds. Health care systems should designate triage officers or teams with multidisciplinary expertise, rather than clinicians caring for these patients, to make allocation decisions.⁴ This independent approach not only serves to decrease or eliminate bias in triage decisions, but also shifts the burden of morally distressing triage decisions from emotionally involved caregivers to those for whom the decisions must be objective. In these crisis situations, emergency physicians may confront difficult decisions about how to allocate limited ED treatment resources provisionally among large numbers of severely ill ED patients, and they may also be responsible to alert triage teams promptly to the presence of ED patients with indications for scarce critical care resources.

In order to standardize the process, triage teams should use an established institutional, system, or statewide process and algorithm. These algorithms should avoid discrimination based on factors not medically relevant. In the absence of disease-specific risk stratification or mortality prediction models, mortality prediction scores, such as sequential organ failure assessment (SOFA) and pediatric logistic organ dysfunction (PELOD), have been widely adopted in triage algorithms.

Physicians, staff, and administrators should maintain transparency with patients and the community. Providers and triage teams should assist patients and families by communicating the reasons for allocation determinations, and should offer supportive services, including ethics consultants, palliative care, social work, and chaplaincy

References

1. Richardson S^,Jamie S. Hirsch JS, et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. JAMA. 2020;323(20):2052-2059.
2. Edelson DP, Sasson C, Chan PS, et al. Interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed COVID-19. Circulation. 2020;141:e933–e943
3. Nonbeneficial (“futile”) emergency medical interventions. Available at: https://www.acep.org/patient-care/policy-statements/nonbeneficial-futile-emergency-medical-interventions/. Accessed May 14, 2020.
4. Truog RD, Mitchell C, Daley GQ. The toughest triage—allocating ventilators in a pandemic. N Engl J Med. 2020;382(21):1973-1975.

Dr. Baker is professor of medical ethics at the University of Toledo College of Medicine and Life Sciences, Toledo, Ohio.

Dr. Moskop is professor of general internal medicine at the Wake Forest School of Medicine.

Dr. Vearrier is is an emergency medicine physician at the University of Mississippi Medical Center in Jackson.

Dr. Derse is the Julia and David Uihlein Chair in Medical Humanities at the Medical College of Wisconsin.

Dr. Marco is professor of emergency medicine & surgery at Wright State University.

Dr. Simon is associate professor of emergency medicine at Columbia University.