|
 U.S. hospitals have over the years come under criticism for
undertaking measures that prolong dying rather than improve
patients' quality of life.
But the care of the first Ebola patient diagnosed in the United
States, who received dialysis and intubation and infected two nurses
caring for him, is spurring hospitals and medical associations to
develop the first guidelines for what can reasonably be done and
what should be withheld.
Officials from at least three hospital systems interviewed by
Reuters said they were considering whether to withhold individual
procedures or leave it up to individual doctors to determine whether
an intervention would be performed.
Ethics experts say they are also fielding more calls from doctors
asking what their professional obligations are to patients if
healthcare workers could be at risk.
U.S. health officials meanwhile are trying to establish a network of
about 20 hospitals nationwide that would be fully equipped to handle
all aspects of Ebola care.
Their concern is that poorly trained or poorly equipped hospitals
that perform invasive procedures will expose staff to bodily fluids
of a patient when they are most infectious. The U.S. Centers for
Disease Control and Prevention is working with kidney specialists on
clinical guidelines for delivering dialysis to Ebola patients. The
recommendations could come as early as this week.
The possibility of withholding care represents a departure from the
"do everything" philosophy in most American hospitals and a return
to a view that held sway a century ago, when doctors were at greater
risk of becoming infected by treating dying patients.
"This is another example of how this 21st century viral threat has
pulled us back into the 19th century," said medical historian Dr.
Howard Markel of the University of Michigan.
Some ethicists and physicians take issue with the shift.
Because the world has almost no experience treating Ebola patients
in state-of-the-art facilities rather than the rudimentary ones in
Africa, there are no reliable data on when someone truly is beyond
help, whether dialysis can make the difference between life and
death, or even whether cardiopulmonary resuscitation (CPR) can be
done safely with proper protective equipment and protocols.
Such procedures "may have diminishing effectiveness as the severity
of the disease increases, but we simply have no data on that," said
Dr. G. Kevin Donovan, director of the bioethics center at Georgetown
University.
Donovan said he had received inquiries from fellow physicians about
whether hospitals should draw up lists of procedures that would not
be performed on an Ebola patient. "To have a blanket refusal to
offer these procedures is not ethically acceptable, he said he told
the doctors.
NEW GUIDELINES
Nevertheless, discussions about adopting policies to withhold care
in Ebola cases are under way at places like Geisinger Health System,
which operates hospitals in Pennsylvania, and Intermountain
Healthcare, which runs facilities in Utah, according to their
spokesmen.
Dr Nancy Kass, a bioethicist at Johns Hopkins Bloomberg School of
Public Health, said healthcare workers should not hesitate to
perform a medically necessary procedure so long as they have robust
personal protective gear.
So far, only two U.S. hospitals have used kidney dialysis: Texas
Health Presbyterian Dallas, which treated Liberian patient Thomas
Duncan and where two nurses became infected, and Emory University
Hospital in Atlanta, which has treated four Ebola patients at its
biocontainment unit without any healthcare workers becoming
infected.
Although it is not yet clear how the Dallas nurses became infected,
health officials have questioned both the lack of adequate training
in the use of protective gear and the decision to perform invasive
procedures.
[to top of second column] |
The American Society of Nephrology and CDC are now working on new
dialysis guidelines for Ebola patients, whose kidneys often fail. In
some cases, dialysis can help a patient get through the worst of the
illness until their own immune system can fend off the virus.
Nephrologist Dr. Harold Franch said the new guidelines will consider
both whether the procedure is medically necessary and whether the
hospital can do it safely.
"Most academic medical centers and many good private tertiary care
hospitals will be able to do this," he said. Yet he thinks many
hospitals may not offer the service, since it takes a lot of money
and time to train people.
TREAT, OR FLEE?
Throughout the history of medicine some doctors have declined to
treat infectious patients or fled epidemics, said Michigan's Markel.
Greek physician and philosopher Galen fled Rome during the bubonic
plague 1,800 years ago, doctors deserted European cities stricken by
the Black Death of the Middle Ages, and some health workers refused
to treat HIV/AIDS patients in the 1980s.
"The idea that a doctor would stick to his post to the last during
an epidemic, that's not part of the Hippocratic Oath," Markel said.
"If you feel your life is at risk you don't have to stay and provide
care."
At University of Chicago Medicine, questions of taking last-ditch
measures were discussed early in the hospital's Ebola planning, said
Dr. Emily Landon, a bioethicist and epidemiologist.
Decisions about offering services such as dialysis or inserting a
breathing tube are made in advance by the hospital's care team in
consultation with patients. But if a doctor on the team feels in the
moment that she cannot provide the service, another may step in and
do the procedure.
Landon views dialysis as a "no brainer" for Ebola patients, and
believes the risks are fairly low to the well-trained nursing staff
who have volunteered for the hospital's isolation ward.
But putting in a breathing tube and putting them on a ventilator is
more controversial.
"We have very little experience with that except for Mr Duncan, who
didn't do well," she said. The hospital plans to consult with
patients before the need arises and plans to insert a breathing tube
at the earliest sign that it might be needed.
CPR, which is performed when a patient's breathing or heart stops,
also poses risks. It can involve chest compressions, inserting
breathing tubes and other invasive procedures.
If a patient goes into cardiac or respiratory arrest, a team would
have to don protective gear. Rushing could leave them without proper
protection, but a delay could make the procedure ineffective.
That represents too great a risk for caregivers for what could be "a
futile act," said Dr. Joseph Fins, chief of medical ethics at Weill
Cornell Medical College in New York City.
(Editing by Michele Gershberg and Ross Colvin)
[© 2014 Thomson Reuters. All rights
reserved.] Copyright 2014 Reuters. All rights reserved. This material may not be published,
broadcast, rewritten or redistributed.
 |
