Welcome to the Mayo Clinic, Critical

Care Insights, covid Ed.

My name is Alex Nivan.

I'm a consultant in the division of

Pulmonary Critical Care and Sleep

Medicine here at Mayo Clinic in

Rochester, Minnesota, and

also the education chair for both

our division and for the independent

multi specialty critical care

practice.

The covid pandemic has changed

the way that we practice,

likely forever, and the

critical care community has been

particularly impacted by

the current pandemic.

Critical Care Insight's covid-19

addition is intended for

health care providers who are caring

for patients with covid-19

across the world in the ICU,

best practices to care for.

These patients have been rapidly

evolving and busy bedside

providers.

I know I have struggled to keep

up with the volume of information,

especially given that the

information sources that have been

providing it are frequently less

than rigorously peer reviewed.

In response, Mayo Clinic

has developed an ask male

expert covid-19 task

force that have

collected and curated

the available contents into

a free public website

under the Mayo Clinic,

ask male experts.

Covid-19 Navigator.

This source provides

basically a curated

site for best practice

recommendations in the care

of covid-19 patients

developed collaboratively by an

interprofessional stakeholder group

of Mayo Clinic subspecialists.

And this information

is continuously informed

by rapid literatura scoping

reviews performed by the current

Center for the Science of

Health Care Delivery.

This online course

is designed to speed dissemination

and implementation of these best

evidence based guidelines,

best practice innovation

and provide discussion of ongoing

clinical controversies that we face

in critical care as we take care

of these patients.

These discussions will feature the

original authors of the content

that is available and ask the

experts and allow them

to discuss the evidence

and best practices

that they have used to provide

these recommendations and

the why behind

the information that they've shared.

We will be continuously updating

this content as time goes on

based on the available

high quality evidence that comes

through our rapid scoping reviews

and our evolving innovations

and evolution of clinical practices

within our own

health care delivery platform here

at Mayo Clinic.

This initial scheme offering

consists of seven lectures,

including topics

from intubations, safety, infection

control, workflow considerations,

navigating drug shortages,

maximizing team performance,

mindset, training for the

individual, humanizing critical

care, respiratory therapy

innovations, among others.

We will continue to evolve this

content as time goes on

with new information on the

epidemiology, virology,

clinical features of covid-19

patients and also evolving

recommendations with regards to

testing and the care

and addition of infection control

considerations in this challenging

population.

We hope that you enjoy this work.

This information has been has been

provided as a series of grand rounds

of presentations to our critical

care community over the course

of the last five weeks and

will continue to evolve over time.

Welcome to Critical Care Insights.

I hope you enjoy our work.

Well, welcome to Critical

Care Grand Rounds

on this Thursday, June

4th.

And it is my true pleasure

to introduce DeMartino,

who is a member of the pulmonary

and Critical Care Division here at

Mayo Clinic, who is going to speak

to us about

ethical issues within

the hour during the Percovich

pandemic.

Aaron is again, she's a member

of our pulmonary and critical care

faculty.

She attended Williams College

and then Dartmouth Medical School

and completed her internal medicine

residency at Dartmouth before

coming to Mayo for her pulmonary

and critical care fellowship.

During her training, she had

completed an additional one year

fellowship at the University of

Chicago's MacLaine's Center

for Clinical Medical Ethics.

Her interests include critical care,

ethics, surrogate decision

making and health care policy

and ethics research has been

published in the Mayo Clinic

Proceedings JAMA and

the New England Journal of Medicine.

Eric has been advising

hikes and our Mayo Clinic

leaders on pandemic

ethics and also

represents Mayo Clinic

on several statewide policy

groups. So I guarantee

you that you are in for a treat

today and I will pass

the I will pass the

microphone to you.

Virtual microphone.

Thank you.

So first, let me

just start by saying how

I've never been more proud to be

part of this critical care workforce

and the group of professionals

with whom I'm working, who

span from our nurses and respiratory

therapist and our

physical and occupational therapist

pharmacists, our house staff

and staff, physicians or nurses,

and was coming together to

take care of patients at a really

difficult time and also

taking care of our community as

a whole. I'm very inspired

by your dedication and

professionalism.

I don't have any financial

conflicts, and I will state that

my knowledge of this topic

is in constant evolution.

As a roadmap, we'll start

with some basic principles

of disaster preparedness.

Then we'll talk about crisis

standards of care, and that's where

we're going to spend the bulk of our

time today

about what goes into preparing

a triage protocol,

how objective our scoring systems

really are, and what scoring

system looks like, and how

we operationalize

triage principles that we put

forth as priorities for us,

including how to protect

populations that are deserving of

additional consideration.

Finally, I want especially

with this as my audience, to spend

a little bit of time about the

delicate balance between personal

risk and professional obligation

or responsibility.

The objectives for today's talk

include being able

to describe, at least

on a high level, what the difference

is between the different standards

of care within the surge continuum,

from standard care to crisis,

standard of care also

to be able to discuss the basic

ethical principles that underlie

fair triage protocols

or procedures and potentially

even to be able to critique

a triage protocol.

So predict where fault lines

might be and

to have the ability to

analyze how well we're doing

with a triage protocols.

Before we launch into emergency

medicine or emergency

management, one on one, so to speak,

I did want to briefly

reorient you to the foundational

principles of biomedical ethics.

Anybody who has taken a board

exam in any type of medical

field, I'm sure, including our

nurses, will be familiar

with the four basic principles,

including autonomy,

where somebody has the self

efficacy to direct his or her

own care, beneficence,

doing good for our patients

justice, meaning

that we are paying

attention to how

each individual's care contributes

to potential inequity

or allocation of

resources to other individuals

and non malfeasants.

In other words, first, do no harm.

So a few words on disaster

preparedness.

If you are like me, you probably

didn't learn about this in medical

school, but the

the backbone of emergency

management is around looking

at three S's

staff space and supplies.

So when a health care system faces

an overwhelming public

health need, demand will

outstrip the supply.

And we have to anticipate

and mitigate shortages in these

three major categories of staff,

space and stuff.

But emergencies are heterogeneous.

As you can imagine, a pandemic

is different from a mass casualty

event or a natural

disaster or different in terms

of the types of medical needs, but

also the tempo at which patients

present and the duration

of their need and the duration

of new

presentations or new admissions into

the health care system.

And so our crisis planning

has changed since I became

engaged in these efforts in early

February, as we have

come to understand more about

what the anticipated duration

and tempo of the pandemic

is in our region.

I've always found this to be a

useful resource,

and it's not necessarily meant for

you to be able to read every word,

but to get a general gestalt.

This comes from the chest

task for Task Force

on Critical Care of which Doctrine

is actually a co-author

of this publication.

And it lists down the left

column these same categories,

staff, space and stuff, and

across the top shows the

different phases in a continuum

of care where we surge from

conventional into contingency

and into crisis.

And it delineates the ways in which

these different resources or

shortages of these resources

can be impacted in

and can look different when we're

in a contingency phase

versus a crisis phase of

medical management.

So just a few more details

on that.

In the conventional

system of care, conventional

standard of care, maybe

we are maximizing all the ICU

beds we currently have or we have a

little bit of overflow,

but we are generally operating

at our maximum capacity.

We may have called in a few backup

staff members, whereas

contingency is when we

have enough patients where we're

about double the normal

number of ICU patients that we

would be caring for and we

might begin to do some things

that you've seen us do, like

conserve and reuse

resources that were previously

single use we might

involve we might stretch

our staffing ratios and

we might repurpose areas of the

hospital that are traditionally not

used to deliver critical care

like the PACU for use

as an ICU.

Whereas when you move into crisis,

standard of care, we're using very

non-traditional areas such as

potentially the operating rooms

and using anesthesia machines to

provide mechanical ventilation.

We might be employing

people who are deployed from

the outpatient practice to help

in the inpatient world under

the supervision of those of us

who have more critical care

expertise.

And we are lacking critical

supplies to the point that we may

not have enough functional ICU beds,

meaning an ICU bed that is

adequately staffed and has adequate

equipment to

meet the needs of all the

individuals coming in.

So these are obviously extremely

austere conditions.

This is another way of looking at

it, a pictorial depiction

where we are moving on this

continuum from conventional

care on the left side of the screen,

where patients receiving care in the

hospital may be in the contingency

phase, we've surged to the point

where we have a tent adjacent to the

hospital where we're providing

overflow intensive care services

and we have a lot more patients that

we're used to. But the patients,

our needs are currently being

met, even if we're having to be a

little creative about how we meet

them.

And finally on the right

is when we're in a crisis mode where

unfortunately we may not be able

to meet the needs of all the

patients who we would normally offer

intensive care to.

And in that circumstance,

patients may be triage

to receive only supportive

hospice care or may not

even be able to be admitted to the

hospital.

Before we talk much about crisis,

standard of care, I think it's

really important and

to focus a lot of attention

and energy on mitigating

strain on our resources,

one way in which we can do this,

everybody can do it and we can do it

now is through targeted

goals of care, conversation with

everybody who's admitted to the

hospital, trying to understand

how somebody is feeling

about their own illness

and what they would want if their

disease were to cause a

deterioration in their health

status.

Likewise, it's important to do

community outreach around

advance care planning and

maybe some targeted community

outreach to high risk populations

with chronic illness or nursing

home residents.

And I will tell you that our

palliative care

colleagues have been fantastic

partners of this in this and very

proactive, have been working on it

for months, very innovative

outreach programs that they are

participating in, and also

finding ways to screen large numbers

of inpatients to identify

those who are most

deserving of

a palliative care consult early

in the course of their hospitalization

or even in the emergency department

before they're admitted.

We can also mitigate resource strain

by changing our policies.

There are a lot of different ways to

do that. We've already seen some of

this in Rochester by deferring

elective procedures and

then at a more extreme end of this

by thinking about

withholding CPR.

So if you imagine a circumstance

in which every single ICU bed is

already full and we have patients

waiting in the emergency room

who are sick enough

to need intensive care,

then we have a floor patient

who has a code and we achieve

Brosque, then where does that

patient go? So there are

circumstances in which

extremely austere circumstances

in which on a case

by case basis, it might be the most

appropriate thing not to resuscitate

patients.

But that is a decision that would be

made on an institutional

or even regional level

as we reach more of a crisis

standard of care.

Finally, I think it's important to

talk about pooling resources

so not only within

the Mayo Clinic health system, but

also with neighbors.

I heard a wonderful piece

on NPR when I was driving into

a hike's meeting early in the

pandemic about.

Hospitals who were previously

competitors in New Jersey

sharing masks, and this was in

March, so when everybody was

really fearful about running out of

masks, gowns and ventilators

with each other, meeting each

other's needs, communicating on a

daily basis, indicating

that they had never had any formal

training to do this and a month ago

had been sworn competitors and would

never have considered helping each

other out. But doing this and rising

to the occasion to meet the needs of

their population,

you'll also notice this radioactive

sign that I've put on the screen

that's intentional because there

are certain aspects of

this presentation that are highly

controversial.

And this the

questions around resuscitation

status fall into that category

where I've been part of

more conversations and conference

calls about these issues on a

statewide level and institutionally

than than I could even

begin to express to you

right now.

But you'll see that several times

through the presentation

where I indicate some of them more

hot button topics.

So as the landscape

around us shifts, so

to do our priorities

about how to provide care

for patients,

so.

In the traditional Western model,

those four principles of biomedical

ethics, usually

autonomy floats to the top,

and in the United States at

least, autonomy prevails.

It's an extremely we

are an extremely autonomy driven

culture when it comes to medical

decision making, as I think all of

us know and feel.

We also highly value

benevolence, non malfeasance.

But there has traditionally been

little emphasis at the bedside, at

least on justice.

So how in individuals

care decisions might impact

the care of other patients in the

hospital or even future patients

who are at home but getting sicker

and might be present into care

in the next week?

But with scarcity, that

lens widens.

So the focus shifts from the

individual patient to the community

were then focusing more

on just unjustice

and autonomy shrinks into

the background and can

in certain circumstances be

completely overridden.

So if a number of individuals

are competing for the same resource,

all of whom are desirous

of maximal care, but we simply

do not have enough

staff space or stuff to

provide that care safely to

the patient, then there may be

circumstances in which that

autonomous decision of the patient

is overridden for the good of the

community.

And that's a really distressing

and difficult place in which to be.

And we've heard dispatches, of

course, from around the world about

how challenging that's been as other

health systems have been overrun.

The shift then focuses

on lives saved

or life years saved,

depending on

kind of the set

of values to which you ascribe

most.

And I will describe again what

the difference is between these two

paradigms in a future slide.

But our

in Minnesota, our triage

protocols will focus on the number

of lives that we can save, save

instead of life years saved.

So I don't mean

to be tongue in cheek about this at

all, this is not

this is not a facetious question.

I think a lot of people might feel

at the bedside at any given point

in time that they can identify

when we are in a crisis mode.

The important thing to know is

that this is not a call that is made

at the bedside.

It's a call that's made by

somebody with a bird's eye view,

not just of our critical care

practice here at Mayo, not

just of our hospital practice here

at Mayo or even throughout the

Midwest or even

in the other destination, health

centers throughout their regions.

These are calls that are made

by regional authorities

or state authorities.

So we by feeding

information into

the Minnesota Department

of Health, we

are able to contribute to

this perception and declaration

of whether or not we are in a

crisis, in which case our standard

of care, as I've mentioned, deviates

officially into

more of a triage and scarce

resource allocation stands

before we reach that point,

withholding or withdrawing life

sustaining treatments shouldn't

occur.

We shouldn't in a unilateral

manner, of course, important

goals of care, conversations

contextualized within the scarce

resources of the pandemic are

still appropriate without

unduly influencing people or

leaning too heavily on people,

people's sense of altruism.

We want them to still be able to

make autonomous decisions.

We don't want individuals to feel

coerced to forego therapies.

But on the other hand, we should

not be unilaterally

withholding or withdrawing life

sustaining therapies in a patchwork

manner. Meaning if we

still have enough ventilators in one

hospital but 10 or 50

miles down the road, there are

are insufficient ventilators for

the number of patients who need

those, then we need to be

sharing resources in a very

systematic way so

that the people who are in that

local region aren't disadvantaged.

I'm going to pause here.

Alex, I think, has been monitoring

slideshow to see if there are any

questions or clarifications related

to those before we transition

to talking about crisis standards

of care.

And right now, we don't have any

questions listed on slide, so,

Erin, can I can I just ask

one question as as you've

given us the opportunity to pause

and think about things a minute

when it comes to

the states making a call

that we are in a crisis situation,

what level of

coverage does the state provide

an individual provider or a health

care system as they transition

to a less than otherwise

considered standard of care?

I'm so glad you brought that up,

because we will be discussing that

toward the end of the presentation.

In terms of are

you asking around resource

allocation or resources

brought to bear or are you asking

about professional liability?

I was asking more about professional

liability, but certainly both

could be a consideration.

Yeah. And I think I can I can

briefly talk about resources

that are being held

in and are ready to be deployed

at the state level.

And then we will all table

the rest of my answer

until later when I discuss

professional liability.

So many of you may

have been listening on the news and

understand that there is a strategic

national stockpile that contains

a certain number of transport

ventilators.

Additionally, our state has been

working very hard to procure

transport, ventilators or other

kind of rudimentary ventilators

and resources, masks,

gloves and medications,

et cetera. And so

we would be looking for a hybrid

of support both on the from

federal resources as well

as state resources

to help

individual health systems

that are finding

themselves very taxed in

terms of a given, say,

supply or even

staffing.

So

there may be female nurses or

female physicians who come to

the site where there's a hot

spot.

And this has happened in other

regions of the country

to lend additional hands.

And then we can talk

at greater length about the

liability in a few minutes.

But I you know, this is such

an unusual format for an ethics

talk. And normally these are

pretty controversial topics and they

spark a lot of conversation and

thoughts. And I welcome

you guys to write in with questions.

Or if I say something that doesn't

sit well with you, I'd love

to hear it.

But for now, I will keep going.

Erin, can I can I just

there's a question that just came

through.

So this question said,

why do we need a crisis to spread

care needs between hospitals?

Why don't those patients without

insurance get proportionally sent to

Rochester for care

normally?

Or why don't those patients without

insurance get proportionately sent

to Rochester for care normally?

That's the question.

I'm not sure if I can speak

to the proportionality

of of insured versus non insured

patients coming in Rochester.

But but but I

guess maybe I'll pose that question

to, you know, and that's an

excellent point.

We don't necessarily need a

declaration of crisis to

be helping

our neighbors. And and in fact,

we've seen that already in our

own practice in the last

week where we've been

taking care of patients who

would otherwise have been admitted

to intensive care units in the metro

region because of the

atmosphere in the metro region

and their surge capacity

in their own issues.

It's it's an excellent point and

very important for hospitals

throughout a region to be helping

each other.

And it's part of the mitigation

mitigation strategy not to reach

crisis mode and trying to continue

to right size

our own operations to help

our community as a whole.

So when we look at crisis standards

of care, there was a

kind of a blossoming of research

and literature in this area in

2009 for it's

not a coincidence during the H1N1

epidemic

and the Institute of Medicine

put out these ethical principles,

that should be.

Foundations for any

triage situation and crisis

standards of care.

Those include fairness, stewardship

of resources, transparency.

And we'll get back to that

consistency across

health care systems,

proportionality.

So not overreacting to a situation

and starting to ration

care before we reach crisis

mode, but also not underreacting

to the end, just continuing

to provide care as normal

accountability.

And then, of course, what we all

feel is the duty to care, the

duty to respond.

I want to tell you a little bit

about the efforts that I have been

part of in the state of Minnesota,

just you understand

what what extraordinary things

are really happening in Minnesota

and have been happening for months

now to prepare us

if we were ever to

change our footing to crisis mode

of care.

So there is a group that convened

of ethicists, attorneys,

public health professors, social

workers, chaplains, very

heterogeneous group, including

also physicians called

the Minnesota Ethics Collaborative

Ethics Collaborative.

And in parallel to this

is a working group from the

Critical Care Compact that started

with just the metro region critical

care groups and now has

representation from every hospital

system in the state of Minnesota.

And that group is mostly

intensivist. There are a few

palliative care doctors who are on

those calls as well, and

the groups share kind of an

infrastructure and organizational

structure and have some

bidirectional communication

that comes through the Minnesota

Department of Health and the

Minnesota Hospitals Association.

And there are a few of us who

participate in both.

And I have been participating

in both from the and for

from their inception.

So Minnesota

has developed an ethical framework

based off work that we did

as a state back in 2009

for the Pandemic Ethics Project

that was based out of Minnesota

Department of Health and the

University of Minnesota's ethics

ethicists.

And these principles

are are really important.

They were informed by a lot of

community engagement research.

And we have said as a community

that we would make allocation

decisions without reference to

sex, gender identity, sexual

orientation, religion, citizenship,

immigration status, criminal

record ability to pay

disability and age.

So at first glance, this

sounds like a

really important fare

list.

But I think you already probably

know from coverage

both in the medical and

and media, medical literature

and media that these questions

around disability and age have

become really

important

areas for for conversation

and exploration.

And I'll delve into

that further

in Coming Slide's.

So these groups

really started by holding

up our different triage protocols

that we were coming up with and

kind of in an organic sense

in each health system we were

facing, looking at the situation

that we were facing and trying to

write our own triage protocols

to deal with this particular

pandemic.

And we match them

up against each other, looked for

common themes, looked for areas

in which they conflicted with each

other, and over the course of

several months have generated

a shared set of triage standards.

And this is crucially important

because you don't want people say

if you use the metro area as an

example to present to one

hospital and subjected to one

group of triage criteria,

but be able to drive

10 minutes down the road and have a

completely different set of triage

criteria, where

so where in one place

you may be offered life sustaining

therapies and the other place you

would be triaged to receive

only supportive care.

And so it's important

that we harmonize to the best

of our ability across

systems in a region.

And this has been really

painstakingly

difficult work to

arrive at a consensus.

And we have a very mature draft

of a triage document at this

point that has been shared with

the scientific advisory

team for Governor

Wallace and with the state

health commissioner.

So how do we assign

triage prioritization,

how do we figure out who gets what

resources?

So, of course, their

medical condition plays into

this decision because all comers

don't stand an equal benefit

or chance of benefiting from

a scarce resource like an ICU

bed.

The components of

how to figure out and assign a

score are

generally generally include

what is supposed to be an objective

measure, like the SOFA score, the

sequential organ functional

assessment.

It also incorporates consideration

of whether patients have comorbid

condition, what the burden of

those illnesses are, and

specifically we're looking

at illnesses that are likely to

impact their six month survival

and in six months is not an

accident. That's so.

Do they meet hospice criteria?

And if so, then they would receive

a prioritization, their

score, they would be up scored,

meaning they would have a higher

score and therefore be sorted

into a group of patients less likely

to receive a scarce resource.

We also and this is

different, we diverge and some

from some states and that we are

proactively looking at length of

anticipate the length of stay.

So a patient who is,

say, admitted for

pulmonary edema, where we expect

their length of stay, at least in

the ICU, may not last

for a week or more

like a covid-19 patient.

They would be relatively

prioritized.

So I should back up and

and be transparent about the fact

that these

criteria would apply to any

patient who is

needing intensive care, not just

patients who are there because of

the prevailing pathology of

the pandemic.

So overdose patients,

patients who have heart failure,

anaphylaxis, any other

patient who requires critical care

could would be subjected to the same

set of criteria.

And these the scoring

system, the composite score that

I've just described, would then help

assign the patients into

a prioritization category

with a low or good

prognosis, low priority individuals,

maybe such good prognosis

that they don't even really need an

ICU bed.

Under normal circumstances, we

might have met them for observation,

but in this case, we would send them

to the floor

and the Blue Group.

It's also important to emphasize

that we don't prospectively

exclude very many people

from these from

receiving a score.

But the patients who receive

the very highest score, the very

sickest patients, particularly

if they are, say, being actively

resuscitated with CPR or

they're in a persistent vegetative

state or something, just where

they're at the very extreme margins

of an individual who would

even receive

intensive care under conventional

standards, that those

patients end up in the Blue

Group and they would receive the

lowest priority to

have an ICU bed.

So they are not excluded from

consideration for care, but they're

prioritized in an extreme

way.

I'll say that we have

not just me, a lot of people who

have been working in this field

for the past few months, significant

misgivings, and I'll be honest

about that, about our

the way in which we can

triage people in 20,

20 so far hasn't

traditionally been used for large

scale triage.

In fact, it hasn't been

prospectively validated.

We have to decide as a

as a society and as a region,

what is the outcome when we're

saying who would benefit from

intensive care? What is the outcome

we're looking for right

now? The definition is really

survival to the hospital discharge.

We're not looking at 10 year

survival.

Is that the right metric?

I don't know.

There is controversy in that area.

I will be honest with you about

that. But there

there are also concerns

about disability rights,

health inequities that start to pop

up as you try to project

and prognostic

uncertainty as you start

to project out further and further

into the future about what

somebody five or ten year survival

might be.

Finally, in order

to formulate a SOFA score

or to understand

a person's burden of illness,

there is a substantial

amount of clinical judgment

that goes into making

these determinations and

assigning these scores.

So even a SOFA score that looks

at the outset like such a clean,

objective measure.

First of all, the SOFA score that's

generated through EPIC

and many of the health systems

in our state use. That

was until recently

spitting out a SOFA score that

treated an absent

value as normal.

So if a patient sofa includes

bilirubin, if the patient's

bilirubin hadn't been checked

within the previous 24

or 72 hours, then they would

be assigned normal liver function

even if they didn't have normal

liver function.

Likewise, it incorporates the

Glasgow coma score.

Well, that's a really difficult

thing to assess when you have a

patient who's deeply

sedated because they're in A.D.s.

And so we are using these scores

not just to assign priorities

and assign beds to patients who

are waiting for ICU, but

for waiting for ICU resources,

but also to consider reallocating

for patients who have been in the

ICU for a while, have received a

time limited trial and are

either not improving or maybe

even deteriorating.

Which is why it's important to think

about how we could objectively

measure these parameters for

patients who are both coming in

and presenting for the first time,

but also who are

consuming resources

in the ICU on an ongoing basis.

Likewise, whose judgment

is it that we're relying on to

determine whether somebody has a

sufficient burden of comorbid

illness that they would have hospice

eligibility?

And yet there is

value, tremendous value in

harmonizing our efforts with our

regional neighbors and I will say

our national community

and critical care in our

international community, about

90 percent of the triage protocols

that I have seen so far is

the backbone.

So, so far is flawed.

But SOFA is

as uniform as we have right

now in 20, 20, and

teams are working fast to develop

better predictive models.

But at the moment,

we sofa is the best we have

and we we have to rely on that.

But understanding

our misgivings about that scoring

system has caused us as

intensive us especially to

push extra hard for

the role of clinical judgment

playing in here and to have

people with critical care expertise

at the table helping to make

decisions and compare patients

who might have the same score

on paper, but might look very

different when you start to dig

into their chart and understand

information about their comorbid

illnesses and the trajectory

of their illness.

So there are some populations that

are deserving of additional

consideration.

Those include children,

pregnant women, disabled

persons, historically

underserved people.

And also I'll just briefly mention

here, essential workers.

So there have been

proposals around the country, around

the world for prioritization

of health care workers in triage

systems so that

they would be kind of pushed

if not to the front of the line,

further up the line, both

as a reward for their

bravery and providing

care under difficult

circumstances, at substantial

self risk.

But there's also an argument

which is described in the ethics

literature as instrumental value.

So to save the life of a health care

worker may allow down

the road more individuals

in the pandemic to be saved.

You can't necessarily make that same

argument. Remember, in a mass

casualty event where

the person who survives because

they've received ICU care

wouldn't be able to immediately turn

around and care for the other

individuals who are prioritized.

But in a pandemic that stretches

over months, it's conceivable that a

person who is health care provider

or plays a part in the health care

team could return

to the workforce and continue to

help the overall good of the

population.

I alluded to this earlier.

Early in

the course of different health

care institutions sharing their

triage protocols, there

was a push for

this consideration of life

cycle stage.

So younger

individuals receiving a higher

priority because to save their

life would mean more

life, years of

benefit from those critical care

resources.

So 20 year old, even

if gravely ill,

if that 20 year old were felt to

have a good chance of recovery with

application of life sustaining

therapies versus saving two

80 year olds, you can imagine

that 20 year old might have 70

more life years to live and

the two 80 year olds would not have

70 more life years to live

as this has evolved.

This is where advocacy has

really influenced policy and

and advocacy, not just from

disability and

and human rights

groups, but even

from individuals who have sued

governments in their regions,

state governments who have endorsed

policies that prioritize

this concept of life years over

individual lives.

And so the pendulum in the past few

months has swung

as nine states, I believe,

have faced civil rights

complaints through HHS,

the Office of Civil Rights, and

or lawsuits

to individual institutions

or states that have endorsed

approaches that

that prioritize life years

over individual number

of lives saved.

Likewise, I think it's important

to acknowledge here as

a as a profession

and maybe even as a society, but

certainly as a profession, there's a

very large body of literature

that support the fact that

we consistently

undervalue the

lives of people with disabilities.

And so some people have

argued that maybe we shouldn't be

looking at the

chronological life years

or so. Somebody is

80 years old.

Maybe we should be looking at their

functional status.

Well, then you get into this very

difficult situation to disentangle

when functional status may also

be influenced by disability

that has no impact on

somebody's likelihood of

long term survival.

And so there's this kind of tug of

war I've started to observe

between ageism

and embolism.

And it's been really

well written about.

I have a few references at the

bottom of the slide and happy to

provide more around this

tension.

Even before the events of the past

few weeks, this has been

a high priority at Mayo

and across the state of Minnesota.

And so I do want you to know that

this is the attention

to to.

Mitigating systemic

racism has been

has been added from the

from the beginning of our working

groups, understanding that

burden of comorbid illness

is influenced by individuals access

to health care and that they

may not individuals who have

been historically disenfranchised

don't have access or may present

later in the course of their

illness.

And so it's really important

for us to think about ways in

which our policies going

forward influence

or potentially exacerbate

existing inequities in our health

care system.

So some examples of this

colorblind reporting of

burden of illness is

making it more difficult to

understand the disproportionate

impact of

covid-19 on African-American

communities. But what we know

is that in counties with

that are predominantly

African-American, the

test positive rate is three to

six times that of predominantly

white counties.

So there there are a lot of

indicators that would

allow us to to

understand that these are

not just theoretical concerns, but

they are real and they are they

are materializing

as as this pandemic proceeds.

No emergency management

lecturer would be complete without

referencing Dwight Eisenhower,

he is commonly quoted in

these circles, and

I think that it's worth stating that

the the effort that has

gone in at Mayo

and also across our region

to the thoughtfulness

that has gone into our planning for

a potential crisis, standard of care

is invaluable and that we

that we have to be nimble and we

might need to change our stance

quickly as we face

more austere conditions.

But the fact that we've established

these working relationships with

our partners around the state and we

have communication strategies now

to to communicate

back and forth with the Department

of health care resources, pool

resources, et cetera, that

is invaluable.

A few just brief points about

implementing a crisis, standard

of care, how would this look,

first of all, if we reached a

crisis, standard of care?

You should be looking for

communication not just from

within our institution, but from

state authorities

to medical professionals, but

also to patients and their families

and to the broader community, kind

of publicizing how things are

changing and what they should

expect. And those plans are

underway and are being written some

and I've been involved in some of

that work only to be deployed

if we were to really reach or

be surging to the point where it

looked like we were going to reach a

crisis standard of care.

It's critically important to

understand that we would not be

expecting the bedside

team to pass to triage

resources for their own patients.

We would be looking to deploy

independent multidisciplinary triage

teams that might include

off duty

ICU or emergency room nurses,

off duty ICU or emergency

room physicians and Pipas,

also ethicists and

diversity and inclusion

representatives.

Again, this has been part of our

plan from the inception

of these planning processes.

It's important that there be an

appeals process in case a triage

decision made to say

disadvantage or even to allow

a patient to continue to receive

ongoing care.

That doesn't sit right with the ICU

team, that there is an appeals

process whereby the team and or

family could appeal the decision

to a secondary review board.

And likewise, it's important

that there be oversight in a very

systematic way and documentation

of how patients are

examined in triage so that we

make sure that we're adhering to

these high principles that we

have set for.

I will stop for maybe one

question, Alex, if one has arisen

otherwise, I can talk about these

the professional and

personal risk.

So there's several questions that

have come up while you've been

talking.

And I think the one that's risen to

the top is particularly timely with

regards to your last slide.

So the comment was that

the individual felt the

communicating with patient relatives

regarding decisions like withholding

CPR due to resource limitation

will be most challenging.

Do you have any recommendations on

how to convey such sensitive

information, especially if you're

thinking about off duty intensivists

as part of a triage team potentially

engaging in that process?

Yes, and

thank you for that question.

We are working to deploy

also communication teams

who would be communicating

triage decision outcomes

to patients and families

so that that burden is not

ideally placed on the shoulders of

their bedside providers.

Of course, we would invite and

encourage bedside providers

to participate

in those difficult conversations

if they wanted to or if it

was beneficial.

And it may very well be because they

would have a therapeutic

relationship with a patient or

family as opposed to a kind of a

Denovo interaction.

But crucially important,

we would not be relying

primarily on the bedside providers

to deliver this type of bad

news. That's kind of coming from

institutional triage policy.

So I want

to finally take a moment to

acknowledge the tension that we face

as a critical care workforce between

prefer personal risk and

professional obligation.

You'll note that I haven't

this is a an

image reference or

an image source, but this is not a

medical literature reference

because I really haven't found

good literature that

addresses that particular set of

challenges that we deal with in our

field.

I think a lot of people choosing a

career in the critical care

world

knew that we face an enhanced

risk of a blood borne infection or

violence against us in the workplace

and and understood

that, but didn't conscript ourselves

to exchange

our lives for the lives of our

patients.

Right.

So and in a world

in which there are concerns

about scarcity of protective

equipment to to protect ourselves

as we provide care during the

pandemic, these are very real

tensions. And they're very

individual and

they depend a lot on an individual's

own risks, both

of their own health status, but also

of the health status of others who

rely on them.

And just like

it's discriminatory,

we talked about discrimination

around age and disability.

It's not possible

legally for your supervisors

to reach out to you

on an individual basis and

make sure you are fit for duty.

But it is incumbent on you to

think about these risks that

you're taking.

Make sure that you feel safe.

Talk to your supervisors about

accommodation if you don't.

And I do want to acknowledge that

because I know that

we all are facing a

different kind of risk.

And nobody in this group,

when they decided to join

this profession, was signing

up to be in the Secret Service and

exchange our lives for the life of

somebody else.

I want to just

close by talking a little bit about

liability, so

this is germane

to Alex's question about

civil and criminal liability

that health care providers face

as we do

deliver care in

crisis mode.

So

there is a precedent in

crisis mode of individuals

who are following crisis standards

of care, being sued

civilly, facing civil lawsuits

for negligence, malpractice

filed by survivors of patients

who have who have died.

And they need to prove

deviation from the standard of

care, which is why it's critically

important that as a region,

we adhere to

and agree upon a triage protocol.

Likewise, there is a precedent for

criminal charges

to be filed for

homicide, for failure

to intervene or for

withdrawing and reallocating

resources from an individual under

a crisis standard.

Health care providers have been

charged by prosecutors for

manslaughter or even murder,

depending on the certainty of

death when

resources withheld or withdrawn.

So I don't mean this to strike

fear into your into your hearts.

Alex Azar, who's the

secretary for HHS, has

earlier in this year

written an open letter to all

of the governors, including Governor

Walz, pleading for waivers

of existing are

variations of existing liability

protections to protect

health care professionals who are

providing care under a crisis.

There have been various

approaches to this.

Some states have had their

governors issued executive

orders protecting health care

professionals.

Some have actually written covid

specific recommendations

to our liability protections.

Minnesota currently does

not have liability protections

for individuals who are providing

care outside of the standard of

care. That said, if our

entire state shifts from

a crisis or from conventional

care to a crisis standard of care,

presumably the providers

would be covered under those

existing liability protections.

But know that the Minnesota

Minnesota Hospitals

Association and the AMA

are working very hard, lobbying

very hard for additional protection

authorized either by the legislature

or by the governor.

So in summary,

as we move into a crisis

standard of care, our obligations

shift from the individual to the

population.

We have to keep an eye on staff

space and supplies.

The declaration of a crisis standard

of care really happens at

a regional level and it happens from

a government agency.

We need to ensure that our triage

protocols are equitable, they're

proportional to the situation,

and they are transparently

communicated to the individuals

who are providing the health care,

the individuals receiving health

care and the broader community.

Finally, I want to acknowledge

that delicate balance of personal

and professional risk,

both our physical

challenge and also liability

risk.

If you read one paper of all the

references that I've listed on my

slide, this would be the one.

And it's particularly important,

I think, in the past couple of

weeks. It's about inequity and

crisis standards of care.

So I highly recommend this one

reference.

Erin, thank you very much for a

fantastic talk, and I think

just queuing off of your last point,

there was one question that came up

during your presentation with

regards to why Minnesota's

ethical framework doesn't mention

race. I think that was probably an

omission on on the first slide that

you had since you addressed that

later.

Yes, it was an omission on the first

slide. Yes.

Yeah.

So there's two interesting

questions here.

And I recognize that there's only

four minutes left.

I will just highlight for everyone

who is not on the chat

that the seemy code for today is

V o f and

you p v o f

and you P.

So two questions here

that that I think are interesting

ones and perhaps overlapping

that, but a little bit outside of

your discussion.

So the first question is how

an individual should balance the

pressure that providers may

feel from social

and public media

with regards to recommended,

but perhaps not evidence based

strategies.

And how do you avoid making

decisions that are that are not

necessarily best practice

but has worked well for others?

So I'd be interested in your ethical

framework for that question.

That is such an excellent question.

And you have actually pinpointed

my question for

a research project that I've

just put to the IRB, because

I think that it's an excellent

individual question about how

when the stakes are so high

in a highly fatal disease that

we are and we're seeing an onslaught

of information and

of varying quality,

how quickly should we be shifting

our practice to

to.

In response to that, I guess,

and I think that our

our stance at Mayo continues

to be a measured stance,

that we're interested in looking at

innovation and studying it as fast

as we can, but trying to

be measured and balanced

and looking at evidence based

instead of following anecdotal

anecdotal reports of benefit.

And then the last question

I have here is also a really

challenging one, which is

when you're in an emergency

situation, in a crisis

mode, how do you employ

that incredibly orderly

but relatively complex triage

framework that you described

versus just relying on fundamental

principles to

keep one safe from liability?

That's actually a simple question.

The answer is that you are on the

side of life, so you save

a life and then you can always

re-evaluate after you say intubated

a patient, you're bagging them.

And you you have to understand

what what you

what you do with that patient.

From that point forward, you would

air on the safe side of saving a

life. And then we invoke cartridge

procedures. So that

would be how we would handle that

type of emergency.

Well, thanks very much, Aaron.

Really an incredible presentation

and I think

a very high level summary of

what I'm going to speculate as

hundreds of hours of work on your

part over the course of the last

couple of months, having had just a

little bit of a window into some

of the work that you've been doing.

So so thank you very much for

this incredible presentation.

I will mention there was one of

their comments with regards to

other members of the community

potentially benefiting from this

presentation,

non critical care providers as well.

And I suspect that your

your attentions and

work will also be of significant

interest to all the other groups

within within the institution of

enterprise.

So. So with that, we will bring

this this session of critical

care grand rounds to a close.

Thank you very much for joining and

participating again.

Thanks, IRA, for a great talk.

Thanks for your attention.

Thanks. Thanks for the great

questions.