cic - what have we learned from covid - abbott, rudner
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Challenges in Care: What Have We Learned from COVID-19?Jean Abbott, MD, MH and Nancy Rudner, DrPH, APRN
CIC
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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 -
Challenges in Care: What Have We Learned from COVID-19?Jean Abbott, MD, MH and Nancy Rudner, DrPH, APRN
CIC
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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
Challenges in Care: What Have We Learned from COVID-19?Jean Abbott, MD, MH and Nancy Rudner, DrPH, APRN
CIC
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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
Challenges in Care: What Have We Learned from COVID-19?Jean Abbott, MD, MH and Nancy Rudner, DrPH, APRN
CIC
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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)
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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
Challenges in Care: What Have We Learned from COVID-19?Jean Abbott, MD, MH and Nancy Rudner, DrPH, APRN
CIC
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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
Challenges in Care: What Have We Learned from COVID-19?Jean Abbott, MD, MH and Nancy Rudner, DrPH, APRN
CIC
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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