Transcription:
Pandemic Ethics

Welcome to the Peds Ethics podcast, where we talk to leaders in pediatric bioethics about a hot topic or a current controversy. Here’s your host, John Lantos from the Children’s Mercy Bioethics Center in Kansas City.

John Lantos, MD (Host):  Hi everybody, this is John Lantos. Welcome back to the Pediatric Ethics Podcast coming to you from Children’s Mercy Hospital in Kansas City and the Children’s Mercy Bioethics Center. We talk to leading experts in pediatrics and bioethics about hot topics of the day. Today, we are thrilled to have Erin Paquette, a Critical Care doctor and lawyer and also faculty in Bioethics at Northwestern University’s Feinberg School of Medicine and at the Ann and Robert H. Lurie Children’s Hospital of Chicago. Dr. Paquette has been working hard on Northwestern and Lurie Hospital’s response to COVID. Thanks so much for taking the time to talk to us. Can you tell us a little bit about what is going on in Chicago at Northwestern and Lurie?

Erin Dashka-Talati Paquette, MD, JD, MBe (Guest):  So, I think like much of the country, we are deeply in the process of responding to the evolving COVID-19 situation, anticipating upcoming issues, planning for them and putting processes in place. Right now, we’re dealing with thinking about how as a pediatric institution in particular we can best utilize our resources in order to support the unfolding situation.

Host:  And you are an Attending Physician in the Pediatric Intensive Care Unit, right?

Dr. Paquette:  I am. That’s correct.

Host:  So, have you had any cases admitted to the PICU yet?

Dr. Paquette:  We have not. We have not had any confirmed Coronavirus cases.

Host:  Have there been confirmed cases at the hospital, kids who are sent home and they were doing okay?

Dr. Paquette:  Not at our institution. We’ve had rule out but not confirmed cases.

Host:  Okay, that’s a lot like our place. We’ve had one confirmed case so far. And the child is doing fine at home. What are you anticipating for the next two weeks? What are the discussions like in your planning committee?

Dr. Paquette:  We are anticipating discussions around staffing, allocation of resources, kind of are our primary two things that we are focusing on as well as complying with sort of supporting the community in terms of the best means to try to suppress the spread of the virus.

Host:  The community outside the hospital. So, public education, messaging.

Dr. Paquette:  Yes. Public education, messaging as well as ensuring that we are responding to the needs of our staff as well as thinking and anticipating potential areas in which we’ll need to potentially make some allocation or triage decisions should different scenarios unfold.

Host:  And has the hospital shut down elective surgeries and nonessential visits?

Dr. Paquette:  There has been a tiered approach to doing that. But in line with I think what many other institutions are doing, most nonessential operations have been stopped both across the clinical and the research enterprises.

Host:  And what are the discussions like about staffing and workforce? There are a lot of docs and nurses who because of the shutdowns of nonessential services are now more free time than usual. Is the anticipation that people will be sort of rotated in and out of the busier services?

Dr. Paquette:  I think that the approach has been largely to make sure that all essential services are covered. And then to recognize that individuals who continue on non-physically essential operations are able to do that remotely and are encouraged to do so. But there’s also been some I think innovative thinking around identifying areas of need and skill set that can fit them for individuals who may not have work functions that are easily transferrable to a remote setting in order to optimize the overall staffing for the hospitals.

Host:  Now you’ve – you had done a lot of work before this on preparation for pandemics or mass casualty events hadn’t you?

Dr. Paquette:  I’ve worked previously in this space. I thought about these questions with our institution when we were dealing with how Ebola might unfold. I think there are some differences this time in terms of the magnitude of efforts both really at every level of an institutional level. But local and at our government levels that have made – some of these questions a bit more pressing than we’ve maybe experienced in the past but we’ve thought about how to approach similar situations previously.

Host:  And have there been any big surprises so far related to COVID? Things that you didn’t anticipate?

Dr. Paquette:  In a positive light, one of the surprising things had been how much the community has really come together in terms of trying to fill gaps where they are needed. So, for example, while we may have anticipated that there might be challenges to our workforce as we saw the situation unfolding in the countries that are a couple of weeks ahead of us, I think places stepping up really are medical students in particular and this has happened not only here but across the country, volunteering their time to organize blood drives, volunteering to provide childcare for healthcare providers or essential workforce to the hospital systems who may have had their usual sources of childcare made unavailable to them; they’ve stepped up to provide that as well as to support some of the more vulnerable populations who in the practicing social distancing are unable to potentially obtain groceries or medications or things of that nature. And I think we’ve seen a really nice response and desire to fill helpful roles from our trainees that have been very welcomed.

Host:  And the students are organizing that themselves?

Dr. Paquette:  Yes. For the large part, both here at Northwestern and I’ve seen other groups doing so around the country as well.

Host:  And your students are out of school, I guess.

Dr. Paquette:  Yes, they’ve been out of school doing some remote learning but also trying I think to help out in other ways as they can.

Host:  How’s the personal protective equipment holding up?

Dr. Paquette:  From what I have heard and been part of, there are plans in place to tier the level of protective equipment based on anticipated need and interaction between like the provider and whoever they are encountering and the risk of infection that’s associated with that. These are ongoing conversations I think that are unfolding with guidance that’s coming out from the CDC as well as the WHO, who are thinking about what is the way to optimize protection but also be mindful of conserving resources particularly as we know some of our community colleagues may be needing them in greater numbers as the adult population is experiencing this more than the pediatric one is.

Host:  Now you’re trained as both a physician and a lawyer. Any surprising legal issues arisen as part of this or are things going smoothly on that front?

Dr. Paquette:  I think that some of it – there are a lot of interesting legal questions that come up and I think the potential for a challenge is that we haven’t quite seen yet. I think from an institutional standpoint, I think there are always legal concerns when you are thinking about the potential need to allocate resources differently than you might do in your usual care. And I think a good sort of understanding of the transition in principles and obligations when you are moving from usual care to crisis standard of care, how in thinking about what those legal obligations might be and any concerns about sort of risk that’s associated with altering the way you do your normal practice of medicine. So, I think that’s one area of the law that people worry about and depending on what things are in place in different states; there is oftentimes some good faith immunity provisions in situations of crisis where the liability risk is lowered. But I think that is a concern for many.

The other is that I just find interesting, not that this has become a problem as of yet is an understanding of what happens in terms of that shift from an individual usual care model to an emergency model in which the public health powers come into play and how people understand that in terms of these things that are coming – the measure that are coming out to protect public health like social distancing, and then even further steps beyond that, that run counter to people’s expectations generally about how they can gather with groups and have general freedom of movement. I think we are starting to potentially see the public understanding of those concepts is growing as we’re seeing some places move to shelter in place where there’s further restriction on their movement. As I think from a law standpoint understanding the background behind that and the powers of the government to do that is another interesting area where some education is likely necessary to help understanding a general level because these measures won’t be effective at slowing disease spread unless they are followed but getting compliance requires an understanding of where they are coming from.

Host:  So far, my understanding is the government requests for sheltering in place and social distancing have all been voluntary. I mean they’ve shut down businesses, but I don’t think anybody is being arrested or fined for going out. And that has been amazing to watch how compliant most people have been in what is a really shocking restriction on our freedoms. What do you think the next two weeks are going to look like?

Dr. Paquette:  I think there’s going to be a lot of continued information gathering over the next two weeks. My sense is that measures that have been taken have been taken with an attempt to recognize the trends that we’ve seen in our countries that have gone ahead of us have been in this process and that we’re hoping that with putting those measures in place that we’ll have a – maybe a slowing of the spread here in the United States but at least a better understanding of what those trends are. I think that if we are seeing continued growth, we maybe in the next two weeks moving into a position where we are needing to start thinking about some of the very challenging – not start thinking, we’re already thinking, but putting more enacting some of the planning that’s gone into effect thinking about shortages and what we will do in different situations. I think that’s what we’re going to see in the next two weeks. We are likely to see a ramp up in availability of testing and I think we’re also likely to see increase in PPE personal protective equipment production. I think there has been a movement to increase that. So, I think those are the things that we’ll see unfolding next.

Host:  It is frightening to sit here and wait knowing what’s coming. Any other thoughts about lesson learned or surprises that you’ve had as this thing unfolds?

Dr. Paquette:  One thing that I have been thinking about is just this is not necessarily a surprise but and I do think that many public health officials as well as institutions are trying to be thoughtful about the unintended but necessary secondary effects of all the measures that are being taken and I just want to highlight that many of those will have an unfortunate disproportionate impact on groups that are already living in risk in some ways. So, individuals who are not able to restrict their movement are more likely to be in places where outbreaks or more cases are likely to happen.

We’ve seen this already in nursing homes and should be mindful that many places in which there are crowded living conditions tend to be places where people may already be at risk for disparities. I think there’s a disproportionate impact of closures on the service industry which also is a population at risk. Those individuals who provide childcare, who often – who may not be receiving that income any longer as well as the secondary effects on mental health of isolation despite attempts to promote a lot of and utilize technology, leverage it to maintain communication. There is often disproportionate access to ability to do that not only in device access but also in access to internet or broadband as so the effects of compounding economic strain with isolation I think is going to be potentially born by an already vulnerable part of our population and I think that we need to just be going into thinking about recovering from this experience, how that group might be impacted and the justice concerns that are raised with that.

Host:  Yeah, that’s a great take home message that we really need to pay special attention to the most vulnerable as this thing unfolds both for health risks and as you say for economic and psychological risks as well. All righty. Thank you very much Dr. Paquette. Dr. Paquette is an Attending Physician in Critical Care, an Assistant Professor of Pediatrics at Northwestern University’s Fienberg School of Medicine and at the Ann and Robert H. Lurie Children’s Hospital of Chicago. Thanks for taking the time. This is John Lantos coming to you on the Pediatric Ethics Podcast from Children’s Mercy Hospital in Kansas City. Thanks for listening.