COVID-19: The Ethical Landscape

On March 11, the World Health Organization (WHO) declared COVID-19 a pandemic, pointing to the over 118,000 cases of the coronavirus illness in over 110 countries and territories around the world and the sustained risk of further global spread. To discuss some of the ethical issues regarding COVID-19 we are joined by Dr. Ken Iserson and Becket Gremmels. This episode was recorded on Friday March 20, 2020.

Our guests in this episode include:

  • Dr. Ken Iserson, Professor Emeritus of Emergency Medicine at The University of Arizona, Medical Director (Emeritus) of the Southern Arizona Rescue Association (search & rescue), a Supervisory Physician with Arizona’s Disaster Medical Assistance Team (AZ-1), and a member of the American Red Cross disaster response team.
  • Becket Gremmels, System Director of Ethics for CHRISTUS Health based in Irving, Texas. CHRISTUS Health can be found in 60 US cities and is comprised of 60 hospitals and long-term care facilities, as well as 175 clinics and outpatient centers.

Additional resources relating to or referenced in this episode:

Sessions are monitored on a monthly basis by CME office and content confirmed to be evidence based and without bias. Secondly, the CME Program Director and CME Coordinator reviewed and approved all material prior to the educational activity being approved to confirm that the educational activity was evidenced based. Peer reviewed journals and other literature are used, as applicable during discussions.

References for Further Study:

Undocumented Patients: Two Journeys

We hear many stories these days about immigration. Certainly, healthcare workers see undocumented individuals in Emergency Rooms or clinics. What is that experience like of being undocumented and needing healthcare? What would be helpful for clinicians to know? Does healthcare ethics have something to say on this topic? Today we hear from two healthcare leaders on these issues. One, who was an undocumented person and who later became a physician in the United States, and the other is the healthcare leader who supported her journey.

Our guests in this episode include:

  • Mark G. Kuczewski, PhD, is the Fr. Michael I. English, S.J., Professor of Medical Ethics and also Director of the Neiswanger Institute for Bioethics and Health Policy at Loyola University, Chicago
  • Dr Johana Mejias-Beck, internal medicine pediatrics specialist, currently at the University of Missouri, Kansas…and one of the first undocumented students to attend the first medical school in the country to accept applicants with DACA status.

Additional resources relating to or referenced in this episode:

Sessions are monitored on a monthly basis by CME office and content confirmed to be evidence based and without bias. Secondly, the CME Program Director and CME Coordinator reviewed and approved all material prior to the educational activity being approved to confirm that the educational activity was evidenced based. Peer reviewed journals and other literature are used, as applicable during discussions.

References for Further Study:

  • Kuczewski, M. G., Mejias-Beck, J., & Blair, A. (2019). Good sanctuary doctoring for undocumented patients. AMA journal of ethics, 21(1), 78-85.
  • Kuczewski, M., Blair, A., Fitz, M., & Mejias-Beck, J. Limbo Really Exists: Undocumented Youth at Risk July-August 2019.
  • Kuczewski, M. (2019). Clinical ethicists awakened: Addressing two generations of clinical ethics issues involving undocumented patients. The American Journal of Bioethics, 19(4), 51-57.
  • Samra, S., Taira, B. R., Pinheiro, E., Trotzky-Sirr, R., & Schneberk, T. (2019). Undocumented Patients in the Emergency Department: Challenges and Opportunities. Western Journal of Emergency Medicine, 20(5), 791.
  • Ellis, P., & Dugdale, L. S. (2019). How should clinicians respond when different standards of care are applied to undocumented patients?. AMA journal of ethics, 21(1), 26-31

End of Life Disparities: The African American Community

Health disparities and health outcomes for African Americans, is egregious… Regarding pain medication, a 2019 published article offered that the pain of African Americans is systematically under-diagnosed and under-treated

Our guests today will offer stories and discuss insights on end of life care in the African American community. Our guests in this episode include:

  • Patrick Smith, professor at the Duke Divinity School and associate faculty with the Trent Center for Bioethics, Humanities, and History of Medicine at Duke University School of Medicine.
  • Dr Farr Curlin, Josiah C. Trent Professor of Medical Humanities in the Trent Center for Bioethics, Humanities and History of Medicine, and Co-Director of the Theology Medicine, and Culture Initiative at Duke Divinity School.
  • Claretta Dupree, Chair of the Academy of Fellows at the Center for Bioethics and Human Dignity at Trinity International University, Deerfield, Illinois.

Additional resources relating to or referenced in this episode:

Sessions are monitored on a monthly basis by CME office and content confirmed to be evidence based and without bias. Secondly, the CME Program Director and CME Coordinator reviewed and approved all material prior to the educational activity being approved to confirm that the educational activity was evidenced based. Peer reviewed journals and other literature are used, as applicable during discussions.

References for Further Study:

  • Boucher, N. A., Raghavan, M., Smith, A., Arnold, R., & Johnson, K. S. (2016). Palliative care in the African American community# 204. Journal of palliative medicine, 19(2), 228-230.
  • Elk, R., Johnson, K., Reaves, A., White-Hammond, G., Williams, S., & Vaughan, L. (2019). “God Is Able”: Miracles and Hope in Our African-American Patients: Challenges, Historical Perspective and the Way Forward (FR459). Journal of Pain and Symptom Management, 57(2), 427-428.
  • Hoffman, K. M., Trawalter, S., Axt, J. R., & Oliver, M. N. (2016). Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proceedings of the National Academy of Sciences, 113(16), 4296-4301.
  • Johnson, J., Hayden, T., True, J., Simkin, D., Colbert, L., Thompson, B., … & Martin, L. (2016). The impact of faith beliefs on perceptions of end-of-life care and decision making among African American church members. Journal of palliative medicine, 19(2), 143-148.
  • Rhodes, R. L., Ukoha, N. C., Williams, K. A., Elwood, B., Knox-Rice, T., Lee, S. C., … & Halm, E. A. (2019). Understanding underuse of advance care planning among a cohort of African American patients with advanced cancer: formative research that examines gaps in intent to discuss options for care. American Journal of Hospice and Palliative Medicine®, 36(12), 1057-1062.

HIV Disclosure: New Ethical Approaches

New research findings regarding HIV status will impact how we understand and practice disclosure of HIV status of patients… specifically whether or not to disclose a sick patients’ HIV serostatus to their family or partner. The new research demonstrates that when an HIV-positive person sticks to their treatment, their HIV is undetectable and untransmittable (U=U). Our three guests are working together on bioethical projects to spread the awareness of U=U.

Our guests in this episode include:

  • Jamie Crist, JD, MA a Clinical Ethics Fellow at the Baylor College of Medicine, Houston Texas and doing clinical ethics consultation at Houston Methodist Hospital. Jamie has a JD and Masters in Bioethics at Case Western University.
  • Nicole Meredyth, MD, is a clinical ethics fellow at Weil Cornell Medicine in New York Presbyterian Hospital. She is also completing her surgical residency at Weil Cornell University.
  • Nekee Pandya, MD; is a clinical ethics fellow at Weil Cornell Hospital and also a hospitalist at that hospital.

Additional resources relating to or referenced in this episode:

Sessions are monitored on a monthly basis by CME office and content confirmed to be evidence based and without bias. Secondly, the CME Program Director and CME Coordinator reviewed and approved all material prior to the educational activity being approved to confirm that the educational activity was evidenced based. Peer reviewed journals and other literature are used, as applicable during discussions.

References for Further Study:

  • Eisinger, R. W., Dieffenbach, C. W., & Fauci, A. S. (2019). HIV viral load and transmissibility of HIV infection: undetectable equals untransmittable. Jama, 321(5), 451-452
  • Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med 2011;365:493-505.
  • Ngure, K., Ongolly, F., Dolla, A., Awour, M., Mugwanya, K. K., Irungu, E., … & Wamoni, E. (2020). “I just believe there is a risk” understanding of undetectable equals untransmissible (U= U) among health providers and HIV‐negative partners in serodiscordant relationships in Kenya. Journal of the International AIDS Society, 23(3), e25466.
  • Calabrese, S. K., & Mayer, K. H. (2019). Providers should discuss U= U with all patients living with HIV. The Lancet HIV, 6(4), e211-e213.
  • Tobin, S. C. (2019). U= U gains strength with release of PARTNER2 data. Aids, 33(3), N1.

Discharge Dilemmas: Patients with Disabilities

Consider someone leaving a hospital, after their care is completed at that location, to return to their home and local community. As discharge plans are made to continue their care, their healing, their rehabilitation, are there ethical challenges that arise? Can there be biases that shape that plan because of their ability, disability, lack of family support systems or resources available in the community? What are the frameworks, tools, approaches that an assist all involved? Our guests will offer their experience in these discharge plan dilemmas and offer the practical approaches they have utilized every day.

Joining us in conversation in this episode are:

  • Debjani Mukherjee, trained as clinical psychologist and clinical ethicist, is Director of the Donnelley Ethics Program at the Shirley Ryan Ability Lab, Associate Professor of Physical Medicine and Rehabilitation and Medical Education at Northwestern University, Feinberg School of Medicine.
  • Preya Tarsney, trained as a lawyer Bioethicist – Donnelley Ethics Program at the Shirley Ryan Ability Lab and a Lecturer of Physical Medicine & Rehabilitation at Northwestern University Feinberg School of Medicine and faculty lecturer at the University of Chicago, MacLean Center for Clinical Medical Ethics.
  • Kristi L. Kirschner MD is a physician in physical medicine and rehabilitation and has practiced in this area for 30 years. She also has a background in clinical ethics and physical disability ethics and a faculty member of the university of Illinois College of Medicine where she directs the sub-theme of Humanities in Ethics for the College of Medicine.

Sessions are monitored on a monthly basis by CME office and content confirmed to be evidence based and without bias. Secondly, the CME Program Director and CME Coordinator reviewed and approved all material prior to the educational activity being approved to confirm that the educational activity was evidenced based. Peer reviewed journals and other literature are used, as applicable during discussions.

References for Further Study:

  • Beware of Discharge: A Case Exploring the Ethics of Societal Expectations Placed on Families at Hospital Discharge
    Castro, A. R., & Tsimicalis, A. (2020). Beware of Discharge: A Case Exploring the Ethics of Societal Expectations Placed on Families at Hospital Discharge. Home Healthcare Now, 38(2), 98-104.
  • Evaluation of an integrated model of discharge planning: achieving quality discharges in an efficient and ethical way
    Wells, D. L., LeClerc, C. M., Craig, D., Martin, D. K., & Marshall, V. W. (2016). Evaluation of an integrated model of discharge planning: achieving quality discharges in an efficient and ethical way. Canadian Journal of Nursing Research Archive, 34(3).
  • Rehabilitation as “destination triage”: a critical examination of discharge planning
    Durocher, E., Gibson, B. E., & Rappolt, S. (2017). Rehabilitation as “destination triage”: a critical examination of discharge planning. Disability and rehabilitation, 39(13), 1271-1278.
  • Thinking about the patient’s wishes: practical wisdom of discharge planning nurses in assisting surrogate decision‐making
    Kageyama, Y., & Asano, M. (2017). Thinking about the patient’s wishes: practical wisdom of discharge planning nurses in assisting surrogate decision‐making. Scandinavian journal of caring sciences, 31(4), 796-804.
  • Schlairet, Maura C. “Complex hospital discharges: Justice considered.” HEC forum. Vol. 26. No. 1., 2014.

Brain Death: A Foundational Yet Emotional Ethical Concept

Brain death is a fundamental ethical topic that is complex and often fraught with emotion. As ethics committees are faced with considerations involving brain death, these cases are often those that stick with professionals the most. Our lead contributor in this episode Becket Gremmels, System Director of Ethics at CHRISTUS Health in Irving TX is in conversation with two nationally recognized ethicists who explore the complexities and challenges surrounding this foundational ethical concept.

Our guests in this episode include:

  • Dr. Alexander M. Capron, University Professor, Vice Dean for Faculty and Academic Affairs, Scott H. Bice Chair in Healthcare Law, Policy and Ethics, Professor of Law and Medicine, Keck School of Medicine, Co-Director, Pacific Center for Health Policy and Ethics at the University of Southern California
  • Dr. Michael Rubin, neurointensivist and clinical ethicist in the department of neurology and neurotherapeutics in the Peter O’Donnell Jr. Brain Institute at the UT Southwestern Medical Center

Sessions are monitored on a monthly basis by CME office and content confirmed to be evidence based and without bias. Secondly, the CME Program Director and CME Coordinator reviewed and approved all material prior to the educational activity being approved to confirm that the educational activity was evidenced based. Peer reviewed journals and other literature are used, as applicable during discussions.

References for Further Study:

Feeding Tubes: Are Things What They Seem?

Why would the question of whether to provide food and water to a patient come up at all? One might assume it is always helpful and never harmful to offer nutrition and hydration to patients. Is that accurate? When might it be appropriate or not appropriate? Our lead contributor in this episode is Alan Sanders, Vice President of Ethics Integration and Strategy at Trinity Health is in conversation with guests in this episode to explore a number of ethical issues related to providing nutrition and hydration to patients who cannot feed themselves.

Our guests in this episode include:

  • Dr. George J. Giokas M.D., Director of Palliative Care, Palliative Care Partners, Inpatient Palliative Care Consult Service, Ellis Hospital
  • Fr. John J. Raphael, SSJ, Catholic Chaplain and Staff Chaplain at Saint Thomas West Hospital in Nashville, TN

Goals of Care

Goals of care is a term so common to health care professionals and yet, our guests describe significant clinical experiences in which the lack of discussion around goals of care led to problematic cases. A goals of care conversation is an important element at the foundation of high quality discussions around code status. In this episode lead contributor Mark Repenshek, Executive Director of Ethics and Mission at Hospital Sisters Health System in Wisconsin, is in conversation with national experts and clinicians who discuss this important topic.

Our guests in this episode are:

  • Dr. Kenneth A. Berkowitz, MD FCCP Chief, Ethics Consultation at VHA National Center for Ethics in Health Care, Associate Professor of Medicine and Population Health at NYU School of Medicine
  • Dr. Tim Jessick, DO, Chair/Co-Founder Palliative Care Network of Wisconsin
    Palliative Medicine Physician, AdvocateAuroraHealth
  • Dr. Jill S. Lowery, Psy.D., Chief, Ethics Policy, National Center for Ethics in Health Care at Veterans Health Administration
  • Dr. James A. Tulsky, MD, Chair, Department of Psychosocial Oncology and Palliative Care at Dana-Farber Cancer Institute, Chief, Division of Palliative Medicine at Brigham and Women’s Hospital, Professor of Medicine at Harvard Medical School

Helpful Goals of Care Resources:

Informed Consent: Supporting Patient Autonomy

Informed consent is one of the foundational ethical principles in health care that supports patient autonomy, or stated differently, the patients right to self-determination. More and more the standard for what clinicians should inform patients about the risks benefits and alternatives of treatment are no longer determined by what a responsible body of physicians deems important, but rather by what a reasonable patient deems important. What is needed to meet that goal is a collaborative communication process between clinicians and patients that integrates the best evidence available with the patients values and preferences to promote high quality health care decisions. In the United States at least half of the states have adopted the reasonable patient standard regarding informed consent.

This episode of EthicsLab Essentials is led by lead contributor Rachelle Barina, VP – Mission Integration at SSM Health based in Wisconsin and is in conversation with two nationally known guests:

  • Dr. Jenny Heyl, Director of Ethics at Mercy Hospital in St. Louis
  • Dr. Kayhan Parsi, Professor of Bioethics at the Neiswanger Institute for Bioethics: Loyola University Chicago

Organ Donation: Foundational Ethical Approaches

The big picture is that 115,000 men, women and children await organ transplants in the United States. Even the largest football stadium in the US could not fit the number of patients on the national transplant waiting list. In 2016, 33,600 transplants brought new life to patients and their families. Since 1988, 683,000 transplants have taken place in this country.

In this episode, our lead contributor Becket Gremmels, speaks to a transplant surgeon, an ICU doctor and a health care ethicist about some of the foundational ethical approaches that honor organ donors, the patients who receive those organs, and the health care professionals who care for both.

Our guests in this episode include:

  • Dr. Carol Bayley, past Vice President for Ethics and Justice Education at Dignity Health, San Francisco
  • Dr. Anji Wall, Abdominal Transplant Surgeon at Baylor Medical Center, Dallas
  • Dr. Wes Ely, Intensivist at Vanderbilt University Medical Center and Nashville VA Hospital, Nashville