Decision making by health professionals during COVID-19: an integrative review

Integrative review in the databases CINAHL, MEDLINE, Scopus, ScienceDirect, WoS, and BVS. Inclusion criteria: original articles available in full, in any language, related to the object investigated.

Results:

During this pandemic, health workers have been making decisions based on ethical/bioethical principles (utility, beneficence, non-maleficence, autonomy, justice, proportionality, flexibility, clinical prognosis, duration of the need, and fair health attention), values (solidarity, equality, equity, utilitarianism, relational autonomy, reliability, reciprocity, maximization of the benefits and resources, and prioritization of those in worse conditions), beliefs and personal motivation, protocols, directives, tools, algorithms, recommendations, and criteria.

Final considerations:

Decision making has never been so necessary as in this pandemic. This article is not a recipe for the professionals, since decision making is based on numerous factors. However, it provides them with a foundation that can be helpful in this difficult process.

Descriptors:
Decision Making; Ethics; Health Personnel; Pandemics; Coronavirus Infections

Database/portal

Search strategies

CINAHL/ MEDLINE/ WoS/ BVS portal

“Decision Making” AND (“Health Personnel” OR “Health Care Provider” OR “Health Care Providers” OR “Healthcare Provider” OR “Healthcare Providers” OR “Healthcare Worker” OR “Healthcare Workers” OR “Personnel, Health” OR “Provider, Health Care” OR “Provider, Healthcare” OR “Providers, Health Care” OR “Providers, Healthcare) AND (“Ethics” OR “Ethical Issue” OR “Ethical Issues” OR “Ethics, Situational” OR “Issues, Ethical” OR “Situational Ethics” OR “ Bioethics” OR “Ethics, Health Care” OR “Health Care Ethics”) AND (“Pandemics” OR “Coronavirus” OR “Covid-19”).

Scopus/ ScienceDirect

“Decision Making” AND (“Health Personnel” OR “Healthcare Worker”) AND (“Ethics” or “Bioethics) and (“Pandemics” or “COVID-19”).

Reference	Year Country	Design mento	Main results
(²2 Iserson K. Healthcare ethics during a pandemic. West J Emerg Med. 2020;21(3):477-83. https://doi.org/10.5811/westjem.2020.4.47549 https://doi.org/10.5811/westjem.2020.4.4... )	2020 USA	Theoretical reflection	In addition to ethics for DM, professionals must consider religious beliefs, motivations, and (personal and professional) values in clinical practice. The study addresses the need to facilitate and dynamize the flow of relevant, transparent, and consistent information about the new coronavirus, for professional training and better DM, and for the population to develop a reasonable risk evaluation in conditions of uncertainty. When there are two patients and one resource, a relocation must take place, and the resource should be offered to the patient with a better prognosis, according to the principle of distributive justice (scarce resources distributed fairly, to those who need most). In these cases, health workers must remain neutral, impartial, and follow the utilitarian principle (the greatest good for the greatest number of people).
(⁴4 Shah A, Aacharya RP. Combating COVID-19 pandemic in Nepal: ethical challenges in an outbreak. JNMA J Nepal Med Assoc. 2020;58(224):276-9. https://doi.org/10.31729/jnma.4959 https://doi.org/10.31729/jnma.4959... )	2020 Nepal	Theoretical reflection	Professional DM must be based on the principles: autonomy (the social wellbeing must be above the individual wellbeing); non-maleficence (the poor, marginalized, and those who need treatment are those who suffer the most with isolation, so there must be a mechanism for the social support of the most vulnerable); beneficence (triage and isolation of cases that are suspicious according with the social wellbeing); and justice (those who are more likely to survive have priority in treatment).
(⁵5 Jeffrey DI. Relational ethical approaches to the COVID-19 pandemic. J Med Ethics. 2020;46:495-8. https://doi.org/10.1136/medethics-2020-106264 https://doi.org/10.1136/medethics-2020-1... )	2020 United Kingdom	Theoretical reflection	Central and ethical values for DM included: solidarity (examine how society cares for the most vulnerable); professional health care based on the ethics of solidarity and the principle of beneficence; equality (fair distribution of resources); equity (when life and health are involved, everyone is worth the same); utility (saving the highest number of lives); relational autonomy (the autonomy of one affects the autonomy of others); reliability and reciprocity (based on the ethics of solidarity, society gives privileges and respect to the professionals and expects them to care for the infected patients). The DM must allocate scarce resources fairly, and the tool Swiss Influenza Pandemic Plan is presented to aid in this task.
(⁶6 Solnica A, Barski L, Jotkowitz A. Allocation of scarce resources during the COVID-19 pandemic: a jewish ethical perspective. J Med Ethics. 2020;46:444-6. https://doi.org/10.1136/medethics-2020-106242 https://doi.org/10.1136/medethics-2020-1... )	2020 Israel	Theoretical reflection	The DM, in the triage, must be based on the utility principle (helping people with a higher life expectancy). When there is one resource for two people with different prognoses, it must be offered and, if necessary, relocated, to the person with the better prognosis. When the utility principle is unable to give support to DM, in the Jewish culture, it is possible to treat according to arrival in the service, through draws, or simply by trusting the decisions made by the professionals.
(⁸8 Chan PS, Berg RA, Nadkarni VM. Code blue during the COVID-19 pandemic. Circ Cardiovasc Qual Outcomes. 2020;13(5):e006779. https://doi.org/10.1161/circoutcomes.120.006779 https://doi.org/10.1161/circoutcomes.120... )	2020 USA	Theoretical reflection	Advocates that, starting at admission, goals must be defined to attend the patient and for the use of PPEs by health workers, especially during cardiorespiratory arrests, to guarantee their safety and make it possible to carry out urgency attention faster. Hospitals must have an ethical team prepared to guide professionals to make difficult decisions, minimizing anguish and the moral suffering that are common in this moment. Protocols adopted must have clear criteria (years of life left and comorbidities) for the cardiopulmonary resuscitation of infected patients.
(⁹9 Morley G, Grady C, Mccarthy J, Ulrich CM. Covid-19: ethical challenges for nurses. Hastings Cent Rep. 2020;50(3):35-9. https://doi.org/10.1002/hast.1110 https://doi.org/10.1002/hast.1110... )	2020 USA	Theoretical reflection	Describes COVID-19 implications for frontline nurses. Three ethical issues are discussed: 1) The dilemma between the duty to care for the patient (beneficence) and dealing with the inadequacies of the health system; 2) The allocation of scarce resources leads to inconsistent DM in a setting filled with uncertainty; and 3) care is focused on the health needs of society. About DM for the allocation of resources, directives and algorithms need to be created by specialists to give support to direct assistance professionals. The relocation of resources must happen when there is one resource and two patients with different prognosis (the one who is more likely to recover will receive the resource). Nurses suffer with the ambiguity and the inability to do what would be morally correct, in addition to the uncertainty about whether the decision made was the most adequate. Specialists that can be consulted about clinical ethics can help minimize the suffering.
(¹⁰10 Nicoli F, Gasparetto A. Italy in a time of emergency and scarce resources: the need for embedding ethical reflection in social and clinical settings. J Clin Ethics. [Internet]. 2020[cited 2020 July 27];31(1):92-4. Available from: https://pubmed.ncbi.nlm.nih.gov/32213700/ https://pubmed.ncbi.nlm.nih.gov/32213700... )	2020 Italy	Reflection (opinion of authorities)	Defends that health institutions should have ethics specialists for difficult DM. From this perspective, the SIAARTI created recommendations to aid physicians making decisions about the admission of COVID-19 patients in the ICU.
(¹¹11 Vincent J-L, Creteur J. Ethical aspects of the COVID-19 crisis: how to deal with an overwhelming shortage of acute beds. Eur Heart J Acute Cardiovasc Care. 2020;9(3):248-52. https://doi.org/10.1177/2048872620922788 https://doi.org/10.1177/2048872620922788... )	2020 Belgium	Reflection	Decisions about the admission into ICUs must prioritize patients that, according to the physician, have a good prognosis for recovery and a good quality of life. When resources are scarce, the distributive justice must be applied to DM (resources must be distributed to those who are more likely to benefit from them). During triage, the age, degree of fragility, and the preference of patients must be considered. The study explains that it is justifiable to relocate a ventilator or a bed from a patient with a bad prognosis to another with a better prognosis. Health services must have an Ethics Committee or a leader that is available 24/7 in the ICU, to be consulted by professionals in the case of difficult decisions. The study presents the Sequential Organ Failure Assessment Score to help professionals make difficult decisions.
(¹³13 Virani A, Singh G, Bewick D, Chow C-M, Clarke B, Cowan S, et al. Guiding cardiac care during the COVID-19 pandemic: How ethics shapes our health system response. Can J Cardiol. 2020;36(8):1313-6. https://doi.org/10.1016/j.cjca.2020.06.002 https://doi.org/10.1016/j.cjca.2020.06.0... )	2020 Canada	Theoretical reflection (consensus from specialists)	Professionals, patients, and patient relatives must make decisions together, based on the following principles: minimizing damage (non-maleficence/beneficence), distribute justice (equity), respect and autonomy, proportionality, reciprocity, flexibility, and process justice. Solidarity is above individual autonomy.
(¹⁴14 Romanò M. Fra cure intensive e cure palliative ai tempi di CoViD-19. Recenti Prog Med. 2020;111(4):223-30. doi: http://doi.org/10.1701/3347.33185 http://doi.org/10.1701/3347.33185... )	2020 Italy	Theoretical reflection (opinion of authorities)	Addresses clinical criteria (severity of the disease, presence and importance of comorbidities, fragility, organ failures and the stage of these failures, age of the patient, and cognitive and functional levels of autonomy) and ethical criteria (beneficence, non-maleficence, autonomy, and distributive justice) to guide the DM about the admission of patients with COVID-19 into the ICU. Distributive justice is not only the right of the patient to have access to the treatments available; it also refers to the correct distribution of the resources available (public ethics). The distributive justice is complemented by proportionality, adaptation of care, equity, equality, and usefulness (allocating resources to provide the maximum benefit at the lowest price). Considering the above, the Italian Society of Anesthesia, Analgesia, Reanimation and Intensive Care (SIAARTI) created recommendations to give ethical support to the DM of professionals who work in the front lines of the struggle against COVID-19. This document states that as many people and as many years of life as possible should be saved. The hospitals need an independent organ formed by specialists, who follow clear and transparent criteria, to give support to DM.
(¹⁵15 Kramer JB, Brown DE, Kopar PK. Ethics in the time of coronavirus: recommendations in the COVID-19 Pandemic. J Am Coll Surg. 2020;230(6):1114-8. https://doi.org/10.1016/j.jamcollsurg.2020.04.004 https://doi.org/10.1016/j.jamcollsurg.20... )	2020 USA	Reflection (recommendation from specialists)	Presents recommendations to confront and solve some ethical challenges that emerged in the pandemic: 1) Can the professional choose whether to provide care to COVID-19 patients? The recommendation is that the care should be provided if the PPEs are adequate; 2) How should the allocation of scarce resources, such as ICU beds, ventilators, and certain medications be done? The recommendation is that systematic and transparent protocols should be adopted to help professionals in DM.
(¹⁶16 Rawlings A, Brandt L, Ferreres A, Asbun H, Shadduck P. Ethical considerations for allocation of scarce resources and alterations in surgical care during a pandemic. Surg Endosc. 2021;35(5)2217-22. https://doi.org/10.1007/s00464-020-07629-x https://doi.org/10.1007/s00464-020-07629... )	2020 USA	Theoretical reflection	Although they can be adopted during a pandemic, bioethical (autonomy, beneficence, non-maleficence, and justice) and ethical values (maximizing the benefit from resources available, treating people with equality, recognizing the instrumental value of professionals and prioritizing those in worse situations), their application changes as the focus of health care becomes the collective. These principles must be considered in DM. Professionals who work in the struggle against the coronavirus are instrumental to society, and, therefore, must have priority when it comes to the allocation of resources when they fall ill. A clinical triage team is a valuable resource to aid professionals in difficult DM.
(²¹21 Flaatten H. The good, the bad and the ugly: pandemic priority decisions and triage. J Med Ethics. 2020;0:1-3. https://doi.org/10.1136/medethics-2020-106489 https://doi.org/10.1136/medethics-2020-1... )	2020 Norway, Israel, Germany, the United Kingdom France and the Netherlands	Reflection (consensus from specialists)	Discusses a change in the criteria for the triage of patients during the pandemic, which classifies them in three stages: stage 1 (good) - there are resources available and the DM is based on good evidence; stage 2 (bad) - the demand grows and some resources are lacking; stage 3 (terrible) - the lack of resources is severe. In the good stage, clinical prioritization can take place and DM can happen as usual, without the need for intensive care and prognoses. In the bad stage, the professional may not admit patients with doubtful prognoses. In the terrible stage, the usual medical triage and the establishment of priorities may not be enough to diminish the influx, and there may not be enough ICU beds. In this stage, different criteria must be applied using a utilitarian approach for the triage. The article also deals with the ethical dilemma faced by professionals when they need to decide whether or not to admit elderly patients (above 80 years old) in the ICU and have to deal with the social consequences of the decision made.
(²²22 Rubio O, Estella A, Cabre L, Saralegui-Reta I, Martin MC, Zapata L, et al. Recomendaciones éticas para la toma de decisiones difíciles en las unidades de cuidados intensivos ante la situación excepcional de crisis por la pandemia por COVID-19: revisión rápida y consenso de expertos. Med Intensiva. 2020. https://doi.org/10.1016/j.medin.2020.04.006 https://doi.org/10.1016/j.medin.2020.04.... )	2020 Spain	Reflection (consensus from specialists)	The ethics group Spanish Society of Intensive, Critical, and Coronary Care (SEMICYUC) and specialists in the field of bioethics, geriatrics, and palliative care developed a document with guidance for professionals regarding DM and the allocation of resources. This document considers, in its structure, the availability of resources and alternatives (the optimization of personal, structural, and material resources, the creation of specialist committees and contingency plans, among others); the characteristics and the state of health of the patient (age, degree of fragility, preferences, values, and adequate palliative care, in cases where the development is bad); and the DM guided by the ethics of the decisions (triage based on the principles of distributive justice and proportionality, shared DM).
(²³23 DeBruin D, Leider JP. COVID-19: The shift from clinical to public health ethics. J Public Health Manag Pract. 2020;26(4):306-9. https://doi.org/10.1097/PHH.0000000000001204 https://doi.org/10.1097/PHH.000000000000... )	2020 USA	Theoretical reflection	Presents bioethics principles (beneficence; respect to autonomy) to DM during the pandemic. To allocate resources, professionals must base their decisions on the principles of justice, clinical prognosis, and on the duration of a need. It addresses the right of the patient to refuse treatment and the need for professionals to communicate clearly and compassionately. The best possible care must be offered to the patient with coronavirus, including palliative support, mental health care, and spiritual assistance.
(²⁴24 Parsons JA, Johal HK. Best interests versus resource allocation: could COVID-19 cloud decision-making for the cognitively impaired? J Med Ethics. 2020;46:447-50. https://doi.org/10.1136/medethics-2020-106323 https://doi.org/10.1136/medethics-2020-1... )	2020 United Kingdom	Theoretical reflection (consensus from specialists)	It addresses DM challenges in patients with cognitive disabilities and provides guidance according with the Mental Capacity Act, which follows the principle of utilitarianism.
(²⁵25 Kirkpatrick JN, Hull SC, Fedson S, Mullen B, Goodlin SJ. Scarce-Resource allocation and patient triage during the COVID-19 pandemic: JACC review topic of the week. J Am Coll Cardiol. 2020;76(1). https://doi.org/10.1016/j.jacc.2020.05.006 https://doi.org/10.1016/j.jacc.2020.05.0... )	2020 USA	Theoretical reflection (recommendations from specialists)	The DM about triage, allocation and relocation of resources must be guided by ethical principles and values: autonomy (in the pandemic, the priority is to maximize the number of lives and years saved, not individual autonomy); beneficence/non-maleficence (workers cannot impose treatments on the patient); justice (patients have equal access to resources, which must be allocated fairly); fairness (the priority should be to allocate resources to younger people, who are more likely to be cured and live longer); instrumental value (health professionals have priority in the access to resources, since, once cured, they can help saving lives). During the pandemic, there must be a team of triage to help professionals in difficult DM, helping to relief their moral suffering and to provide protection. Criteria to allocate and relocate resources must be transparent. Professionals must provide the best attention possible, adopting transparent and clear communication, respecting the autonomy of the patient (which is below the greater objective of protecting more lives) and acting based on an utilitarian approach.
(²⁶26 Herreros B, Gella P, Asua DR. Triage during the COVID-19 epidemic in Spain: better and worse ethical arguments. J Med Ethics. 2020;46:455-58. https://doi.org/10.1136/medethics-2020-106352 https://doi.org/10.1136/medethics-2020-1... )	2020 Spain	Descriptive with a qualitative approach	Presents clinical criteria to guide the professional DM in the triage of ICU patients, by calculating the base functional and cognitive index, measuring the severity of the disease, the possibility of a reversal, and the potential for recovery after treatment. It claims that each hospital must have a triage committee with members with experience in treating people with COVID-19 and members of the Institutional Health Ethics Committee to give support to the DM professionals.

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