Despite a generation’s work on the ethics of end-of-life decision-making, we still struggle to know who gets to make critical decisions, and when. In this issue, CiaffaReference Ciaffa ¹ explores the ethics of unilateral do not resuscitate (DNR) orders for patients with COVID-19. He reviews several widely discussed guidelines recommending unilateral DNR orders during the pandemic and argues that the key ethical principles on which they rely, futility and utilitarianism, fail to provide adequate justification. The first, futility, suggests that clinicians are not obligated to provide interventions that have no demonstrable chance of success. As Ciaffa correctly points out, universal unilateral DNR orders for patients with COVID-19 unreasonably expand futility beyond the accepted notion of physiologic futility, in which a procedure has no chance of achieving the intended physiologic effect. The second principle, utilitarianism, suggests that in a pandemic clinicians should not be exposed to unnecessary risk that may reduce their ability to help the greatest number of patients. Ciaffa maintains that such a justification overestimates risk in all but situations that invoke crisis standards of care. He concludes by calling for more proactive communication with patients, families, and the public about the potential benefits and burdens of CPR.

Ciaffa puts forth a valid and important critique of the well-intentioned efforts to limit potentially non-beneficial interventions during the pandemic. In discussing unilateral DNRs, though, we must also consider the human factors that complicate end-of-life decision-making for patients, surrogates, and clinicians, particularly in an unprecedented global crisis.

Paradigms for shared decision-making around CPR and intubation draw heavily on the science of serious illness communication.Reference Tulsky ² In the face of a life-threatening illness, patients and their surrogates confront powerful emotions — sadness, grief, anger, guilt, and fear, among others. These emotions overwhelm them and limit their cognitive abilities to make decisions. For instance, when faced with an open-ended question about code status, a family member serving as a health care proxy agent may opt for CPR and intubation, as she fears “giving up” prematurely and feeling responsible for her loved one’s death. Evidence-based approaches to these conversations thus involve clinicians eliciting patient and family goals and values and then making medical recommendations considering these values and the clinical situation.Reference Back ³ Amid these challenging decisions, patients and their surrogates look for guidance from their clinicians. In turn, this guidance exists on a spectrum, ranging from a soft-pedaled suggestion to a strong, definitive recommendation. The University of Washington protocol for informed assent during COVIDReference Curtis, Kross and Stapleton ⁴ exists at the far end of this continuum, whereby the clinician asserts the plan to withhold CPR, and then, importantly, checks in with the patient or surrogate to assess their agreement or disagreement. Some families may never be able to decide to withhold treatments aimed at prolonging life; they may, however, be able to assent to a compassionate, yet strong recommendation from a clinician.

Ciaffa’s critique also underemphasizes the risk to the clinician of performing CPR on a patient with COVID-19. Early in the pandemic, when most of the referenced protocols were written, hospitals lacked sufficient personal protective equipment (PPE) and knowledge of COVID-19’s transmissibility continued to evolve. As a result, clinicians and staff on the front lines justifiably feared for their safety. Indeed, 3,607 American health care workers died in the first year of the pandemic. ⁵ Ciaffa maintains that health care workers should be protected based on a utilitarian conception of their value to society. It follows, then, that such arguments function only when the health care system views all its components through a utilitarian lens, i.e., in crisis standards of care. However, the utilitarian view fails to consider health care workers’ intrinsic moral weight as individuals, not just as vehicles to achieve the greater good. Along with transparency and justice, reciprocity for clinicians forms a critical piece of pandemic ethical frameworks. Reciprocity suggests that health care workers deserve to be fairly compensated for their work, and adequately protected while doing it.Reference Jecker, Wightman and Diekema ⁶ We must then balance the principle of reciprocity against patient autonomy. Whereas the balance will generally tilt in favor of the patient, there are situations in which CPR could be exposing health care workers to unnecessary risk as the procedure’s chance of success is not zero, but extremely low. Even outside of crisis standards, it behooves health systems to consider how to best protect their staff in these cases. And, the same systems should be obligated to rethink their approach as the data and frontline situation (i.e. availability of PPE) change.

Proactive efforts at patient education, as Ciaffa points out, may allow us to avoid unilateral DNRs completely. We agree that education is critical, but believe that the time, effort, and money spent on education would be better spent on teaching clinicians how to have an effective goal of care or code status conversations.Reference Lakin, Tulsky and Bernacki ⁷ Clinicians, patients, and surrogates often share similar goals — to see the patient improve and, if that proves to be impossible, to see them comfortable at the end-of-life. For the reasons stated earlier, a clinician trained in high quality serious illness communication may have the requisite skill to elicit these goals, align with them, and make a goal-concordant recommendation to withhold CPR.

When faced with new, uncertain situations, overworked and fearful clinicians need guardrails that reinforce established ethical principles and standards of care. Unilateral DNRs, too often serve as shortcuts to skilled goals of care and code status conversations. If anything, individual patient and family goals and values assume more importance when there is considerable prognostic uncertainty. At the same time, frontline health care workers who, in this pandemic, have been willing to put themselves at great risk physically and emotionally to meet their obligations to patients need to know that hospital policymakers place intrinsic value on their health and safety.