There were 261 physician responses with a completion rate of 84%. Respondents worked in Canada (98.2%), at hospitals with greater than 400 beds (71.7%), in emergency medicine (68.9%), and critical care (32.9%), treating adults (94.5%), and children (44.3%).10 Residents and clinical fellows constituted 23.3% of all responses, with the remainder being staff physicians. Respondents were evenly distributed across seniority categories (0–5 years 27.9%, 6–10 years 25.6%, 10–15 years 15.6%, more than 15 years 31.1%).
Most respondents (86.1%) felt confident or very confident in performing their clinical role in the pandemic. Only 48.7% felt confident or very confident in their ability to decide who should get a ventilator if resources were scarce. Factors associated with greater confidence in triaging ventilators included knowledge (91.2%), hospital policies (48.7%), existing evidence (77.0%), and consultation with other physicians (76.1%). Factors associated with a lack of confidence included lack of knowledge (50.0%), lack of previous experience triaging critical care resources (71.2%), medicolegal liability concerns (57.7%), ethical (75.0%), and personal moral concerns (69.2%).
Between group comparisons found that residents were less confident than attendings in their role (p<0.001) and ability to triage critical care resources (p<0.001). Critical care physicians were more confident than emergency physicians in their role (4.5/5 vs 4.1/5 p = 0.001) and ability to triage scarce resources (3.7/5 vs 3.2/5, p = 0.001).
Both critical care and emergency physicians favored multidisciplinary teams over single physicians to allocate scarce critical care resources in crisis scenarios but differed with respect to most responsible physician (MRP) inclusion (Table 1). Critical care physicians were more likely to favor decision making by teams not involved in patient care (3.4/5 vs 2.9/5 p = 0.04) compared to emergency physicians who preferred to maintain MRP involvement (3.4/5 vs 4.0/5 p = 0.007).
Table 1 Critical care resource allocation decision making (n= 221)
|
Number (%)
|
|
Strongly Disagree
(1)
|
Somewhat Disagree
(2)
|
Neutral
(3)
|
Somewhat Agree
(4)
|
Strongly Agree
(5)
|
|
MRP
|
46 (20.8)
|
45 (20.4)
|
44 (19.9)
|
61 (27.6)
|
25 (11.3)
|
|
Multidisciplinary team, including MRP
|
12 (5.4)
|
21 (9.5)
|
30 (13.6)
|
77 (34.8)
|
81 (36.7)
|
|
Multidisciplinary team, not involved in patient care
|
47 (21.3)
|
45 (20.4)
|
27 (12.2)
|
45 (20.4)
|
57 (25.8)
|
|
Single triage physician not involved in patient care
|
94 (42.5)
|
56 (25.3)
|
34 (15.4)
|
26 (11.8)
|
11 (5.0)
|
|
MRP = most responsible physician (involved in patient care)
Most respondents reported feeling anxious due to the pandemic (6.4% not at all anxious, 21.0% somewhat anxious, 28.3% neutral, 39.3% moderately anxious, 5.0% very anxious). Many physicians had concerns about the negative psychological impact that engaging in critical care resource allocation may result in (7.4% not at all concerned, 19.7% somewhat concerned, 15.7% neutral, 35.8% moderately concerned, 21.4% very concerned).
Respondents reported high levels of confidence in the surge-capacity of their health system to meet demands for critical care resources in COVID–19, with 13.7% not at all or somewhat confident, and 67.6% confident or very confident. Additionally, COVID–19 was found to have bolstered Canadian physician commitment to their medical careers with 40.2% more committed and 9.6% less committed.
Five themes were identified by consensus from responses to the free text question: “What resources would be helpful to reduce moral distress and the negative psychological impact of triaging critical care resources?”. Themes included the need for guidance on existing triage policies, bioethicist support in decision making, health care provider medico-legal protection, therapeutic communications support, and peer-support and physician psychological services.
First, respondents requested a clear policy or guideline endorsed by a professional association or government. They requested that guidelines be evidence based, and easy to use, noting that existing guidelines are too vague and complex to be used in a crisis setting. A need for consistency and review of provincial and regional protocols, along with educational outreach to disseminate established protocols was also noted.
Second, respondents were aligned in their desire to have teams, rather than individuals, make triage decisions. Many desired a bioethicist to be part of these teams. While most physicians wanted third-party teams to make triage decision, some expressed a desire to be a part of the decision making process for the patients they were caring for.
Third, respondents expressed concern that their involvement in triage decisions may result in civil litigation or regulatory body discipline. They requested the support of their hospitals, professional colleges, and regulatory bodies along with the “legislative protection of health care providers involved in making such decisions”.
Fourth, respondents felt ill-equipped to have conversations with patients and families about resource triage decisions. Many worried that there would be no time to communicate with patients and families if there was an overwhelming surge in patients. Supports such as scripts, “written materials to give to patients and families”, allied health professionals including social workers were desired.
Lastly, respondents were worried for their own mental health if faced with an overwhelming demand for critical care resources, with many referencing the events in China, Italy and New York as current stressors. Clinicians acknowledged the great psychological burden placed on them if forced to ration critical care resources, with one describing it as “unprecedented and antithetical to Canadian healthcare”.Suggested interventions to support mental wellbeing, including peer support teams, professional counselling and formal debriefing were requested.