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Bioethical aspects of pre-hospital care in times of COVID-19

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The global coronavirus pandemic overwhelmed all health systems within and outside hospitals. The demand for material and human resources outstripped the ability to cope and led to a cascade of hasty decisions. These decisions did not always have positive results either in terms of human lives or global economies and the mental health of the general population.

While different dilemmas were experienced in the hospice services than those faced in the hospital setting, they were both based on the poor preparedness of staff to cope with a pandemic of initially unknown causes and the overstretch of needs over resources. However, pre-hospital care had an advantage in dealing with such scenarios: the knowledge, mastery and execution of triage protocols focused on prioritizing care and making resources more efficient.

Although one of the most dilemmas of the pandemic was choosing some patients over others, other problems left the door open to uncertainty, which should be reflected upon today in the face of an increasingly threatening future.

Pre-hospital care is defined by instability and uncertainty about the scenarios and patients that paramedics will attend to on arrival at a scene. Likewise, the dangerousness of the environments where care is provided must be assessed when making certain decisions, and time is always against us so that sometimes decisions must be based on protocols and the confidence that they have been tested and endorsed by prestigious institutions and authorities rather than on prudential judgements motivated by emotions and subjective feelings.

Thus, COVID represented a significant challenge for pre-hospital care because of the need to respond in the shortest possible time with resources that were not always available, but also because of the uncertain decisions faced by patients whose condition was unknown and whose prognosis was uncertain. 

Unlike in the hospital setting, paramedics cannot perform laboratory examinations or sophisticated tests at the site of the call because they do not have the resources or the time, making it very difficult to make both the decision to respond to the call for help and the decision whether or not to transport the patient.

This was made even more complex by the increasing saturation of hospitals no longer receiving suspected COVID patients. Nevertheless, aware of their professional and ethical responsibility and that a person’s survival depends on their actions, the paramedics were on the front line, never abandoning their patients. They did the most with the least.

In this chaos, it is worth mentioning some principles of bioethics that can serve as a guide for the future actions of paramedics in scenarios of stress, confusion and lack of information, such as the pandemic.

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Bioethics has been situated in many dimensions of human life, particularly in the medical field, to generate reflection on human actions in the face of life and health. (1), which is why it must propose ethical principles that illuminate the actions of health professionals in dilemmatic situations.

There are many currents in Bioethics (2), and each one has its principles, but there are some common principles that are shared and universally applicable; among them are the following:

  1. Principle of beneficence (3): stemming from the Hippocratic oath and which obliges us always to seek the good of the patient, the most practical application of which is to safeguard the physical life and integrity of the patient and always assist them at their moment of greatest vulnerability without omission or delay.
  2. Principle of non-maleficence(4): also derived from the oath mentioned above, this principle obliges avoiding all practices and treatments considered harmful or likely to aggravate the patient’s condition further.
  3. Principle of autonomy (5): This allows the patient to make decisions concerning his or her health and life through the rational use of the information provided. Autonomy has been debated because situations undermine the patient’s ability to decide (6), such as anxiety, fear, pain, anguish, and others. For this reason, three elements have been determined that help to consider whether the patient is autonomous or not: voluntariness, understanding of the information and freedom from coercion or manipulation (7).
  4. Principle of justice (8): establishes criteria and conditions for a fair and equitable distribution of resources that benefit all people. International protocols such as triage contribute to meeting these criteria.

These principles and others (9) also apply to the pre-hospital setting and should be extended to any other setting where interaction between one or more patients and one or more health professionals. They seek to elucidate the values at stake in a given situation, ranging from life itself, bodily integrity, freedom or the loss of a function to the need to protect the patient’s life and health.

Now, taking into account these guiding principles of Bioethics, during the COVID, there were many cases in which they should have intervened in pre-hospital decisions, especially in the dilemmas generated by the pandemic. We will discuss some of these in the following paragraphs.

Pre-hospital triage.

With its origins in the Napoleonic wars (10), triage was a protocol established to determine patients who had a chance of survival and could be transferred as a priority. Thus, through rapid movement analysis, understanding of commands, and assessing vital signs, patients are assigned specific colours and moved according to their assigned colour.

Selecting patients is a challenging and emotionally stressful decision (11) because even if you want to save everyone, you have limited resources and therefore have to give preference to others. However, if the triage protocol were not followed, no one would be saved. In these situations, another bioethical principle is the principle of the greater good (12, 13). This consists of appealing to a good that is considered greater, not only quantitatively but also qualitatively, and having to leave others aside. The greater good pursued in performing a triage is to save as many people as possible, knowing that it is impossible to save them all. The unethical thing to do would be to do nothing and be paralyzed just because the total good is impossible to achieve.

The many cases of people infected in the pandemic collapsed calls to the emergency response systems, and the rescue services had to start devising modifications to the protocols for handling calls to determine whether or not they were suspected COVID patients. If they were, they had to try to predict their condition to assess whether or not it was worthwhile to send an ambulance to the scene and make a transfer, knowing that it would most likely take hours to be admitted to a hospital, leaving other people with other types of emergencies unattended as a consequence.

From this point of view, there was a duty to look out for the patient’s wellbeing by the principle of beneficence. However, the situation that was being experienced was one of collective crisis, that is, the common good had to be preserved above the individual good, and therefore this principle guided to devise strategies such as assigning a limited number of ambulances to attend COVID cases without interrupting the care services of other emergencies. Once again, the principle of the greater good is present here.

Conscientious objection, omission of assistance and abandonment of patients

It is necessary to reaffirm that the safety of paramedics is the fundamental pillar on which all their activity rests. Therefore, given the untimely outbreak of the pandemic and the lack of knowledge regarding the modes of transmission of the virus, it was bioethically justifiable not to attend emergencies if they did not have the necessary personal protective equipment in order to protect their own lives and the lives of other colleagues, which is also a priority.

In no way does this mean that the conscientious objection of health personnel is valid, something that, due to the same search for the good of health, is not ethically valid, but rather that, in many cases lacking adequate protection, the personnel were not obliged to attend, but rather to channel help to other institutions that did have protective equipment and units available to attend to COVID patients. The omission of assistance and the abandonment of patients are contrary to the principle of beneficence and the very practice of intra- and extra-hospital medicine and being considered crimes in many legislations (14).

Informed consent and pre-hospital palliative care

Defined as “the process of transmitting information from the physician to the patient regarding diagnosis, prognosis and treatment in order for the patient to accept or reject it” (15). This process ensures the use of patient autonomy. In pre-hospital care, it is sometimes difficult to guarantee this due to the urgency to stabilize the patient while respecting the priorities of life, function and aesthetics; however, whenever possible and whenever the patient is alert, the patient should be informed about the procedures to be performed and, above all, when transferring the patient, his or her authorization should be requested, as long as it is not an imminent emergency in which every second counts for the patient’s life.

At COVID, this informed consent proved relevant for referring patients to palliative care when they were evaluated in the respiratory triage areas. Although the patients did not have favourable conditions for survival, medical attention could not be denied. Therefore they were referred to palliative care.

Although very effective in the hospital setting, Palliative care is not often practised in the pre-hospital setting. One of the debates that arose from this pandemic was to open up the possibility of palliative practice in pre-hospital care in order to provide comfort and care for dying patients who, if transferred, would die en route or be turned away from hospitals, but to help them not to show signs and not to feel the symptoms of approaching death (16, 17).

Palliative care remains an unresolved issue on the pre-hospital agenda but is of high importance in this pandemic context and in many others where it would make a difference to patients. A palliative medicine training programme appropriate to paramedics’ skills, abilities, and aptitudes would be invaluable and necessary.

Undoubtedly, the pandemic marked a before and after for everyone, and pre-hospital care is not and cannot continue to be the same. It is therefore urgent to reflect on its scope and limitations in these extraordinary situations. Reviewing protocols, reinforcing knowledge, analyzing decisions and implementing training plans in other areas will be crucial for the care provided to evolve and strengthen its standards of excellence.

In this year and a half, we have seen one of the most profound truths of our human condition: vulnerability and fragility. We, paramedics, are always there to help others, but today we are just as vulnerable as they are, so it is now appropriate to ask ourselves how do we deal with these emergencies when we, too, have become fragile and vulnerable?

References

  1. Sgreccia, E. Personalist Bioethics. Philadelphia: National Catholic Bioethics Center; 2012. P. 5.
  2. Tarasco, M. “Diversas posturas que influyen en el razonamiento bioético” en Kuthy, P. Et.al. Introducción a la Bioética. México; Méndez Editores. Pps. 25-44.
  3. Childress, J. Beauchamp, T. Principles of Biomedical Ethics. 7th ed. New York/Oxford; Oxford University Press. P. 202.
  4. Childress, J. Beauchamp, T. Principles of Biomedical Ethics. 7th ed. New York/Oxford; Oxford University Press. P. 150.
  5. Childress, J. Beauchamp, T. Principles of Biomedical Ethics. 7th ed. New York/Oxford; Oxford University Press. P. 101.
  6. Jonsen, A. Siegler, M. Winslade, W. Clinical Ethics. 7th ed. United States of America; McGraw-Hill; 2010. Pps. 65-73
  7. Childress, J. Beauchamp, T. Principles of Biomedical Ethics. 7th ed. New York/Oxford; Oxford University Press. P. 104.
  8. Childress, J. Beauchamp, T. Principles of Biomedical Ethics. 7th ed. New York/Oxford; Oxford University Press. P. 249.
  9. Sgreccia, E. Personalist Bioethics. Philadelphia: National Catholic Bioethics Center; 2012. P. 176-190.
  10. Nakao, Hiroyuki, Isao Ukai, and Joji Kotani. “A Review of the History of the Origin of Triage from a Disaster Medicine Perspective.” Acute medicine & surgery 4.4 (2017): 379–384.
  11. Rådestad, Monica et al. “Attitudes Towards and Experience of the Use of Triage Tags in Major Incidents: A Mixed-Method Study.” Pre-hospital and disaster medicine 31.4 (2016): 376–385.
  12. Sgreccia, E. Personalist Bioethics. Philadelphia: National Catholic Bioethics Center; 2012. P. 189.
  13. Dónal O’Mathúna. (2016). Ideal and nonideal moral theory for disaster bioethics: Postdisciplinary humanities & social sciences quarterly. Human Affairs, 26(1), 8-17. doi:http://dx.doi.org/10.1515/humaff-2016-0002.
  14. Jonsen, A. Siegler, M. Winslade, W. Clinical Ethics. 7th ed. United States of America; McGraw-Hill; 2010. Pps. 98-100.
  15. Jonsen, A. Siegler, M. Winslade, W. Clinical Ethics. 7th ed. United States of America; McGraw-Hill; 2010. Pps. 122-125..
  16. Wiese CHR, Lassen CL, Bartels UE, Taghavi M, Elhabash S, Graf BM, et al. International recommendations for outpatient palliative care and pre-hospital palliative emergencies — a prospective questionnaire-based investigation. BMC Palliative Care [Internet]. 2013 Jan [cited 2021 Oct 8];12(1):10–6.
  17. Kamphausen, Anne et al. “Challenges Faced by Prehospital Emergency Physicians Providing Emergency Care to Patients with Advanced Incurable Diseases.” Emergency medicine international 2019 (2019): 3456471–11. Web.
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