Best Practice in Clinical Ethics and Compassionate Care during COVID-19 Crisis: CHAPTER 2 - DNR AND END-OF-LIFE CARE - DECISION, COMMUNICATION, AND MANAGEMENT

INTRODUCTION

• Clinical ethics is analytic and reflective. It gives clarity and suggests resolution.
• There is a difference between a patient-centred approach to clinical care on a normal day and a public-centred approach to clinical care during the pandemic crisis. Thus, clinicians face what we call moral distress (MD) during the pandemic, which results from a perceived violation of one’s core values and duties, concurrent with a feeling of being constrained from taking the ethical or right actions. 
• MD could originate from a different clinical decision-making flow and standard of care, an altered patient and physician relationship, the limited chance for the usual personal and compassionate care, and the constant conflict of obligations between patients, self, colleagues, and families. 

OBJECTIVES

• These chapters aim to guide and support clinicians, and eventually reduce the impact of public health-centred clinical care on clinicians, patients, and families. Along with practical steps and tools, they give clarity and suggests ways to resolve some of the most challenging clinical practice during the COVID-19 pandemic.

"Best Practice in Clinical Ethics and Compassionate Care during COVID-19 Crisis"

CHAPTER 2: DNR AND END-OF-LIFE CARE - DECISION, COMMUNICATION, AND MANAGEMENT 

Ethical Question: How should clinicians decide on DNR/DNACPR in the context of end-of-life care, and how should these conversations take place?

Scenarios:

1. A 75-year-old man in the SARI ward presented with cough and cervical lymph nodes enlargement with lung nodules on CXR, possible malignancy or TB. He’s lonely & depressed, eventually refused any blood monitoring & lymph nodes biopsy.

2. An 80-year-old man with triple vessel heart disease, NYHA Class III, and two previous ICU admissions, currently suspected to have COVID-19 and needs ventilatory support. Patient’s goals and wishes unknown, eldest son from overseas wants “all-out.”

After Chapter 1 on crisis decision-making, Chapter 2 offers practical steps for young and senior clinicians on the assessment and communication for DNR and EOL care with easily applicable communication tools for breaking bad news and discussion in the goals of care. 

Related chapters:

Chapter 1 - Crisis Decision-Making Support Pathways. http://doi.org/10.5281/zenodo.5111535  
Chapter 3 - Palliative Care. http://doi.org/10.5281/zenodo.5101092  
Chapter 4 - Compassionate Care. http://doi.org/10.5281/zenodo.5105289 

Contact email: ethicsampang@gmail.com (HESS)

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