 I'd like to introduce the fourth panel today called Ethical Issues and COVID-19. The moderator for that panel is Dr. William Parker, who's an assistant professor of pulmonary and critical care, as well as an assistant director of the McLean Center. Dr. Parker's research interests include the impact of organ allocation policies on patients and transplant programs. His overall career goal is to apply advanced state of science methods such as deep learning to organ allocation and design systems that efficiently and fairly allocate these scarce healthcare resources, organ transplants, to the patients most in need. Recently, Dr. Parker received a K Award from the National Heart, Blood, and Lung Institute to develop a novel heart allocation system using data analytics and artificial intelligence. In addition to moderating today's second panel on ethical issues in COVID-19, Dr. Parker will give the first talk entitled Simulating Scarce Healthcare Resource Allocation Systems Bringing Data to Debate. The other speakers in the fourth panel will include John Lapuma, Alexia Torchi, and Anup Malani. Please join me in welcoming the moderator, Dr. Will Parker. Thank you. Thank you, Dr. Siegler. You know, you promoted me a little bit early. I'm still instructor of medicine until the end of the year, but since I've known you, I guess only for 30% of my life in the percentage of life someone has known, Dr. Siegler, you've been promoting me that entire time, so it's a huge honor to be moderating this session and to be giving a talk here at the McLean Conference. So I think I should just jump right in. I have a lot of content I wanted to get through today. So what I'm going to talk about today are Christ's, oh, first I should mention my KOA, which Mark already outlined is my only disclosure. So I'm going to talk about Christ's standards of care today. And what are these? This is the Memorial Hospital in New Orleans. As you can see, it was completely flooded by Hurricane Katrina. Temperatures inside the hospital reached 100 degrees at its peak. They were without power for days as the patients slowly started to die because of lack of medical care. The physicians inside had to make the tragic choice of deciding which patients would receive critical care in which would be made comfortable. Because of this crisis and several others, the Institute of Medicine formally defined the crisis as standards of care as a substantial change in usual healthcare operations that is possible to deliver. So when a disaster hits and it's no longer possible to provide all patients that they need, the care that they need, these are situations of what's called absolute scarcity, where the flood of patients that need critical care or healthcare resources in general vastly exceeds the amount of available care. Unfortunately, during the first surge in the US, we largely avoided absolute scarcity. There was lots of regional disparities in care, but the healthcare system was able to handle the load. Unfortunately, now with the current trends in the COVID-19 pandemic, we may very well hit a scenario where in major US cities across the country, there are just simply too many patients. And what would this look like? You'd imagine scenarios like this playing out across the US, where there are three patients and one remaining ICU vet. And the physicians at the hospital have to somehow decide who is going to get critical care treatment and which patients are going to be assigned a palliative care and presumably die shortly thereafter, because they will not be receiving life support that they desperately need at that time as the COVID-19 infection progresses. So you would imagine that they'd have demographic information about each of these patients, age, gender, and then you'd have some prediction of survival you could make based on their clinical data. Here is the sequential work and failure assessment score, SOFA score, which I'll be describing in more detail later on, that give you a rough prediction of what their probability of surviving their hospital stay is. Then you also have other information about their medical condition. And finally, social factors, which I think most of us would think would be unethical to base an objective allocation system on. However, if you didn't have an allocation system in place, may actually dominate how scarce resources would be allocated in practice. So, Andrew Hantel this morning in his wonderful talk on his allocation work, already outlined this great paper by Jeevan Prasad in the Lancet in 2009, where he develops a rich framework of all the possible principles one could use to allocate scarce resources. Roughly there's four big categories, treating people equally, utilitarianism, treating the worse off, and promoting or rewarding social usefulness. Now I'm not going to go into the merits, the pros and cons of each of those at great length. I would refer you to this paper. But the important conclusion from that work is that you can't put all your eggs in one basket. You have to construct a multi-principle framework and draw each of these principles should be respected in one way or the other in order to create a rich, robust framework that will be acceptable to all stakeholders in the process. But I would say that the problem goes further than that. Oh, I just wanted to say that they did update their framework for the COVID-19 pandemic. This is Zika Manuel is the first author in this paper in the New England Journal of Medicine. So you can see the framework is roughly the same in terms of the principles that they refer to and the recommendations. However, all the authors were 10 years older. So prioritizing younger patients first kind of fell to the bottom of the list. So I don't know if that was a coincidence or not. It was heavily emphasized in their first framework. So, you know, what are the general points of consensus amongst ethicists about how you would allocate resources in this terrible situation where you have to make these tragic choices? Well, first come first serve is not acceptable. If you relied on that sort of status quo system, the well connected and well off would clearly cut the line and get critical care first. So you can't rely on that system. And then triage committees, not frontline providers, not people shouldn't be rationing at the bedside to use that. She's making triage committee decisions and how should these committees make decide who's going to get resources, critical care resources, ventilators, etc. Well, objective scores and algorithms designed to maximize benefits of the population should be employed. However, we're already running to a problem, right? What is a benefit to the population? Should these scores maximize the total number of lives saved or the total number of life years saved? So if we go back to our example of the three patients deciding who gets the one ICU bed remaining, if you're allocating based on survival to hospital discharge, the older patient, the eight year old patient in our example would sort of win the rationing process and go to the ICU. However, you're allocating based on potential future life expectancy. So if you multiply the probability of survival by remaining life years, the 28 year old patient, even though she's much sicker, would be allocating critical care resources first. So what this example highlights is that you can have a very well thought out and rich normative ethical framework. But when you design a practical allocation protocol, you have to make real choices which actually will influence how those different principles that you've laid on your framework are weighed relative to one another. And so how have states started to do this? Well, the answer is a lot haven't. In this great work by Dr. Pissicello from Rush and other McLean fellow, she found that only 28 states even had implemented a crisis standard of care in their state. And the guidance documents varied widely state to state. The first time Gina made this figure, basically every state was its own color because each of these protocols is materially different in the way they rank order patients in the setting of a scarce condition, an absolute scarcity. But most of them use, rely on objective measurements of in-hospital mortality as their primary way of rank ordering patients like the sequential organ failure assessment score. So this is something that we can calculate at the bedside. It's actually fairly accurate in terms of predicting in-hospital mortality. So can discriminate in theory between patients. This is true in COVID-19 patients as well. Who will survive from or die if assigned to critical care? And so most states hang their hat on the SOFA score. But the way they use the SOFA score varies dramatically. So in New York, they have certain cut-offs where if your SOFA score is over 11, you're not allocated by ICU resources, a ventilator under any circumstances. You're given sort of a blue armband in the military triage literature. Whereas Pennsylvania has totally different cut-offs, much lower threshold to get into that top priority score one of a SOFA score of less than six. And they incorporate explicit chronic disease points which are designed to identify patients who have the longest life expectancy and de-prioritize patients who are expected to die soon regardless of their COVID-19 diagnosis. And the examples they use for these chronic condition points have actually now been removed from the state website because of various legal challenges and general outcry that these potentially would perpetuate disparities against people with disabilities in particular. But it kind of goes further than that which in terms of racial and ethnic disparities. So here's an example of a 40-year-old patient who's on dialysis under the Pennsylvania system. They would be prioritized lower than an 80-year-old patient who had a much higher risk of death with no chronic medical conditions. So, you know, just simple application of these scores to real patients, real data produces a lot of surprising results. And, you know, the concern that we had, you know, Monica Peek who spoke wonderfully this morning about this issue in a larger context is that if you actually had to implement one of these crisis standard of care in a diverse urban population, you would end up exacerbating the chronic disparities that we've seen in the COVID-19 pandemic. It would make the allocation of ICU resources to minority communities even lower than they already are. And Maryland is another example of a state protocol which divides up the SOFA score in a different metric. And so the main point of me showing you this is that every state has their own way to cut the SOFA score up into different categories and translate the SOFA score into a numerical score that they're going to rank order patients by. And then furthermore, if two patients have the same score, the way they break the ties between each state also varies widely. A lot of the green here is not mentioned, so they don't have a plan for that situation. But, you know, some just use a peer lottery. Others use an age tiebreaker, which is important to remember as I actually started showing you some of the data. So basically the conclusions from our review of the state protocols is that there's total lack of consistency. All the components of the protocols vary, even though, you know, they all are kind of drawing from the same general ethical framework that, you know, you want to try to maximize the benefits of the populations. The way that's implemented varies widely across the country in meaningful, practical ways. And, you know, what a lot of us started thinking about is, you know, what if we apply these protocols to real data and actually simulate how they would perform? Maybe that would inform some of these choices. So, through the McLean Center and connections therein, you'll see many authors like Kelly Mickelson, Monica Peake on this paper, who which is now, hopefully we'll get accepted fairly soon, decided to do just that. Let's take these protocols, let's take real data from COVID patients and see how they would perform under a hypothetical allocation, a scarcity scenario. So we got all of the data of all the COVID positive patients admitted to the ICU at University of Chicago and Northwestern, as well as the Northwestern affiliates. If you look closely at this table, you can probably figure out which column is U of C and which column is Northwestern. The patients at U of C tended to be more predominantly African-American and had higher SOFA scores on presentations who were more critically ill when they arrived to the hospital than those at Northwestern or the Northwestern community hospitals. But all these patients were sick, they were all requiring critical care resources immediately and all would have died without critical care. And so basically what we did is apply the ranking systems, all those three state protocols I outlined earlier, as well as some pragmatic ones. Sick is first, not as a serious thing that we're proposing, but sort of showing how bad things could be. If we assigned the highest SOFA score first, how would that, how badly would that perform in terms of saving lives? Because that's, you're giving ICU resources to the sickest patients, those least likely to survive with ICU care. Lotteries, random and youngest verses, the youngest go first, pretty straightforward. And then the rest are the complicated priority scores that New York and Maryland and Pennsylvania came up with. And so if you look at the distribution of priority scores, I want you to remember this when I show you some results at the end, what jumped out to us right away is that a big clumping and the top priority tier. So most patients in the New York system would be red. Meaning that they would be, you know, top priority for the ICU. But when 70 patients are top priority for the ICU, the system is more or less kind of operating like a lottery, right? Very few patients are getting excluded based on their SOFA score. Maryland was even more extreme because it has a higher SOFA cutoff. So what are we doing with the simulation modeling? Well, what we're doing is we have a sample of a thousand patients. We randomly draw with replacement, a brand new sample from that data, apply the allocation rule. And then so assuming a 50% scarcity, we assign 50% of the patients to palliative care who will die and the other 50% will get critical care. And then amongst those who are assigned critical care, those that we calculate the survival from their actual observed outcomes. So this is obviously completely hypothetical where we could put all the patients in Chicago in one bucket and allocate all at once. Nevertheless, we thought it was a good first approximation of the way these allocation rules would perform. And so these are the main results. So 50% scarcity threshold here so the protocols could save it most 50% of the patients, right? Because that's all the critical care resources we had available. And as you see the sickest first as expected performing the worst, those, you're assigning critical care to patients giving ICU care to patients with the highest selfish score and the highest chance of death. So that makes sense. Sort of a sanity check that SOFA works at all. Lottery improves that significantly over a sickest first. And then the state protocols get you more lives saved per, you know, so pretty significant 5 per 100 lives saved. However, the state protocols achieve this increased efficiency at a cost to patients with severe and chronic major chronic conditions. So if you had a major chronic or severe condition in the Pennsylvania system, none of those patients were allocated critical care resources. And the same goes for patients with severe critical care or severe chronic conditions in the Maryland system. So, you know, I don't think the people who designed these systems intended them to be completely exclusionary of patients with preexisting medical conditions but in practice they would be. And then next, even more surprisingly because all of the patients in the Maryland system, more or less like 75% got that top priority score. The aged high breaker dominated the SOFA score. And what Maryland ended up kind of resulting in is a youngest first protocol where nobody over the age of 70 was allocated critical care. Now, again, this is not, was definitely not intended by the designers of the Maryland system. But before you apply to this your protocol to data you can't actually see if it's achieving the intended ethical consequences you wanted. And then, you know, disappointingly, but I guess not unsurprisingly, in all three state protocol, self-identified black patients were less likely to receive critical care. And this falls directly from the fact that black patients had higher SOFA scores of presentation and increased levels of chronic conditions. You know, we're more likely to have comorbid conditions. So, again, our fears that these allocation algorithms could exacerbate healthcare disparities were realized. All right, so I'm over time, but you know there's, I think I've already mentioned sort of the limitations of this analysis. This is a static model. We, you know, we had to, we were not capturing any of the diamondism of what actually happens when patients are allocated or going up to the ICU and all of the complexities they're in. And, but I wanted to finish with the point that, you know, I think simulation model and empirical analysis plays a really important role in these types of allocation decisions. Because, you know, in theory what you would do is, you know, you design your normative ethical framework, out of that pops out an allocation protocol, then you observe the empirical outcomes with that protocol and then you fine-tune your protocol to achieve your normative ethical framework, right? But it may actually cause you to think a little bit more carefully about the way you constructed those ethical principles together and how they're constraining each other and how they're weighed relative to what other. Once you actually see the consequences intended and unintended, maybe it makes you to go back and start doing some more ethics. So it's both an implementation science problem as well as an ethical analysis issue. So what, our next steps is to better model this process with a dynamic micro simulation that Burhan Sandhiki from Booth has already built is great on historical data and we're just about to get enough COVID data to make this work for patients with COVID-19. And I'm over but I have to make a plug for relative scarcity and like we just, the previous panel was discussing large academic centers with many ICU beds simply have better outcomes for critically ill patients with COVID-19 and they need to bear the brunt of the burden of these patients. So elective surgeries need to stop and these hospitals need to focus on saving lives from critically ill patients with COVID-19. We can do it. We're very good at it and that should be, that's our role, our moral obligation in the pandemic. So with that, I'm going to finish and introduce our next speaker. I'm sorry, I ran a little bit over Dr. John Lapuma. He's a clinical director and founder of the chef clinic who's been eating and fitness program to prevent and treat obesity maintain weight loss and promote wellness. He's also a professionally trained chef organic farmer and board certified physician who's pioneered the field of culinary medicine. Dr. Lapuma is author or co-authored seven books, two of which are New York Times bestsellers. Dr. Lapuma also co-founded ChefMD a Freddie award winning health media brand that promotes culinary medicine. Additionally, he co-hosts Lifetime TV's health corner shorts as well as PBS specials on diet and fitness. Dr. Lapuma also recently released a documentary series on nature therapy called green rx. Today, Dr. Lapuma will give a talk titled silver linings to the pandemic. Some good news. We're all looking forward to that talk for sure. Please join me and give me a warm welcome to Dr. John Lapuma. Well, thank you so much. Really enjoyed your talk. It was great. A little bit about silver linings of the pandemic. Seven in particular. So if we could have the first slide, please. Thank you. Let me talk about my disclosures first. I'm founder as well mentioned of Chef Clinic and ChefMD and Plant with a Doc which is a new iteration of green rx. We're discussing off-label or investigational uses of drugs unless you count plants and food which I do. So there's that. Today, where does silver lining come from? Milton actually coined the term in 1634 in his work Comus 1 and he described it as appearing underneath a sable cloud, a dark cloud. He also coined the term pandemonium in 1667, 30 years later in Paradise Lost in that mask and a few years later wrote Paradise Regained. So Milton was way ahead. He saw that there were bright spots even when there was darkness. He described hell which a lot of us have been through. And then he saw a way out and I want to say that here are seven ways that we can think of that way out right now. First, there has been during the pandemic a moral elevation of scientists and clinicians. We're finally kind of cool again. And the idea that healthcare has a lane has been made friend and center. Donald Burke wrote in JAMA in July about the moral determinants of health in a wonderful essay that I'm sure you've all read and that I recommend to anyone who hasn't. The question of course is whether we ought to diagnose and treat like doctors do and only do that or if we should as Will just alluded to improve social conditions and do it in a way that is about policy not just about treating patients. You'll see from this research data that the confidence of the medical in medical scientists and scientists in general actually has risen over time. And the ethical standards of medical doctors you'll be happy to see has gone up in 2020. The same thing is true for the percentage of U.S. adults saying scientists should take an active role in a 60-40 split and make usually better choices around policy decisions than other people or at least not as neither better nor worse. Oh, that's a preview. Our second silver lining is that gardening and home cooking are now essential. They're not just nice to have or something to do on a weekend but they're really important and that's a wonderful thing because they have all kinds of beneficial effects. They get you outside if you're gardening they help you move they give you a feeling of accomplishment both for cooking and gardening they're meditative both of them and of course they help you escape boredom or eat really isn't so good. 40 square foot garden can help you sequester either a quarter to a half a ton of carbon. That's something that actually makes a difference in climate change. More of us than ever are eating at home and stress baking I gave you a quick preview of the slide that shows chocolate chip cookie dough which some people believe is a separate cookie than cooked chocolate chip cookies baked chocolate chip cookies but nonetheless this is how people have been stressed baking. This is really how one ought to be baking or rather cooking and doing so and we're seeing more of this as well with fresh greens with whole eggs and with oranges oranges during the pandemic actually in the second quarter this year were the most popular fruit ever that is by cash sales. About 75% of Florida's oranges have been lost as you probably know to a greening disease but California produces about 80% of the country's oranges. Nevertheless people have bought them because they associate them with better immunity because of their vitamin C content. Never mind that a red bell pepper has four times the vitamin C of a beautiful Washington naval. Gardening and cooking are important not just because they give you more produce because they reduce your bills because they alleviate boredom it can be meditative as I said but also because they actually have a therapeutic value they begin to relieve stress that idea that being in touch with nature and being in touch with the soil is a powerful personal tool to feeling better and we all need to. Here Josie is with four large Armenian cucumbers that we grew from one vine and here are pickles that you can make from those cucumbers and someone did in a photo of pickled cucumbers and tomatoes this all to show that putting up what you grow using extras from what you grow is part of what we have been learning. The third silver lion climate change is actually reversible who knew and that the outdoors is safer than the indoors in a particular matter 2.5 microns in carbon dioxide and nitrogen dioxide pollution all dropped in the first quarter they all have started to go up in the second and now third quarter there are thousands in the Venice canals you could see the Himalayas could hear the dawn chorus and the songs from the songbirds making up the dawn chorus were both more complex and softer because there was less ambient noise and noise pollution here you see the drop in carbon dioxide emissions in the first quarter of 2020 more than any other year 2020 according to this nature study showing that we can actually begin to reverse this if we are resolved to. The fourth silver lion is that mindfulness became essential not just a tool of titans like Tim Ferriss writes about in his great book about CEOs and productivity and creativity and not just for Nettie Californians but for everybody who wants to be able to focus and not have the pressure of the world upon them with everything from echo anxiety to homelessness and other serious problems for example see this side of the top iPhone app downloads you can find the top four iPhone app downloads in the last year of calm the next was number four motivation the next one Headspace and the final one Reflectly these four of the top nine iPhone downloads in health and fitness can turn meditation if you don't have a meditation practice you should investigate one because it helps you focus it helps you concentrate it helps you put things in perspective the next slide will show those kinds of trends in either in the next in the final quarter where we see calm Reflectly, Headspace, Fabulous and then to electric extent Metatopia all in the top 100 downloads of iPhone health and fitness apps in the last corner again emphasizing the importance of meditation in keeping keeping sane fifth Silver lining it created perspective as I just alluded to with this meditation practice what is really most important to us what is it that you get up in the morning for do you get up in the morning and concern yourself with self-care perhaps you should do you get up in the morning and concern yourself with community care oh is that how are those related COVID has showed us that those are intimate related you really can't have one without the other if you want to participate in American lives what is one small tangible thing that you can do today or tomorrow because today is almost over to make somebody else's life in the community better that might be a family member it might be someone next door it might be someone cross country if you think about that one small tangible thing you can do today to make someone else's life better then everything begins to have a perspective you have developed perspective and that perspective is truly valuable and of course at the core of ethics the sixth silver lining more pets have been adopted and fostered in the last six months than in the previous 30 months there is 43% less euthanasia adoption rate of pets is up 73% over the same time period last year this data from a corollary society to the humane society it is remarkable that we are saving so many lives of dogs and cats and I am not being facetious they are wonderful they offer unconditional love and in this study showed by nextdoor.com not terribly scientific study members in California versus the US were asked about whether they intend to adopt pets this shows that it is a national phenomenon that pet adoption and we are going to have an adopted pet for the first time ever in January all the other pets have been from breeders by the way and that is remarkable because saving lives of animals is a powerful tool for doing good which is of course what we all want to do and as well being is the goal of medicine that creates more well being as you care for animals they in a way care for you as well and then finally adopt this or this unconditional love save a dog, save a life adopt, don't shop next and finally we got to binge watch four seasons of the good place during the pandemic this year in 2020 that is an improvement over last year we only got to binge watch three seasons of the good place on Netflix I recommend you do so if you have it and I'll show you a couple of clips to show why as you know the good place is a sitcom originally aired on NBC now on Netflix that puts front and center ethical principles it is a way to make ethics fun funny and at the same time ask the important questions that ethics does it's more successful than any other television show I know or actually any other feature film I know in communicating a lot of the things that we care about the hard questions of what's right and what's wrong and of helping people see those questions as in fact ethics questions not financial ones or social ones but in fact ones of right and wrong now here we get to see ethical principles on television and with it we get to see the humanity of the people who voice them it's super to start let's see if we can do this utilitarian not utilitarian I know more than I read all the same books Mike read for research for the part yes she did and Kristen Bell can make anything wonderful and Mike of course is the creator of the good place he also created parks and rec he's a really talented guy Mike sure here is another way the good place instructs us about our humanity and the questions that we deal with with patients all the time but in a different way nothing more human than that nothing better as an actor than Ted dancing in a sitcom nothing more important than putting front and center what it means to be human especially during this time of COVID and then finally here is a little clip that shows what a good teacher can do much better because of you and that is really true Mark Siegler we are much better because of you and thank you so much for your attention well thank you John that was just what I think a lot of us needed especially me staring at the barrel at several weeks and what will increasingly become a COVID ICU some silver linings I have the privilege of oh I'm supposed to from housekeeping you remind you to put your questions in the Q&A session and then upvote the ones you want us to act as because there's already a lot so we'll have to focus our efforts but now it's my pleasure to introduce Dr. Alexi Torki associate professor of medicine and associate division chief of general internal medicine and geriatrics at Indiana University additionally Dr. Torki is the director of the Daniel F. Evans Center for Medicine, Health Care and also the fellowship director of the Fairbank Center for Medical Ethics. She's also a research scientist with the Indiana University Center for Aging Research at the oh I'm going to maybe miss this one, Reagan Strife Institute and practices outpatient palliative care at IU Health Methodist Hospital her research focuses on end-of-life care, patient communication, spiritual aspects of care and surrogate decision making. She was the first person to describe and analyze the relationship between doctors and healthcare surrogates. Today Dr. Torki will give it a talk titled surrogate decision making in COVID-19 patients. Please join me in giving a warm welcome to Dr. Alexi Torki. Hi, thank you all it's great to be here and I agree that that talk by Dr. Lapuma was just what I needed. I feel calmer already. So we can begin with my first slide I don't have any disclosures but have some NIH funding for this. Back when Mark asked me to give this talk my head was just spinning. We were in the early stages of the pandemic it was really all I could think about I usually don't do any inpatient care but probably like some of you I was called in to do inpatient palliative care consults to help support our incredibly busy service and I was living through new challenges in a topic that I researched for many years surrogate decision making. For this talk I'm going to take us back to the earlier stages of the pandemic and talk about a case I'll also talk a little bit about some research we've been doing about provider experiences and also some innovations that we've been using to help support our patients and families you know and then we'll think about how we might address similar cases going forward. So take yourself back to early April there was tremendous uncertainty about transmission to clinicians as other speakers have mentioned especially during resuscitation, intubation and procedures there was restriction on providing resuscitation at least in our institution where we were really encouraged not to go running into rooms but to make sure we were wearing proper PPE before we initiated resuscitation there was restriction or complete shutdown of family visitors which put family in a place of increased stress and grief as they made decisions and coped with serious illness from far away. There were actual shortages and also feared shortages of PPE particularly things like N95 masks and PAPR. There were staffing and unit reorganizations in many hospitals including ours. There was fear of ventilator shortages although we did not actually experience that and I think really very few places have yet. There was knowledge of COVID disease management which was incredibly distressing. We didn't know what medications to use, what ICU and ventilator settings to use things like prone positioning and other strategies were just being uncovered and finally tremendous clinician distress about so many aspects many of which have been covered by other speakers. I'm going to briefly tell you about a study that I conducted with one of our fellows at the time Ariba Javed who's now off to Wayne State University but she conducted a cross-sectional survey of clinicians in May through June of 2020 in two large health systems in Indianapolis that was administered electronically and got a response rate of about 25% with over a thousand respondents. I just want to describe some of her findings because I think it gives some examples of the kind of distress people were feeling. Many of our, probably the majority of our respondents were physicians and nurse practitioners. We also had small numbers of nurses, social workers and others and the specialty were primarily in internal medicine although there was a wide variety and 89% had participated in direct patient care during the COVID times. We first asked them questions about moral distress kind of items that we identified a priori that might cause moral distress. I wish I'd asked something specifically about surrogate decision-making but I really didn't think of it at the time. As you can see the one that was most common was witnessing the rationing of health care resources followed by witnessing deviation of clinical practices from the standard of care. We asked for those who endorsed having experienced an item, we asked them to rate it on a moral distress thermometer from 0 to 10 which has been a measure that's been validated. You can see that things cluster pretty closely. Moderate to high distress for all these items with a variety of experiences. Looking at general distress there was tremendous suffering witnessing suffering in patients and families. Fear of litigation was quite high surprisingly given that in other surveys we found that to be quite low. Watching colleagues suffer and not having access to the PPE that people needed were all things that were that caused suffering. Fear of transferring disease to a family member was also quite high. But finally positive emotions which I think to John's point about silver linings I truly feel that clinicians felt a calling and I think we see that validation of that that while the pandemic has been terrible and continues to be terrible many people did experience things like witnessing their colleagues providing excellent care supporting each other during this crisis and witnessing healthcare systems developing ethical policies. We also used the impact of events scale and found that 13% had high scores suggestive of risk of post-traumatic stress something that we're going to have to watch for carefully. So I really do that to set the stage to the case. So here it is the end of March beginning of April many of us have been called in from other services we are extremely scared and stressed out we worry about endangering our families and ourselves and into that context I came upon this case Mr. Smith a 78 year old man with advanced COPD and a history of stroke who was cared for at home by his daughter she comes to his home daily to visit him and help with meals he becomes short of breath on April 2nd and was brought to the emergency room buying a town from across the country and went to visit their father none of the family are allowed to see him they ask for an exemption to the visitor policy so all three can visit daily they're told no he develops respiratory distress and the attending physician goes to the bedside discuss goals of care and preferences for intubation he says he wants full treatment he's intubated and transferred to the ICU three days later he's completely unresponsive unresponsive sorry blood pressure is 80 over 44 that means that his blood pressure is dropping despite maximal interventions he's on 100% oxygen his arterial pH is 7.29 which is abnormal very abnormal his physicians do not think he'll survive the day so I'll talk a little bit briefly about our ethical model this will be very familiar to most of you it's a widespread framework put forward by B.Hannon and Brock and we asked two questions who decides surrogates have high authority both those appointed by the patient and the defaults in state law and then we have well-agreed upon principles that prioritize respect for autonomy advanced directives substituted judgment and as we know Daniel Brittany has put forward the idea that a narrative view can be helpful and then also best interests in this contrast with pandemic decision-making in which decision-making is much more centralized and our primary principle is to promote the common good through concepts such as greatest good for the greatest number a utilitarian framework or justice and fairness respect for autonomy and best interest might matter but they are not the primary guides so back to these case back to these principles this is the setting in which we find ourselves that I think really increases our anxiety about how we proceed I want to talk a little bit about a volunteer initiative that our palliative care service undertook we were as of the first weekend of April completely overwhelmed in our Indiana hospitals and there were two things that we did one is we recruited clinicians from closed departments such as outpatient care and surgery we interviewed people to determine their prior experience and serious illness communication and then provided them with a one-hour training through our ethics center on advanced care planning and serious illness we recruited three nurses two physical therapists at our downtown hospital and actually several others around our health system we also had several oncology physicians volunteer to do palliative care consults and if you know any history about many relationships between palliative care and oncology you'll realize that that was quite wonderful they provided additional palliative care consultations on weekends and in the evenings and were assigned to units to round with ICU teams and identify unmet palliative care issues we really fought that they would primarily do advanced care planning and in fact they did do 22 advanced care planning conversations with patients who were decisional and completed 12 health care representative documents but we realized that actually an incredibly amazing thing they could do was video visits our patients and families had such anxiety about being separated from each other and it was so hard to facilitate family meetings and so these video visits connecting patients and families even connecting families with patients who were intubated and completely unresponsive but who could hear the voice of their family member and the family member could at least express their love and concern for the patient here's a quote from one of our nurses I had the most meaningful interaction with M while he was still on the vent in video conferencing with C M was awake and kept looking up at me and then back to C he did this five or six times I was overwhelmed with emotion to think that this man who'd been critically ill for over two weeks and unable to see his family is thanking me a stranger and protective gear from head to toe I tried to keep it together but the tears came collecting in my goggles and running into my mask back to the case the palliative care service was consulted we did some interventions that include using zoom and face time between the palliative care team and family we conducted video visits so the family could speak to the patient even though the patient was completely unresponsive and the chaplain conducted meetings with the family by phone the physician called the daughter and stated that the patient is dying and that the physician plans to withdraw life sustaining treatment and shift in goals to comfort the daughter was tearful but did not protest she requested another video visit with multiple family members to say goodbye over an hour spent with an iPad facing the patient so family members could take turns saying goodbye the ventilator and pressers were stopped and the patient died within 15 minutes I want to pause for a minute here just to reflect on my own reactions to this case as the palliative care provider I have struggled over time with the degree of autonomy that we often allow families under the best of circumstances we often provide care that clinicians think is unwise or not medically indicated because families want it sometimes because they articulate that that's something that the patient would have wanted sometimes it's because they perhaps are not ready to shift the goals of comfort themselves but in general we allow families a wide degree of leeway I think it's important to note that we at least in our health system made some changes to our approach to surrogate decision making even without having actually run out of ventilators the stress about the unknown the lack of knowledge about appropriate treatment the lack of PPE and the fear of running into a situation in which we had limited ventilators actually changed our approach to practice in ways that I don't even think we fully realized at the time so I think it's important to acknowledge that while we thought that ventilator triage was not upon us there were in fact ways in which we are adjusting our standards of care for a pandemic setting in some ways I think this is probably appropriate I think that there were many patients in the ICU such as this patient who were almost certainly not going to survive their hospitalization and that taking a clearer stand about the use of life sustaining treatment in that setting may be appropriate but it raises challenging issues I feel challenged and I hope you feel challenged with me and as we get to questions I hope you'll ask some probing questions about how we address this case and how we address cases going forward I'll say in closing that we are in a state where cases are rising again as you see basically with every passing day cases are skyrocketing and in fact we are now at risk of running into another ventilator triage situation and so I think we're entering into a new wave where we're going to be facing these challenges again and we're in fact ventilator triage may become a reality so thank you for walking with me through our experiences and my experience with this case and again I do really do want to thank all of you for being here with you and to have this time to kind of pause for a moment and consider our experience with COVID as we move into the next phase of the pandemic so thank you very much alright well thank you Dr. Torky that was an excellent talk I think mine was more about this crisis scenario of absolute scarcity that we haven't hit yet but there's plenty of ethical controversies to ponder in the contingency care strain situation that we're experiencing now it's my pleasure to introduce Dr. Anu Manali he's the Lee and Brina Freeman Professor at the University of Chicago Law School and a Professor of Medicine at Pritzker Professor Manali is clerked for Judge Stephen Williams of the U.S. Court of Appeals for D.C. and for Justice Henry O'Connor on the U.S. Supreme Court Professor Manali's interests include Health Economics and Development Economics and Healthcare Financing and Quality of Life in the Urban Slums of India notably through the Indian Health Insurance Experiment in his Impact Evaluation and Mission Kakataya today Dr. Professor Manali will give a talk titled Ethical Issues in India's Response to COVID-19 Please join me in welcoming Dr. Anu Malani Thank you Thanks Will I don't know if everybody can see the presentations so if we can go ahead and start that so let me go ahead and begin with my disclosure so I don't have any particular conflicts of interest I have some funding from Asian Development Bank to support some of the work that we've been doing for the Indonesian Government on COVID response and then funding that we're receiving from the University of Chicago and elsewhere to support our efforts to help the Indian Government in its response and to do some research there and then some prizes that were associated with the work that we did I'm going to give you a little bit of background on India and COVID in India and then I'm going to talk about some of the ethical challenges that we've faced I want to preface all this by saying I'm not an ethicist I don't have really great training in ethics I would call it an undergraduate level of understanding but I do think there are difficult ethical issues that are involved based upon that understanding and so I'm going to apologize ahead of time for using what I would call non-technical language and see being kind of simplistic about these ethical issues but I appreciate you give me some leeway there so let me go ahead and give you a little bit of background of what happens in India it's just a more severe case of what you see in the United States so this is a figure that describes over time so just before the epidemic hits through the beginning of the epidemic you see these dashed lines and dotted lines that gives you a those are measures of the severity of the lockdown that you saw in India and then you see these colorful lines solid ones that are just basic Google mobility lines for different sectors and you can see that there's a massive decline around March massive increase in lockdowns there's a decline in corresponding decline in mobility especially in work areas the only place where mobility rises as we say is in residential interesting about this is that some of the decline occurs a little bit before the lockdown actually happens but this is quite a severe lockdown if you look at the dashed line that's India's lockdown measured by our world and data and on their severity metric the dotted line is a severe lockdown and this continues so this is now extending it past June to something close to the present and you can see that mobility actually has returned about 50% and the lockdown severity has fallen so there's kind of a lockdown fatigue that's settling in and a relaxation now unsurprisingly you're also seeing a skyrocketing of cases these are confirmed cases so just as the severity the mobility reduction is coming back that is to say mobility is coming back you're also seeing in the black line an increase in the number of daily cases of course when you're interpreting that you have to be a little bit careful because testing per million the green line is also rising during this period but I don't think there's any question that there's an increase in the number of cases that we've seen at least as measured by confirmed cases I'm going to give you a little bit different story in a sec so I want to talk a little bit about the ethical issues that have come up as we've provided public health consultation to the Indian government and that's both the center and states so the first one is as I said India had a massive lockdown it was quite severe but interestingly in India there's a lot of opposition to lockdown in the United States but it was just kind of at a higher level I would say in India and one of the issues that comes up although the next slide is going to give you even a more salient issue one of the issues that comes up is that there's implicitly a massive redistribution that's involved in lockdown so on the right hand side you're going to see two figures that are based upon two studies we did one is based upon a serological study we did in Mumbai in slums and non-slums of Mumbai we're also able to look at what the age distribution of IFR is using those that represented serological study and you see a older individuals have a higher death rate on the bottom we were providing some services to Bihar helping them analyze tests that were coming in their RT-PCR tests and again you can see this massive skew in the probability of death given COVID in Bihar the levels were lower in Mumbai than they are in Bihar but there's still this skew and you're getting numbers something like if you're over 70 you have 30 times greater likelihood of dying than if you're under 20 what that implies is that when you think about a lockdown if it's reducing the probability of infection evenly across the population and as far as we can tell from the data the probability of getting infected is roughly even across the ages but the health benefits are dramatically higher in the older individuals so older individuals are getting a lot more of health benefit but then when you think about the economic costs the economic costs are evenly split if anything older individuals because they're more likely to be retired have a lower cost and what that suggests is that there's this massive redistribution that's going on which has ethical implications so in lockdown we're basically asking younger individuals in some sense to cross subsidize older individuals I'm not saying that it's not beneficial to have a lockdown I'm just saying that there's disparate impacts or benefits of a lockdown so let me go ahead and advance the slide and show you another dimension along which this is true so here on the right is a study that I'm working on with ARPID Gupta where we look at, we have a panel data of what happens very detailed data on the finances of about 175,000 households in India over the last few years including into COVID and what we see is that when COVID hits so you see on the x-axis the first dashed line is the first case that you see in India the second dashed line is when India does a lockdown we're plotting your income for different income occupational categories relative to what it was or as a percentage of what it was in March 2019 and you can see that there is a massive drop off an income much more severe than you see in the United States by far for nearly all occupational groups but you see that white people that are salaried employees white color blue color they're seeing maybe 25-35% drop but if you look at the poorest people so people that are daily wage earners daily laborers they're seeing a 90% drop in income massive massive reduction and this persists so I'm not showing you the data that we have going out but this kind of captures the falling off a cliff it's shocking and unlike the United States there's no CARES Act so there's not a lot of fiscal support to buffer that so what this really implies though is that there's another massive redistribution that's going on in the lockdown lockdown's economic costs are being borne by the poor but the health benefits are roughly evenly distributed in the population as far as we can tell so that's kind of the big benefit a big impact in fact you could also make an argument that the health benefits are a little bit bigger for the rich because they happen to live a little bit longer too so in terms of life years that you would sacrifice it would be bigger for rich individuals than poor individuals so again there's a health skew as well so let me now turn that was talking about lockdown but now I want to think about ethical issues associated with testing so we've been doing a lot of testing either supporting through data analysis, RT-PCR testing that states are doing or by doing our own serological work but that raises a really interesting question around informed consent so let me set the frame here India tells people they got to give up work and that doesn't give them a choice, say voluntarily give up work it tells people that they can't get access to certain types of health care because we're kind of shutting down access to a lot of facilities, elective services again you don't have a choice in this matter and in fact it could have done the exact same thing with respect to testing they actually invoked what's called the pandemic act from 1897 and said we can make people test but in practice they didn't, they actually were part of consent to get tested for a lot of their work, especially for their serological surveys including the serological surveys that we supported in Mumbai and Karnataka and I'm going to show you in the next slide as the result of one of these I'll show you the other one in the next one but this is one that just came out this week it is a serological study in the state of Karnataka population 67 million, it's in south and central India we went around through various regions of Karnataka both in urban and rural areas we're finding results in terms of seroprevalence we're finding overall seroprevalence 46% and then you see something like 44% in rural areas and 53% in urban areas it's a very, India is much less urbanized than say the United States is so that's suggesting that there's higher urbanization but it's really important to remember oops, I think it's, I want to go this way it's important to remember that we consent and now consent raises the possibility that you're getting a biased estimate, that is to say people that are more likely to have had COVID in the past are more likely to consent, you're going to overestimate if it's the opposite you'll underestimate seroprevalence and so one of the things that we did to check to see if this is true and we had a unique data set that allowed us to look at people that didn't consent because we had the historical data as well as the people that did consent and what we found is that there's dramatically different results that is to say the sorts of people that consent are different along tons of dimensions education, income, etc and so you're going to have to seriously think about whether consent is biasing results even in a representative sample and that seems like a very important issue when it's the studies like this that are guiding suppression policies and so you might want to ask yourself, you know, if we're doing requiring people to give up work or certain elective surgeries without consent should we also require them to test without consent would that give us, would that inform public policy a little bit better, would that be better overall? Okay, so let me oops, let me go ahead and tell you about another test but here I'm not going to talk about testing, we'll talk about the ethics of lockdown so this is kind of like that first issue about what the redistributive effect is here I want to focus specifically narrowly on lockdown in slums so one of the studies we did back in July and we did it again in August is we did a seroprevalence study again representative populations in slums and non-slums of the city of Mumbai and one of the notable findings that we had from this was that as of early July seropositivity and seroprevalence in slums was dramatically higher about 3 to 4 times higher in slums than non-slums the level in slums was around 58% seroprevalence and the level in non-slums was around 16-17% so that's a massive difference and so you want to ask like how is in July that we already got this and one possibility that you kind of have to entertain or seems natural to entertain is did lockdown actually cause these problems so for example maybe what happened was we made people go home those people that went to their slums they didn't actually while they weren't interacting with the world generally those quarters with tons of other people like the example I like to give is the average distance between any two people in the slum of Dharavi which is the slum for example you might remember from slum dog millionaire the average distance is 6 feet so if that's what's going on in slums and you're using things like communal toilets maybe what you did is you basically increase the average level of density that they lived in because they had to stay home rather than getting out and that might have accelerated the epidemic so that's kind of a really interesting thing then compounding that is that now even though maybe a majority of these individuals are actually now recovered now we're saying let them out in the population now in fact they might be safer if they stayed in slums at this point because they've already gone over the hump but if you let them out in the population implicitly you're providing protection to the non-slum dwellers who were protected by lockdown in the first place so that kind of raises some interesting questions of who should be bearing the costs and benefits and how that varies over the timeline of an epidemic so let me with my final few minutes talk a little bit about vaccinations so one of the things we're working on now is we're taking the serological studies that we've done in India some of the data analysis we've done in Indonesia and generate vaccine allocation plans for those countries so these are plans that say if you've got a limited number of doses who should you vaccinate first, second and third then you can vaccinate the direct and indirect benefits of vaccination for different demographic groups in different locations direct benefits is the benefit to mark a vaccinating mark and the indirect benefits are something like what is the indirect benefit to lexia of vaccinating mark something like that so we calculate these things and then we come up with social demand curves for different groups so on the right you see an example of one we did for Indonesia across the different provinces and different age groups when we did these demand curves and we monetized the value of life because the Ministry of Finance asked us to do that to help them figure out how much to spend on vaccination we have to decide whether we're going to do VSL or VSLY on the right we did VSL but we can see that there's massive differences when you do VSL versus VSLY not only does our prioritization change shifting towards younger populations to some extent but it's also the case that the absolute value of the vaccination is lost dramatically when you value life years and the reason is I think probably pretty clear to people that are in this group and so they're implicitly in that strong redistributive effects ethical decisions that are embedded in your vaccination decision so let me try one last thing in my last 20 seconds or so one really interesting thing in all of this that doesn't get a lot of attention is the speed with which we finish vaccination so an interesting question is we know especially in developing countries lower income and middle income countries vaccines are going to come later than they're going to come in developed countries at least as a percentage of the population so speed really matters for those guys so delays in development of vaccinations actually pushes that out a little bit further so what we'd like to do is have it done faster so a natural way to do this is to do for example human challenge trials for cases quickly and the standard objection to this as well this is bad because the people that would take the human challenge trials might be unethical for them even if you paid them it would be the poor that would take it up the same arguments made against for example the army and the all volunteer force but we're comfortable making those decisions in other contexts like construction and the army and all sorts of risky jobs the question is should we be comfortable in this context especially when from a consequentialist perspective in the long run poor countries and poor individuals might actually benefit if we were able to get the vaccine earlier in fact they benefit more because they're maybe less able to suppress and stay home let me stop there and because I think my time's done alright well thank you for that fantastic talk Professor Wane it's always interesting to see the economic lens apply to this these problems so we'll transition to our last talk of the session from Dr. Lydia Dugdale who is the Dorothy and L. Daniel H. Silberg associate professor of medicine at Columbia University College of Physicians and Surgeons and director of the center of clinical medical ethics she also serves as associate director of clinical ethics at New York Presbyterian Hospital Columbia University Army Medical Center practicing internist Dr. Dougdale's scholarship focuses on the life issues of Dr. patient relationship she edited the book Dying in the 21st Century and is now the author of The Lost Art of Dying Well a popular press book on the preparation for death Dr. Dugdale attended medical school at the University of Chicago and completed her residency at Yale New Haven Hospital please join me in welcoming Dr. Lydia Dugdale great thanks so much to everyone on the panel and thanks to Mark for the invitation it's as so many have said my career is completely different for the better because of Mark Siegler and I'm grateful to you and to Anna so thanks so much if I could have the slides up please so I thought I would start by just painting a picture of what it was like in New York in March I have lived in New York City for just over one year after medical school at U of C I went to Yale for residency I stayed on faculty there for a decade and it was only a couple of years ago that Columbia recruited me to build a center for clinical medical ethics there so I have to say it's been a very strange season to be a New Yorker we moved to the city COVID hit and 40% of my neighborhood left the city based on forwarding addresses and cell phone data and two thirds of the Upper East Side also left the city the streets were empty and what was particularly eerie is that you would almost never see children outside I don't know what kids did who stayed in the city but you would never see them the streets were very empty and very quiet except for the sound of sirens and the sirens were constant it was not uncommon to hear four or five, six ambulances in the space of an hour and I didn't quite put it all together because there generally is so much noise in New York City I didn't put the sirens together with the virus until the streets were completely empty and my daughter pointed it out and then we started seeing people carried out of their buildings in one case my neighbor across the street was carried out through a window because the EMS were unable to get in through the door so it was an eerie time and a time of high anxiety in the hospital thinking about this current nationwide surge now and contrasting it to what we knew in March it's a very different time but I just wanted to sort of set that stage I'm going to be talking however today about what we experienced as ethics consultants at New York Presbyterian Hospital during the surge and this paper we published in the Journal of Clinical Ethics my consultant colleagues and I did and I'll just say this from the beginning the COVID pandemic as it swept through New York City it was devastating we couldn't test we could test somewhat but we only tested patients who met criteria for admission to the hospital because we had such a short supply of the swabs we couldn't quarantine people so I mostly was in the emergency room I'm an outpatient internist but I was redeployed to the emergency room and I was routinely sending patients back to apartments and I was supposed to tell them go home and quarantine use your own bathroom stay in your own bedroom and Columbia's hospital where I work is in a largely Hispanic neighborhood and they would look at me and say doctor there are eight people living in a two bedroom I don't have my own bathroom I'm in a situation that we were in when Alexia talked about PTSD certainly I know that that has been real for many of my colleagues we knew that we were spreading COVID and we had no choice but to do that so we also saw a significant number of consults specifically for COVID patients and it was so stark the difference between our normal way of doing ethics consults and what we experienced during the peak of the pandemic that we ended up writing up our results and we did a series of papers together with colleagues from Cornell so let me just give you an idea of just to sort of paint the picture of what the hospital did we have two main hospitals, Milstein is the big one up at 168th Street for those of you who know New York and the Allen is way north in Manhattan so Milstein is a 745 bed acute care hospital and Allen is a 225 bed hospital that is kind of more like a community hospital but that we service. Now you can see that the number of ICU beds almost tripled at the mothership hospital and almost tripled also at the community hospital. In terms of renal replacement therapy we can typically accommodate about 15 patients and during the surge we had as many as 60 patients who required dialysis we couldn't do continuous dialysis and we ended up interestingly we did not run out of ventilators and that's something that I'd be happy to talk about in the Q&A but we did experience shortages of dialysate and of course of the machines themselves so we had to get very creative with how we were able to essentially partially dialyze many patients you know not standard of care of course in order to sort of spread around the resources that we had and then of course coming up with creative solutions to obtaining dialysate was another part of that. You can see that our ICU nursing doubled or tripled in terms of what the nurses even quadrupled in terms of the number of patients that the nurses were expected to care for and then our operating rooms were almost entirely converted to what we called the O-RICUs, the operating room ICUs, makeshift ICUs to accommodate the growing number of patients and so during the height of the pandemic we only had three functional operating rooms and they were used for the purposes of emergency surgeries and that was it. All of the rest of them were for ICU patients so in a similar way to the hospital surge and the surge of patients we had a surge of ethics consultations and so that's what we describe in this paper. What we did is we took an eight-week period starting with March 16 which was the first day that we had an ethics consult for a patient who was known to be COVID positive and then we went forward eight weeks from that period and we contrasted ethics consultations from the 2028 week period to the same dates in 2019 and what we found is that during 2020 we had almost a four-fold increase in the number of consultations so we had almost 100 consults in that eight-week period in contrast to 25 the year prior. Interestingly the vast majority of them were for patients with COVID and that reflected what the state of the hospital was so 83% of those nearly 100 patients had COVID and at the time that we were looking at this data 77% of our patients hospitalized overall had COVID. Now you might think that a four-fold increase in ethics consultations during the height of the pandemic is not much and maybe that's true and I think that the reason why it's only a four-fold increase and not for example a six or eight-fold increase is because of the work of my palliative care colleagues at Columbia. Similarly to what Alexi described our palliative care team retrained and then deployed forces really armies of folks who could go into the emergency rooms and council patients who were presumed to be COVID positive appeared to have COVID on goals of care and so this is a paper that my colleagues at Columbia put together they describe a two-week period during the height of the pandemic where they retrained psychiatry residents fourth-year medical students who we graduated our fourth-year medical students early at Columbia to help out in the hospital and some geriatricians there were several groups but those are the main ones and they retrained them to be able to have these goals of care conversation and then sent them out in teams and that had a huge impact both on sort of getting advanced care documents in place but also offloading the burden on the ethics consultants. So I'm just going to highlight a few remarkable pieces of data from our study and that is that we had a significant increase in the number of patients who were Hispanic or Latinx you can see that we went from 4% in 2019 to 40% so a 10-fold increase. There's sort of several ways to perhaps explain that of course our primary hospital is located in a largely Dominican neighborhood but it's also interesting to note that in non-COVID times anyone from all over the country would come to Columbia for various reasons so we have a very large catchment area in non-pandemic times but what happens during the pandemic well first of all tons of people get out of town but they also don't want to come to New York City so we did not we largely drew during the pandemic from our neighborhood and only from our neighborhood and I think that that was reflected both in the number of patients who were in the hospital of Hispanic and Latinx origin but also of those for whom we were consulted. It's also worth pointing out that our patients during the pandemic were much, much sicker than in non-pandemic times so if in non-pandemic times about two-thirds of our consultations are in non-ICU patients it flipped during the height of the pandemic and about two-thirds of our patients for whom we were consulted were located in the ICU also notably the vast majority did not have advanced directives so only 11% of the patients for whom we were consulted had advanced directives I told you that the vast majority were of Dominican origin and when we look at Kaiser Health data for who has advanced directives we know that nationwide about 37% of people have advanced directives but of Hispanic communities the typical number is about 11% so what we found in terms of the patients for whom we were consulted again from our neighborhood it was the fact that about 11% had advanced directives that's in keeping with what we have from Kaiser now this was interesting so we broke down all of our consultations into the reasons for the consults and then we sort of tried to group them together so for example care at the end of life includes things like assistance with goals of care but it also includes issues surrounding brain death and again New York City has a large Orthodox Jewish population so we actually not infrequently have consultations regarding questions related to brain death medical futility unnecessary care there were a number of consultations especially later in that 8 week period on whether teams needed to perform CPR for patients who were already maximally resuscitated if you will intubated on multiple pressers but all of those sorts of questions come together into this category of care at the end of life decision making and then of course there's conflict there was probably more conflict than normal because as others have described families were not allowed to come into the hospitals and that created a lot of concern that perhaps loved ones weren't going to get the ventilator or they weren't going to get the best care things that have in the media we would all often hear from family members these questions of resource allocation and a lot of concern that their loved ones would not be receiving standard of care. Capacity and treatment over objection is sort of a perennial question in our hospital we tend to have also a relatively large homeless population with mental health mental illnesses and so that often raises these questions of capacity that ethics gets drawn into and then kind of a catch all category. So I just want to pivot very quickly to this image it's an etching by the Italian artist Luigi Sabatelli and Sabatelli if you can see in the Italian at the bottom it says the plague of Florence as described by Boccaccio so Sabatelli was an artist that lived in the late 1700s and early 1800s but the scene that he is describing was written about by the humanist and the philosopher, the writer, the thinker Giovanni Boccaccio who lived in the 1300s and this is a scene we are outside the walls of Florence during the bubonic plague and I know Laurie Zoloth ended the last the last panel talking about the bubonic plague outbreak in the 1600s and here we are in the 1300s outside of the walls of Florence and you can see in the foreground middle to slightly to the right there's a heap of corpses a mass of dead bodies and there's a guy with something that looks like a gurney it may be a funeral beer he's adding more corpses to the mass and in the background you can see some men with pickaxes they are presumably waiting to bury the dead and this was a time in history when historians estimate that perhaps as many as two thirds of the population died and it prompted a real reckoning with the need to prepare well for death and that has been sort of one of the themes of my own scholarly work and in fact led to both of my books but this one most recently the manuscript for which I completed a year before the pandemic started but this book takes as a foil the bubonic plague outbreak of the mid 1300s which prompted a whole genre of literature on the preparation for death and it asks how we might prepare for death today and I think in this moment of a surge nationwide the coronavirus sort of reeling out of control but also the hope of a vaccine we have to think all of us are still going to at some point die and so taking what we know what we have learned in the last eight months the hope for a vaccine but also knowing that there is no magic bullet and at the same time staying sober and remembering that all of us all of us want to die well in order to die well we really have to live well and so living well requires a certain amount of intentionality and that's what I'm encouraging us all to think about so I'm going to end my remarks because I'm out of time and I look forward to the panel. Thanks so much. Alright well that was a fantastic talk Dr. Dugdale and it really seems like well not technically under crisis standard of care that Columbia, New York was right on the brink so we're going to start to moderate the panel discussion now if you can look through the questions and upvote ones you want us to address we will dive right in but I wanted to ask I guess starting with Doug Dugdale a question about that I had about CPR and the issues of you know when CPR peers medically feudal because the patient's on maximum ICU support whether or not your response to those the consults changed given the enormous strain on resources you had at your hospital. Yeah great question thank you. So New York state law holds that if a patient or family insists on medical technology that we have to continue that there is a very subtle caveat but it is so complicated that our legal council has advised us essentially if a family wants full core press that's what we do. So that's essentially the practice. Now in the Washington Post there was an article during the height of the pandemic in New York City that NYU's emergency room had unilaterally decided that they would not do CPR on COVID patients those of us at Columbia felt like that was not we couldn't have done that we didn't have the freedom to do that having said that there there is a way in which we saw the maximally resuscitated patients as being a patient who would not benefit from chest compressions should the heart stop right so patient max out on pressures intubated in the ICU if that patient's heart were to stop you know doing some chest compressions is not going to going to give this person a shot at life and so the hospital legal counsel did give us permission to not to authorize a foregoing that but to give teams essentially the discretion to make a decision that was a very narrow slice of time when that was actually authorized so for the rest of the time we were resuscitating yeah I mean to use mark marks four box model you know that's a situation where CPR arguably is not medically indicated right so it's sort of a relevant whether or not there's a COVID-19 pandemic but I think a lot of hospitals all of a sudden because of this contextual feature of the pandemic okay now with the right to do unilateral DNRs for situations like you described which I think was sort of a you know the logic there doesn't totally follow right the rationale for CPR and that patient is equivalent whether or not they have COVID-19 but you know the same thing happened at Northwestern they had a different interpretation of the state law in Illinois and we're always code patients but change their policy during the pandemic now they're signing whether to roll it back or not it sounds like you guys already rolled back on the well so the ethicists have a yeah and the ethicists have a different view than the legal counsel right but we're sort of the console I'll just say briefly that there was a period of time when Governor Cuomo did give authorization to EMS to first responders and ambulances not to resuscitate patients they thought were COVID positive and there was a massive massive backlash and he quickly rescinded that executive order so the sort of ethos in New York State is you know people first and you don't necessarily trust the establishment and so we err on the side of life interestingly it's a Dr. Turkey how about you at Indiana in CPR was there yeah I mean a couple points I will make is that I think from an ethical point of view there genuinely is a difference in terms of the risk to clinicians in performing CPR on patients with COVID that was especially acute when PPE was very limited and hard to get your hands on you know our we do not have such a strict state law although our practice is generally that we have a very complex procedure for overriding patient or family preferences regarding both code status and withdrawal of life sustaining treatment and I would just say that in practice that was changed somewhat the DNR thing was changed actually with the kind of explicit blessing of our leadership that we could be we could make unilateral DNR decisions but I saw it even go beyond that and I think that was the part of the case that I presented that I feel the most concerned about and that change in practice was something that wasn't discussed in an open forum or carefully thought out but just sort of occurred and I really think it's time to take a pause and think seriously about the right way to proceed while we have a chance to do that yeah no it's a serious I think the over use or over stretching the scenarios where a CPR is not medically indicated right that's a very kind of tricky clinical judgment even you know we can describe the scenario that they're maxed out on pressers and it clearly won't work but a lot of times as a critical care physician it's a lot more gray right and so we saw pretty a lot of heterogeneity in the implementation of DNR orders for COVID patients in our ICU unsurprisingly for that reason and I think it is an area that should bear for the discussion I would add that now with full PPE we know that the risk to providers is near zero if you're wearing your N95 half mask you're fine but at the beginning we didn't right so it's interesting how that part of the calculator anybody else want anything to add on that point in particular before I move on to the questions here I would just say that for ethics consultation Lydia you're really in new new territory and you it sounds to me like you've been able to negotiate it really well the tension between ethics consultants and hospital attorneys has always been there in ethics consultation but it's often been more of an alliance than an adversarial relationship and so I'm sad to hear that the clinical judgment in ethics consultation has been so effectively challenged by your hospital attorneys and hand in really by the state law because that's it wasn't often the case when I was doing a lot more of that and as Will was saying I wonder if when you're addressing goals of care you're as I'm sure you are since you've had such good training looking at not just Will work immediately but Will work for discharging the patient to from the hospital in healthy condition yeah John if I can just reply really quickly so I don't mean to misrepresent the relationship between ethics and the legal counsel I think we work together very well but the state the state of New York has some pretty you know strong feelings about this and I'll just say during the height of the pandemic the ethicists were very strong with the hospital with the hospital legal in part because it was such a moving target there were new executive orders we had a couple of different orders that did give retroactive protections to healthcare workers sort of a an expansion of the good Samaritan law if you will so that healthcare workers knew that even if it was crisis standards of care they would be protected but we were never given a sort and withdraw life support. There was a zero permission for that. And so the hospital legal understood very much the situation on the ground. They were very responsive, but we were bound by the state. And I think that Governor Cuomo, honestly, I think that Governor Cuomo, even though it felt that he wasn't budging at the time, I think he was wise because while there were a couple of hospitals that really, really got pummeled for a couple of weeks, I do think the New York Times sort of over dramatized everything that was happening in New York and a lot of us felt that way. So it was really bad for a couple of weeks and a couple of hospitals, particularly bad. Our smaller hospital, the Allen was pretty bad for a couple of weeks, but we didn't run out of ventilators. And if we would have been given permission to start pulling people off of machines, I do think we would have contributed to deaths that did not end up happening because of the pandemic. So, you know, I think all of these things we have to approach with humility and sobriety and move slowly and err on the side of life. And I do believe there's wisdom there. Great, thanks so much. Well, I think we could talk about New York for the rest of the time, but I wanted to shift to some, we got some really good questions about Professor Milani's work. In particular, some people, a couple of people asked, do you see any applications of your study of India's response to COVID-19 to the US? And I had a very specific question about the idea of using an instrument to potentially estimate unbiased estimates of COVID-19 prevalence in various populations, maybe like a small financial award for getting tested. Yeah. Okay, so I think there's, I'll tell you a few things. First is one of the reasons why I focused on India almost exclusively during this epidemic was the sense that I got from talking to colleagues of mine that got involved in US policymaking where it was that it was very difficult, it was a very political environment here in a way that it wasn't in India. And so that it made it very hard to have an open discussion about different approaches to handling the pandemic without people making judgments about that. So you could actually get a full airing of what's going on. And so that's one of the reasons I worked there. I think that that would be a lesson for us to bring back here is I think that there was just a huge amount of uncertainty at the beginning. And if at the beginning, we were just a little bit more modest about what we knew and didn't jump down each other's throats, I think that we, I think we probably would have seen, maybe you would have seen a lot more stuff. I would have been able to analyze the data a little bit better. I think that's nice. It's something that we did in India a little bit more. It did help to have some distance. I'm sitting in Chicago, the work's being done there or in Jakarta. A second thing that I think was very interesting is that there was a ton of collaboration on the private sector side. And I think that part of that happened because we thought that there would be less capacity of the government. We organized a task force of heads of different types of industries. So a bunch of CEOs, civil sector, civil society, organizations, World Bank, et cetera, all got together to basically and plugged in with government officials to kind of help them wherever things were needed. And so there's the sense of collaboration that I think would have been probably a little bit nicer here. The third thing is there's a lot more stuff that happens in formally in India. So in some ways, we're very slow to test. But on the other hand, we've done a lot of zero surveys. And I compare that to my colleagues that have gone through a really rough time getting zero surveys out, representing surveys out. There are ethical issues, there's issues about approval of the tests, there are just issues about recruitment, there's liability issues. We worry about very little of that in India, so we're able to act a lot more quickly. The last thing is, we're able to just kind of have open discussions about vaccine priorities. Not everybody's gonna listen to us, but at least we're thinking about it. And we're taking, at least when I say we, I mean, folks that are working with India and Indonesia are taking like the limited supply stuff very seriously and understand that there's just tough trade-offs and they're not really, it's not as big a deal. On paying people to get consent, it's something that actually a group of researchers at Chicago have been thinking about. People like, you might be working with them like Alex Torgavitsky and Magna, Moksad and Vinny Bundy. And the difficulty has been, it's just very hard to get approval for that sort of stuff in the United States. We tried to do that when we did the Karnataka study at the beginning. And the thing that stopped us wasn't the ethical review. And just to be clear, I was involved just in a public health capacity doing that stuff. I only see the data at the back end. But in that context, when we suggested this as a design, it wasn't the government that was opposed to it, it was the certainty that was going out to doing a lot of the work was worried that this would kind of create an expectation of payment. So they didn't want to do it. But we are, we were able to gather data on people that didn't consent and people that did consent. So we're able to see what the impact of consent is. And so now we're working on that topic now to see if we're getting real bias due to consent. Yeah, thanks. I did hear about that from Magna when it took as econometrics class in the spring. So I survived it barely. But so, yeah, no, it's a very interesting idea with vaccines in particular, what you said about examining sort of even the WHO things that have come out from a perspective of, you know, how much benefit to the overall population is vaccinating healthcare workers first going to achieve, right? Obviously protecting a very important workforce from getting sick in the community. But now that we know that with proper PPE, the risk is pretty low, getting infected maybe vaccinating high-risk populations would actually save more lives. So, you know, hopefully there's still time in the US and the world before we distribute the vaccine to sort of very carefully allocate this scarce resource to save the most people. And then, you know, with the added dimension of whether you want lives or life years, like you mentioned. I also want to point out there's just fundamentally something different in the United States than these LMICs, low and middle income countries. In the US, when I just compare their two situations, we live in prosperity. It sounds weird to say in this context, but I don't think there's any question that we're gonna have enough doses for everybody. It's just a question of pure distribution. Whereas for a lot of other countries, it's the distribution is also there, but they also are not getting the doses that they need to cover a large percent of the population. Another super interesting thing that goes on in India that's a strong ethical issue, we had a long conversation about this earlier today, is if we take our Karnataka work seriously and we think that we're at 46% prevalence in Karnataka. And that's probably an underestimate as we're doing zero studies, rather than looking at T-cell assays, we're doing that next in Bangalore. What if you find that by January, February, 75% of the population's already exposed in one area and 40% in another area? Do we want to then say we're gonna prioritize the 40% area, cause that's where it's gonna be a bigger impact and let the 70% they've kind of got natural immunity. And I want to be careful about herd immunity because I think that there's a reason to go beyond it sometimes, cause there's still value to reducing the rate of spread even though the rate of spread is less than one, but those sorts of issues occur and you are more likely to make those sorts of decisions in a world where you've got severe supply restraints. India is actually in a much better situation cause it produces vaccines than Indonesia but Indonesia is gonna face that quite severely as well as other countries in that in both. Let's certainly still bring to think of how relatively lucky we are. Oh yeah, go ahead. Sorry, Lydia. We're speaking before, would you consider a payment for testing sort of would that be similar to you can't do your job unless you get a test? Isn't that a sort of a different sort of payment? Like we'll give you your paycheck if you get a test. I know it's just reflected our ID badges won't work if we aren't tested. They're gonna just cut us off from work. That's a really great point. I mean, I think we are very often being ethically inconsistent. So we're happy to tell students that if they wanna come back to campus they gotta get tested. But we don't wanna say on the other hand, and that's a penalty by the way cause they've already given you the money and they're ready to come. But then we're uncomfortable saying let's pay people to participate in human challenge trials. We're only by the way having that discussion in the context of vaccines. Even before a vaccine we could have had an ethical a really interesting ethical discussion in April and say should we just have human challenge trials to learn about the epidemiology of COVID so that we can provide better medical protocols for treating patients. That would have had a huge impact. Worldwide benefit cause there's tons of scale associated with that. It seems like a good question and we've kind of violated that principle if we had it later on. We do that now with our students. So I think that's a great question. Well, it's always fun to hear you write everything down in terms of a utility function. So I think we should probably I should probably read some of these questions from the chat directly. John Lantos asked Lydia, people talk of crisis standards of care. Were there crisis standards of ethics? Did you make different recommendations than in non-COVID times? Hi, John, thanks. So not really. I mean, with the exception of at the end of the worst part of the pandemic, changing our thinking, if you will, on what is maximal resuscitation, that was really it for us. We did draw up a number of policies that were not adopted or enacted. So that's what I've got. All right. The next one is from Kelly who asked me, given what you know, how would you structure critical care, scarce resource allocation policies? What would the primary ethical driver be? So I guess I don't totally haven't totally decided I want to do better modeling with more data. But I think I'm gravitating more and more towards just peer lottery systems because in the US, you would think any absolute scarcity in a given place would hopefully be brief, right? It sounds like Columbia was right up against the point where they were thinking about it in New York and in order to get these efficiency gains with the SOFA system, their minor, first of all, over lottery and our simulations, you have to create significant disparities among racial lines and against people with chronic conditions. So maybe it's best that if you're only going to be out of ICU beds for a short period of time that the principle of treating people easily dominates and you just allocate by a simple lottery. Now it's hard to tease out like, isn't there a first come first serve and that intrinsically because people have to get in the line to get into the lottery in the first place but at least, you know, you make progress towards distributing the resource fairly if not the most efficient way. And I should say I didn't get a chance at the end of my slides to thank Laney Ross who is my along with Mark, my main mentor over the years in thinking about scarce resource allocation really got me started in this area. So thanks, Laney, if you're still listening. I don't know if any other people have thoughts about, you know, if you could design the scarce resource allocation, critical care resource allocation system if that's where we're headed, you know, if you thought any of the state protocols were compelling or what? So I have an interesting, that I actually emailed you separately about this based upon your presentation, which is when you use these lottery systems there's this kind of weird spillover benefit which is that you can learn about the efficacy of the treatment when you do that. And it seems kind of weird to talk about it that way but there's actually discussion now by folks like Alex Tabarak and Scott Commoners saying that we ought to think about that for vaccines. So if we have limited supply of vaccines what if we are distributed by lottery? Not only is there a fairness benefit but we actually as a society benefit because we can learn about the efficacy of the vaccine or side effects from the vaccine in a large population. And so I think it's a really interesting question about whether or not, I think there are a lot of benefits to the appropriate taking. I'll just say that, are you talking, Will? Can't hear you. I think you muted. Well, maybe while, Will are you getting your sound? Okay, I'll just talk for a quick second. The one thing that really struck us so our John Lantos, our contingency plan was sort of something modified version of SOFA and triaging based on that. And what we realized because we weren't allowed to enact any of those sort of emergency plans, we realized that there were patients whose SOFA score based on their SOFA scores we should have removed the vent if it had come to that and we needed the ventilator and they ended up surviving to discharge. So what we found with COVID is that the patient, it just didn't make sense. It didn't make sense on how we understood previous viral illnesses. We were constantly surprised. We were constantly surprised by very elderly people who would go out with treks and pegs and then come to follow-up visits later having had the devices removed and they were sort of back. It took months to recover but we were constantly surprised. And that's why, Well, I do, I guess I've become more nervous about using those kinds of protocols such as SOFA. I mean, you're still trying to talk well and we still can't hear you. But at any rate, I do like the idea of the lottery. I'm moving towards that myself. You should speak. Can I merge in? Can you hear me at all? I can hear Mark. Yeah. Can you hear me? I'd like to just say a quick word to thank your panel. It was a fabulous group. I mean, Will and John and Lexi and Lydia and Anup. I have one thing that I wanted to say and that is that John Lapuma was the first fellow that we trained at the McLean Center in July of 20, July of 1985. We had opened the McLean Center in December of 84 and John was number one fellow trained. He was the only fellow that year. And so I just wanted to renounce that. I'd like to say a quick word about tomorrow morning. Who mentioned Lanie Ross just a minute ago, Will did. Lanie Ross is going to be moderating the morning panel at eight o'clock in the morning on pediatric ethics. The speakers will be Mark Sheldon of Northwestern, Megan Collins from Hopkins, Lanie herself, Rick Kodish from Cleveland and John Lantos from Missouri. So that'll be on pediatric ethics and that'll be before the Dean comes on the Dean Polanski with the award presentation. But I wanted to congratulate your group and thank you so much for joining us. Thanks guys. Thanks Will. Bye Anup. Thank you. We should say that the award presentation tomorrow after the first panel is to Mark and the McLean center prize is one that not only he initiated, but he gets and that in itself is an accomplishment. But you know, I don't get the money. Everybody else before me. Oh no, what happened? Because I'm a University of Chicago faculty member. And so the $50,000 prize that has gone to all previous winners is not going. Oh, can't we take a leave of absence for a day? I'm delighted to get the prize without the money. That's fine. Well, we really look forward to your marks Mark and it will be a wonderful, wonderful occasion. And I will give remarks afterwards his. Yeah. Okay, great. I really appreciate it. Thanks so much to your committee and to Will. Thanks guys. Bye bye. Well, we'll see you tomorrow. Thank you. See you tomorrow. Bye. Bye bye now.