CIC - What Have We Learned from COVID - Abbott, Rudner

Challenges in Care: What Have We Learned from COVID-19?Jean Abbott, MD, MH and Nancy Rudner, DrPH, APRN

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National Nurse Practitioner Symposium 2021

Challenges in Care

What Have We Learned from COVID-19?

Jean Abbott, MD, MH

Nancy Rudner, DrPH, APRN

Disclosures

The speakers have no relevant financial relationships with any commercial

interests to disclose.

Objectives

1. Assess COVID-19 vaccine distribution strategy choices and challenges in USA and globally

2. Discuss NPs’ COVID-19-related moral distress

3. Evaluate challenges of immunization mandates

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What do you like best about being here

A. Mountains

B. Colleagues

C. Learning new content

D. Being away from home

E. Thin air

COVID cases and deaths (as of 6/1/21)

WORLD USA

Cases 170 million 33 million (19% of world’s cases)

Deaths 3,539,000 593,000(17% of global deaths)

% of world population 100% 4%

Washington Post (2021) U.S. coronavirus cases and state maps: Tracking cases, deaths -


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Lost at the front line:Health care workers deaths

3607 health care workers died of COVID as of April 2021

1 in 3 were nurses 1 in 5 were support staff

1 in 4 were Black 1 in 5 were AAPI

Know someone? Submit a name toLost on the frontline: US healthcare workers who died fighting Covid-19 | US news | The Guardian

Lost on the frontline: US healthcare workers who died fighting Covid-19 | US news | The Guardian

Health care provider’s duty to care:Why do we expect healthcare professionals (HCP’s) and first responders to risk their health/lives in this pandemic?

Promise to care: promise to provide medical care to those in need – our “social contract”

Few in our community have medical/nursing and other HCP skills

Skills are not transferrable. HCPs cannot easily be replaced by others who lack appropriate training

Healthcare worker contract with society – respect, writing prescriptions, salaries vs. a level of predicted risk.

Reciprocal employer commitments: safety, support

Considerations that may limit a Health Care Professional’s “duty to treat”

Level of risk

Ability to provide benefit to victims

Professional obligations to other patients

Relevance of professional expertise

Obligations to family

Availability of others to respond

Duties of Clinical Ethics

Duty of

Care

• Fidelity to the patient (non-abandonment)

• Relief of suffering• Respect for the rights

and preferences of patients

Duties of Public Health Ethics

Clinical Ethics and Public Health Ethics

Moral equality of persons and equity (fairness relative to need) in distribution of risks and benefits

• Promote public safety

• Protect community health

• Fairly allocate limited resources

Prioritize CommunitiesPrioritize Individuals

Moral distress

Sick patients

Unable to make a difference

Mask mandate enforcement

Communication with families

Staff attrition, travelers

Loss of coworkers, friends, family


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CDC (2021) https://www.cdc.gov/nchs/nvss/vsrr/covid19/excess_deaths.htm

Excess deaths, United States, January 2017- May 2021

0%

10%

20%

30%

40%

50%

60%

White Black Hispanic AI/AN Asian

Excess Deaths Associated with COVID-19, by Age and Race and Ethnicity — United States,

January 26–October 3, 2020 (cdc.gov)

Excess Deaths Associated with COVID-19, by Age and Race and Ethnicity — United States, January 26–October 3, 2020 (cdc.gov)

What Causes Non-COVID Excess Deaths?

Missed COVID deaths

Failure to get treatment for other acute diseases

Failure to maintain treatment program for chronic diseases

Deaths of isolation?

Ethics of vaccine distribution-Reduce severe disease or reduce spread?

If deaths- seniors

If spread- those not able to protect/self isolate

Frontline healthcare workers

Essential workers exposed to public

Those in crowded living situations

ICE

Prisoners

Our US vaccine distribution policies….

Who has access to vaccine?

Who has time to be available?

Who can isolate?

Do we want federal leadership v 50 state strategies


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Percent of Total Population Vaccinated, by Race and Ethnicity, United States, 5/24/21,

public state data

43%

29% 32%

54%

0%

10%

20%

30%

40%

50%

60%

% of TotalWhite

PopulationVaccinated

% of Total BlackPopulationVaccinated

% of TotalHispanic

PopulationVaccinated

% of Total AsianPopulationVaccinated

Percent of Total Population that has Received a COVID-19 Vaccine by Race/Ethnicity | KFF

66% of US adults have had 1-2 immunizations or intend to (based on survey. as of 6/2/2021)

Let’s interact!

Are you immunized

A. yes, fully

B. partial, 1 of 2 doses

C. no, but I plan to soon

D. no, I do not plan to soon.

E. other

13% DEFINITELY Do NOT plan to get vaccineMay 30, 2021 KFF COVID-19 Vaccine Monitor Dashboard | KFF

12% want to “wait and see” (as of May 30, 2021)

80% trust health care provider


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May 26 Colorado COVID hospitalization rate among UNVACCINATED = the January 11 hospitalization rate. Death rate = February rate CASE

You work in a primary care practice. The receptionist and medical assistant have opted to not be vaccinated.

What are your obligations?

What are their obligations?

Require vaccination????

What circumstances justify requiring vaccination? Working in a nursing home?Public school?Concert?Airplane?Cruise?

Washington Post April 3, 2021 Opinion | Vaccine passports and the tough questions we haven’t confronted - The Washington Post

Require vaccination????

How much risk should the rest of us have to accept to respect the conscience rights and bodily autonomy of fellow citizens who

don’t want to get vaccinated?

At risk: people with cancer, transplants, immunosuppression

All of us at risk: Choosing to not to get vaccinated creates a reservoir of disease for mutations, variants which will spread to us, because our immunity wanes or a variant can evade our defenses.

Washington Post April 3, 2021 Opinion | Vaccine passports and the tough questions we haven’t confronted - The Washington Post

Covid-19 vaccine tracker: View vaccinations by country (cnn.com)

Global COVID vaccination doses per 100 people by June 1, 2021

Coronavirus (COVID-19) Vaccinations -Statistics and Research - Our World in Data


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Global distribution, access

Availability of vaccine

Developed with USA funding Should it be patent protected? Jan 2021 WHO Director warns

of a “catastrophic moral failure,”

39 million doses given in 49 higher-income countries

25 doses given in 1 lowest-income country

Impact if not universally available

Global health interconnectedness

Uncontrolled, more variants

Is COVID control a commodity? Are free market forces applicable?

Coronavirus vaccine rollout: World's 'moral failure' WHO says (cnbc.com

An Ethical Framework For Sharing

It is the right thing to do

It protects us by allowing us to travel sooner

It protects us by curtailing the evolution of variants

CONCLUSIONS

Pandemic has exacerbated the disparities and ethical choices we face every day as health care professionals.

The public health framework can cause moral distress to us in our daily care for patients.

This disaster has several unique aspects that have made it particularly stressful (contagion, duration, fatigue)

Vaccination is part of the way out, but it is unclear what is around the corner.

What ethical principles guide us in this public health crisis?

National Academy of Medicine, Guidance for Establishing Crisis Standards of Care for Use in Disaster Situation: A Letter Report, 2009

References

CNBC (2021, Jan 18) Coronavirus vaccine rollout: World's 'moral failure' WHO says (cnbc.com)

Guardian (2021) Lost on the frontline: US healthcare workers who died fighting Covid-19 | US news | The Guardian

Kaiser Family Foundation (2021) Percent of Total Population that has Received a COVID-19 Vaccine by Race/Ethnicity | KFF

National Academy of Medicine, Guidance for Establishing Crisis Standards of Care for Use in Disaster Situation: A Letter Report, 2009

New York Times (2021, March 21) Rich Countries Signed Away a Chance to Vaccinate the World - The New York Times (nytimes.com)

Our World in Data (2021) https://ourworldindata.org/grapher/covid-vaccination-doses-per-capita

Washington Post (2021) U.S. coronavirus cases and state maps: Tracking cases, deaths - Washington Post

Washington Post (2021, April 31 Opinion | Vaccine passports and the tough questions we haven’t confronted - The Washington Post

Documents

CIC - What Have We Learned from COVID - Abbott, Rudner