SHEA Conference: Ethics in infection control: How to balance the one against the many

SHEA Conference

Ethics in infection control: How to balance the one against the many

SHEA: Crises, daily choices raise ethical dilemmas

Whether it’s rationing scarce medical supplies or placing patients in isolation, ethical dilemmas in infection control frequently pit the needs of the one against the protection of the many.

"As one chases after microbes and tries to contain them, there may be challenges that result in the compromise of care," said Lauris Kaldjian, MD, PhD, an infectious disease physician at the University of Iowa College of Medicine in Iowa City. "There is this basic tension between protecting the population of patients [without] minimizing the care or concern for the individual patient."

A physician with a PhD in ethics, Kaldjian offered a succinct definition of the field recently in Los Angeles at the annual meeting of the Society for Healthcare Epidemiology of America (SHEA). "Ethics can mean many things to many people, but the simplest [definition is] it is about what is right and what is wrong, what is good and bad. There is no grand theory — [no way of] doing this in advance rather than hammering it out on the ground," he explained.

Infection control professionals and epidemiologists typically have a clinical background that ties them to the well-being of the individual patient. But infection control encompasses broader concerns, including groups of patients, health care workers, and the financial health of the institution.

"I think you have a dual identity that is part of your formation as a professional," Kaldjian said. "In talking to some of your colleagues, I get the sense that that is part of the challenge. Figuring out how to play both the role of a resource manager but also struggling with the heart and mind of a clinician — trying to bring your two schizophrenic selves into one person. [You] are trying to [accommodate] both population protection and patient respect."

The starting point of good ethics is good medicine, he stressed. "If you are not competent and evidence-based in medicine, you can’t hope to do good ethics," Kaldjian told SHEA attendees. "It is not going to whitewash an otherwise bad situation."

In addition to a practice founded in science, an ethical approach to infection control requires what he called "role fidelity." That means, in essence, know the parameters of your job and hold your ground in tough times.

"Fulfill your primary obligation," Kaldjian said. "I am a big fan of the division of labor in the moral life as well as the political life. It’s not for no reason that we have three branches of government. There is nothing wrong — and everything right — for you as an infection control person to say your job is A.’ Let the clinicians be the advocates for the patients they are caring for and [then] have a great discussion, sometimes a great argument about what really is best."

In tracking their ethical choices about a given situation, ICPs must weigh many competing interests.

"In general, we take the epidemiologic circumstance and then there are a whole bunch of overlapping issues that influence our decisions," said Trish Perl, MD, hospital epidemiologist at Johns Hopkins University in Baltimore. "As practitioners, we really look carefully at the research. We focus a lot on evidence-based interventions as one of the tenets of our practice going forward. Then we are forced to deal with the realities of the pragmatic situations where we practice: money, how many beds you have, and how much influenza vaccine you [have]," she added.

Vaccine drops from 27,000 to 2,000 doses

Indeed, consider the situation Perl and colleagues faced during last year’s influenza vaccine shortage. The hospital and affiliated institutions normally dispense some 27,000 doses of influenza vaccine. When the shortage hit last year, Johns Hopkins had 2,000 doses and an ethical minefield to navigate in dispensing them.

Do you immunize patients at high risk for influenza complications, health care workers, or some combination of both? Though additional vaccine ultimately became available, in the early going of the shortage, all bets were off. Not knowing if any other vaccine was forthcoming, Perl opted for a strategy of emphasizing respiratory etiquette, stocking up on influenza antivirals, and immunizing clinical care health care workers.

"Influenza-infected health care workers can transmit this deadly virus to vulnerable patients," she reasoned. "The complications of influenza are a particular burden to the elderly, immunocompromised, and critically ill and young children. Last time I checked, those are kind of the people that are in our hospital."

Another factor was influenza can be transmitted by both symptomatic and asymptomatic health care workers, so furloughing sick workers would not prevent all transmission. "Health care workers continue to work while they have influenza, exposing patients and colleagues," Perl added. The decision was difficult, but that is the nature of the balancing act required to proceed ethically in a crisis situation.

"I don’t think it’s clear — I don’t think it is black and white whatsoever," she told SHEA attendees. "We made the decision that we had to vaccinate health care workers first, but it was also very much [from] an academic medical center perspective that has an unbelievably high-risk patient population. We were bailed out. We were able to get both live attenuated as well as killed vaccine, so we didn’t end up implementing that very Draconian strategy."

Moreover, the ethical issues raised by the flu vaccine shortage would seem simple compared to the thorny mire faced in the wake of a bioterrorism attack, Perl noted. Following such an event, tough decisions will need to be made about who is going to receive the limited supply of antibiotics, vaccines, or other medical supplies.

"We recognize that we may be on our own for several days before we get any of these precious commodities," she said. "It becomes a little more complicated with a bioterrorism attack [because of] the whole issue of family members. With influenza, the risk to family is something that we can live with a little bit more. But I worry about it with [bioterrorism]. We would actually have people who would have ethical issues: Do I stay in the hospital and work?’ vs. Do I take my kids to the public health distribution center and make sure that they are protected?’"

If an institution commits to protecting health care workers’ families, a line of definition will have to be drawn. "There are issues around what is a family," Perl said. "Is a family your spouse? Is it your baby sitter who takes care of your kids?"

Tough choices have to be made, and unfortunately, in trying to do the right thing, ICPs know that money and resources always are an object. In a similar vein, the possible liability to the institutions always must be considered in the decision-making process.

"We have to protect the institution from unnecessary risk, and whether we like it or not, there are huge medical/legal and financial risks that we all weigh daily," Perl noted. "One of the things about ethical decisions is that it really does compel us to chose between our competing values. I think all of us struggle with the whole concept of justice and to do something fairly. We can’t identify all of the ethical dilemmas. We can hope that the decisions that we make lead to the best overall outcome. One of the problems is that we really never know. We do the best we can, but we really don’t know."

The ethics of isolation

Consider the longstanding practice of placing infected patients under isolation measures so that other patients will not become victims of cross-transmission. Straightforward enough, right? Yet the ethical implications of placing patients in isolation — even for infections as serious as methicillin-resistant Staphylococcus aureus (MRSA) — increasingly are being called into question in an era of heightened patient advocacy. In the last two years, several studies have concluded that patients in isolation may receive compromised care.

William Jarvis, MD, a former medical epidemiologist with the Centers for Disease Control and Prevention who now is a private consultant based in Hilton Head, SC, reviewed the studies at SHEA and took exception with some of the findings. In particular, he questioned the epidemiological rigor and statistical power of a highly publicized study that concluded, "patients isolated for infection control precautions experience more preventable adverse events, express greater dissatisfaction with their treatment, and have less documented care."¹

"They were looking at CDC isolation precautions, but it is not noted in this paper what the frequency of the compliance was," Jarvis said.

"As we have seen from other studies, precautions are oftentimes not fully implemented." That could skew the findings, which as reported were based on scant data, he noted. "We’re talking about 12 episodes vs. three episodes so the numbers here are exceedingly small. The adverse events that were being measured here were very infrequent events in both the populations studied, and yet this study is [frequently] mentioned and referenced to say, We shouldn’t place patients in isolation. It will have an adverse impact on them.’"

Two other studies show, however, that isolated patients may be less likely to be visited by surgeons and attending physicians. One study found that senior medical residents were unfazed by isolation, going in 87% of the time if the patient was not isolated and 84% if they were. In contrast, attending physicians went into the room only 35% of the time if the patient was isolated, as opposed to 73% if patients were not.²

"Attending physicians not willing to go in the room — that should be just unacceptable," Jarvis said.

Similarly, a study of surgeons found that isolated patients were visited fewer times (5.3 vs. 10.9 visits) and had less contact overall.³

"Clearly, surgeons were not going to go in the room if they had to gown and glove," Jarvis said. "And we have seen that in our intensive care units, where they don’t like to gown and glove or they like to gown and glove once and then go see everybody [without changing]."

Another side of the issue is that health care workers who fail to don protective gear when calling on infected patients put themselves and their families at risk, he noted.

"An important part of the ethical discussion that we’re having is that there are very good data now to show that health care workers taking care of these patients — particularly if they don’t comply well with the recommended precautions — do have increased risk of becoming MRSA culture-positive themselves," he said. "They have increased risk of transmitting MRSA to their family members and close associates at home and outside the hospital. Obviously, acquiring MRSA in the hospital is not a benign event for a health care worker."

Rational discrimination

In essence, placing a patient in contact isolation for MRSA infection is an act of reasoned "discrimination," Kaldjian noted. "There are reasons for deliberate discrimination," he explained.

"Discrimination has a bad name for good reasons, but if you think about being a discriminating connoisseur of wine that is a compliment, not a criticism. Likewise, we have a basis of discrimination when it comes to MRSA. We have a rational bias to differentiate one patient from another," Kaldjian added.

One aspect of justice is to treat similarly situated patients similarly, so it is fair to put an MRSA-positive patient in isolation if other patients would be treated similarly, he noted. That said, patients might increasingly question aspects of their care. Actions made for the "common good" have been eclipsed by a narrow focus on patient autonomy, Kaldjian explained.

"Patient autonomy is really the trump card of medical ethics today, for better or worse," he said. "But we should have very legitimate expectations that patients accept practices that decrease the risk of transmission, whether they are MRSA-positive or not."

As part of the SHEA session, speakers surveyed audience members with electronic voting equipment. Asked whether they thought isolation of MRSA patients "worsens their medical outcomes," 18% said yes, 60% no, and 22% were not sure. Kaldjian then asked, "If isolation does worsen medical outcomes, do you believe that patients who are MRSA-positive should have to accept the increased risk of poor outcomes because of isolation so that patients who are MRSA-negative can have a lower risk of acquiring MRSA?" The audience was divided, with 42% saying yes, 44% no, and 13% not sure.

"There are a number of [you] who think there are trade-offs in life and trade-offs in the hospital," he said, referring to those who answered yes. "People have to bear and share burdens."

References

1. Stelfox HT, Bates DW, Redelmeier DA. Safety of patients isolated for infection control. JAMA 2003; 290:1,899-1,905.
2. Saint S, Higgins LA, Nallamothu BK, et al. Do physicians examine patients in contact isolation less frequently: A brief report. Am J Infect Control 2003; 31:354-356.
3. Evans HL, Shaffer MM, Hughes MG, et al. Contact isolation in surgical patients: A barrier to care? Surgery 2003; 134:180-188.