ESPNIC Ethics Section: COVID-19 Pandemic Ethics Statement

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We understand these are very challenging times – the ESPNIC Ethics section offers the following information and guidance on decision-making

Covid-19 is now a worldwide pandemic & Europe is very badly affected
The greatest burden is in our older citizens, those with complex health problems and in health care workers
From early data from China, [1] and Italy, it seems children have not been badly affected – though cases of immunosuppressed children with severe lung disease, and severe illness in those with chronic lung disease exist. We caution against relying on data collected through crowd-sourcing without peer review.
The largest effects on Paediatric & Neonatal Intensive Care teams are likely to be:
- Support/providing resource to overwhelmed local adult ICU
- NICUs being asked to take care of toddlers and smaller children
- Redistribution of critical care beds, high dependency and ward level beds usually available for children to free up adult capacity
- A reorganisation of transport services reviewing policies and processes concerning the transport and acceptance of critically ill patients to tertiary care centres
- Long-term patients may become infected, which may worsen their underlying disease by a direct infective effect or by compromising usual treatments e.g. immunosuppression may be reduced, or renal replacement less available
- Children with complex care needs in the community may have a reduced service (e.g. decreased LTV teams or lack of access to acute care facilities)
- Children requiring elective surgery may deteriorate as their disease progresses due to lack of theatre space, e.g. congenital heart disease
- Sickness in our own multi-disciplinary team
- Sickness in colleagues in other specialities, or vital staff such as cleaners, lab staff or management
- Sickness in the parents and families of the children we treat
- Sickness in our own families and friends, meaning some of us cannot work
- Burnout in colleagues (multidisciplinary team) because of moral distress to the demanding shifts and shortages of staff, space, and supplies
- Concerns about personal safety with inadequate PPE provision or standards
Institutions and government must ensure the safety of their citizens INCLUDING healthcare staff – testing and PPE provision in line with WHO guidance is necessary
We must do our duty for our patients, but also look after ourselves, our teams and colleagues

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Ensure policies and pathways are both clear and workable
Look after the children we care for, both in ICU and wards e.g. those we cannot admit – as we usually would
Ensure emotional, pastoral and psychological support for teams is available both during and after the pandemic
Ensure trainees e.g. medical/nursing students, and residents have a psychological safe involvement, recognizing their vulnerability
Ensure educational support for healthcare staff working outside usual context – practical (e.g. Basic PICU) and psychological

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Simulation about how to care for COVID-19 cases must be undertaken urgently and be ongoing – e.g. radiographers, non-ICU staff
Consider Intubation Teams– anaesthetic/senior intensivist with video-laryngoscope seems safest (simulation)
PPE must be provided and used in line with WHO recommendations ^{^[2]} with standard obligatory training in use for all relevant staff
Develop videoconference facilities if not available (supporting staff but also parents and children)
Give parents clear information about adequate behaviour during hospitalisation and current screening for COVID-19
Work with referring colleagues to optimize treatment
Comply with state recommendations re personal security
Be kind to each other
Stay safe

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The level of ICU, HDU and acute bed availability will necessitate increasing levels of restriction of normal practice – which is very varied in Europe
Nevertheless, there will be hard decisions at all levels of child health:
- Identification of potential triage decisions, tools, and processes
- A decision regarding the level of care (ICU vs. medical ward)
- Initiation of life-sustaining treatment (including CPR and ventilation or organ replacement support);
- Withdrawal of life-sustaining treatment
- Referral to palliative care if a life-sustaining treatment will not be initiated or is withdrawn. (e.g reverse triage)
- Any usual policy of admitting when referrers and families request in situations where the ICU team are uncertain of the benefit of admission may need to be reconsidered – e.g. borderline cases
  - Usual therapy may need to be withheld – ECMO if the healthcare system is overwhelmed
  - Treatments that may increase vulnerability may need to be deferred – e.g. semi-elective bone marrow transplant
  - Early palliative care involvement is recommended for children with life-limiting conditions
A framework for health care during public health emergencies rises from the necessity to change the usual primacy of both patient-centred duties of care over public-focused duties to promote equality of persons and equity in the distribution of risks and benefits in society.

Note, healthcare and Institutional leaders during a public health emergency have to plan, to safeguard, and to guide.

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These are unprecedented times
- When resources are truly overwhelmed, hard decisions need to be made, more frequently and more rapidly – overt rationing decisions become necessary.
- Some are existential for patients/people
Short of overt Major Incident Disaster Triaging, we need to ensure that decisions are:

Reasonable; Open and transparent; Inclusive; Responsive and Accountable ^[4]

The principles are well laid out by Emmanuel and colleagues, [5] and the Italian College of Anesthesia, Analgesia, Resuscitation, and Intensive Care (SIAARTI) recently issued recommendations considering “clinical reasonableness,” and a “soft utilitarian” approach in the face of a shortage of resources.^[6]

However, several paediatric considerations do not feature in these overarching documents. [7]

We need to ensure consistency between centres and across regions, with both administrative and regulatory oversight. Crucially, there must be both real-time and future support for the teams making these challenging decisions.

The level of intervention may need to be based on more utilitarian-type principles than normal – e.g. doing the greatest good for the greatest number of people. This means replacing our usual focus on doing what is in an individual’s best interests by considering distributive justice (the socially just allocation of resources).

This is not to say discrimination is ever acceptable, however, decisions based on the best use of resources, such as ventilators, may need to be made.

Factors to consider include chances of recovery, length of time likely to make that recovery and with the greatest stress on the system some consideration of the long-term quality of that person’s recovery.

For clinical teams making these challenging decisions ethics support (e.g. local Ethical committee) must be provided during the acute decision-making phase ideally by – this can help ensure decisions are:

1. Morally acceptable and lawful
2. Recorded
- It will help protect patients from any discrimination, whether overt or subconscious.
- It will help protect practitioners who are doing their best from later unfair scrutiny.
- It will ensure second opinions can be obtained in a reasonable time-frame, though this is unlikely to occur during the acute resuscitation phase.
These considerations are not limited to the commencement of interventions: accelerated withdrawal of life-sustaining treatment may be necessary in order to minimize opportunity costs for others – this reverse triage similarly needs consistency, oversight and support.

Essentially, (1) do your best, (2) treat people fairly, (3) there must be ethical help available – if there is not ask your institution to set it up urgently, (4) show your working out – i.e. keep excellent contemporary notes and seek ethical and hospital management support, (5) Communicate decisions honestly and compassionately
Prepared March 2020 by ESPNIC Ethics Section
Joe Brierley, Anna Zanin & Marek Migdal (ESPNIC Ethics Section) on behalf of ESPNIC