Recommendations for the Navigation of Moral Dilemmas during the COVID Pandemic

Emergency Physicians are at potential risk for moral conflict and burnout when trying to accommodate the many challenges for caring for seriously ill patients in the ED. The patient care needs and what the physician “feels is right” have become more apparent with the large volume of patients requiring treatment during the COVID-19 pandemic. There are some recommendations and resources, which may allow all physicians to be more successful in navigating the potential situations faced during this unprecedented time. These resources are not exclusive to COVID patients and can assist physicians in their management of other seriously ill patients and during end of life situations.

Emergency physicians are encouraged to:

  • Know. Each state has its own laws regarding surrogacy in the absence of a designated Health Care Proxy (HCP). It’s important to understand the law in the state(s) in which you practice. This can be challenging for those physicians who work in multiple states.
  • Identify. The HCP, surrogate decision-maker, and an alternative surrogate should be identified in the emergency department. This information can facilitate goal-concordant care during the current and subsequent admissions.
  • Document. Include documentation of the advanced care planning conversation and its participants in the medical record. Include Physician’s Orders for Life-Sustaining Treatment (POLST), healthcare power of attorney forms, or advanced care planning forms, if present.
  • Consult. Initiate a palliative care consult early in the course of emergency department care for patients likely to die during this hospitalization. If your hospital does not have palliative care consults, consider virtual consults via phone or video.
  • Delegate. Consider bringing in others: volunteers, social workers, nurses, chaplains, or others to help with documentation of decision-makers and help with communication with families.
  • Advocate. Know your institution’s visitor policy and, if necessary, advocate for a compassionate end of life process. Advocate for vulnerable populations, including older adults. Continue to advocate for the optimal delivery of ethical and appropriate care and the inclusion of appropriate stakeholders and experts during policy making and resource allocation decisions.
  • Seek. Seek peer support and wellness resources during and after difficult interactions with patients, including morally challenging situations.