Circulation: Cardiovascular Quality and Outcomes

CARDIOVASCULAR PERSPECTIVE

Code Blue During the COVID-19 Pandemic

T
he surging coronavirus disease 2019 (COVID-19) pandemic has raised ethi- Paul S. Chan , MD, MSc
cal and moral dilemmas that Western nations with first-rate medical care Robert A. Berg, MD
facilities rarely confront—how to best allocate standard life-saving medical Vinay M. Nadkarni, MD,
resources when escalating demand outstrips supply. Sadly, these quandaries are MS
familiar challenges in resource-poor countries. What makes this pandemic notable
is that the scope and number of reported cases have been primarily in First World
nations, raising questions in some settings about the use of emergency treatments
like resuscitation care for in-hospital cardiac arrest (IHCA). This perspective reviews
the debate around these ethical and moral dilemmas more broadly but focuses
specifically on IHCA and the response of the medical community.
To date, the impact of the COVID-19 pandemic in the United States has varied
widely by region. Already in certain areas of the United States, hospitals have run
out of intensive care unit (ICU) beds and mechanical ventilators for patients and
Downloaded from http://ahajournals.org by on February 14, 2021

personal protective equipment (PPE) for healthcare providers. Like Italian physicians
in Lombardy before them, physicians are faced with decisions about rationing of
healthcare resources. Deontological ethics emphasize that each person is valuable
and should have an equal chance of receiving life-saving care (ie, first-come, first-
served). However, this framework in some instances is becoming an exercise of
abstract argumentation as clinicians may be forced to apply utilitarian ethics to
prioritize saving the most lives in settings with extremely limited resources.
But the disconnect is that, to date, physicians in the United States have had the
luxury to practice medicine with an individual rather than a societal perspective.
We have learned from and coveted our caring relationships with fellow human
beings, and we have been largely spared from confronting medical scarcity at the
bedside. By nature, training, and experience, we practice medicine in an ethical
framework of deontology and not utilitarianism. Yet that equation changes when
facing two patients with equal need but insufficient resources to care for both.
Choosing between which patient receives life-saving care when the alternative
outcome is certain death presents a situation of imminent moral distress.
Utilitarian decision-making has been the foundation with which some regions
in Italy have handled medical personnel and extreme resource scarcity. In their
document, “Clinical Ethics Recommendations for Allocation of Care in Resource-
The opinions expressed in this article are
Limited Circumstances,” 1 the Italian Scientific Society of Anesthesiologists, Inten- not necessarily those of the editors or
sivists, and Pain Therapists recommend setting an age limit during this pandemic of the American Heart Association.
by which to deny a patient a ventilator and an ICU bed so as to maximize the ben- Key Words:  emergency treatment
efit of limited intensive care resources for the greatest number of patients. Others ◼ ethics ◼ pandemic ◼ personal
in the United States have also advocated for a rationing approach in the setting of protective equipment ◼ resuscitation

ventilator and ICU bed scarcity.2–4 Critical to these policies is that these guidelines © 2020 American Heart Association, Inc.
are set by ethics teams and provide a framework by which physicians abide. Such https://www.ahajournals.org/journal/
guiding principles permit physicians during this pandemic to exit the deontological circoutcomes

Circ Cardiovasc Qual Outcomes. 2020;13:e006779. DOI: 10.1161/CIRCOUTCOMES.120.006779 May 2020 261
 Chan et al; Code Blue in the COVID-19 Pandemic
framework by which they have always practiced and
provide them some protection from the moral anguish
in the impossible treatment decisions to be made.
In this ethical context, the management of IHCA,
which affects an estimated 300 000 hospitalized patients
in the United States annually in a nonpandemic year, is
ever more important to address. IHCA is a medical emer-
gency where prompt response and treatment are criti-
cal. In normal times, more than 1 in 5 patients with an
IHCA survive to hospital discharge—a marked improve-
ment from just 2 decades ago when 1 in 8 survived to
discharge.5 During the COVID-19 pandemic, survival is
expected to be much lower as there will be substantial
delays in delivering potentially life-saving cardiopulmo-
nary resuscitation (CPR) during the first minutes after
IHCA as healthcare providers don PPE before initiating
resuscitations. Given the expected shortage of ventilators
and ICU beds for patients and PPE for providers in some
US regions, some have even advocated do-not-attempt-
resuscitate/allow natural death orders for all patients with
COVID-19 irrespective of patient preferences or progno-
sis.6 Other hospitals have instituted policies delaying ini-
tiation of critical chest compressions until a patient with
IHCA has been intubated because of the concern that
CPR is an aerosol-generating procedure and thus may
endanger the health care provider. The time necessary
for arrival at a patient’s room, donning PPE, and securing
an invasive airway may delay CPR by up to 10 minutes.
Based on data from delays in CPR initiation for out-of-
Downloaded from http://ahajournals.org by on February 14, 2021
hospital cardiac arrests, deferring initiation of CPR for 10
minutes may decrease IHCA survival to far below 10%
for all patients irrespective of COVID-19 status.
As leaders in resuscitation science, we understand
and appreciate concerns with resuscitation care dur-
ing the COVID-19 pandemic. Yet we think there is a
way to implement a more nuanced and contextualized
approach to Code Blue responses for IHCA to balance
ethics, healthcare provider safety, and scarce resources.
To start, we think hospitals should implement policies
to clarify patients’ advanced directives and their COV-
ID-19 status as soon as possible. All admitted patients
regardless of COVID-19 status should have meaningful
discussions about goals of care and do-not-attempt-
resuscitate/allow natural death status on admission.
Next, resource management during an IHCA will vary
depending on whether one’s hospital is confronted with
imminent and extreme resource scarcity. For hospitals
not in an extreme COVID-19 case surge but with moder-
ate to high COVID-19 prevalence in the community and
that have adequate ventilator and ICU bed capacity and
PPE for the foreseeable future, a reasonable approach
for IHCA resuscitations can be as follows. Among
patients with suspected or confirmed COVID-19 dis-
ease, medical providers should don PPE before resuscita-
tions. This is to protect healthcare providers as the Italian
experience has shown that 1 in 6 hospitalized patients
Circ Cardiovasc Qual Outcomes. 2020;13:e006779. DOI: 10.1161/CIRCOUTCOMES.120.006779
with COVID-19 is a healthcare worker.7 However, initia-
tion of CPR—an aerosolizing procedure—should not be
delayed before securing an invasive airway, as this will
unnecessarily deprive the patient of life-saving CPR as
medical providers will already be in PPE. PPE, however,
should be conserved; thus, the total number of provid-
ers in the resuscitation room should be limited to essen-
tial individuals for delivering CPR, securing an airway,
administering intravenous drugs, and obtaining central
venous access if needed. For patients whose COVID-19
status is unknown, resuscitation team members should
still don PPE to protect themselves given that COVID-19
transmission can occur from asymptomatic patients.
For hospitals in the midst of an overwhelming COV-
ID-19 surge with an existing or imminent shortage of
ventilators, ICU beds, and PPE, we expect systems to con-
sider instituting a utilitarian approach to guide whether
or not to resuscitate any patient with IHCA, irrespective of
COVID-19 status. To accomplish this, each hospital may
need to organize an ethics team comprised of a physi-
cian, nurse, respiratory therapist, and ethicist to develop
written protocols and review all admitted patients who
are not do-not-attempt-resuscitate/allow natural death
during a hospitalization and determine whether, in the
event of cardiac arrest, the patient should undergo resus-
citation efforts or be made do-not-attempt-resuscitate/
allow natural death. If the latter, the patient would be
informed as to the decision and the rationale. Alloca-
tion criteria could include evidence-based criteria such as
age and comorbidities and evolve as epidemiology and
outcomes data emerge. Such allocation criteria would
be based on a patient’s expected number of years of
life left to be lived and should be agnostic to race, sex,
income, and position in society. The criteria ought to be
reviewed regularly as treatment and knowledge about
COVID-19 evolves and as hospital resources change.
And if resources do not allow for this to occur for each
admitted patient, a hospital’s ethics team may choose to
focus on patients at the highest risk for clinical decline
and IHCA—for example, patients who are ventilated and
on intravenous vasopressors. In so doing, the ethics team
will relieve individual responding healthcare providers of
the responsibility in making rationing decisions—ration-
ing decisions which will nonetheless occur when scarce
resources in these settings are allocated on a first-come,
first-served deontological framework. Unfortunately, in
some settings, the already dire circumstances may pre-
clude such an approach due to manpower.
Even for patients who are already on a ventila-
tor, hospitals’ allocation criteria in areas with extreme
resource scarcity could also recommend no resuscita-
tive efforts if the likelihood of survival is expected to
be extremely low to make available resources for oth-
ers. Within Get With The Guidelines-Resuscitation, we
know that patients 80 years of age or older who have
an IHCA while on a ventilator with an initial rhythm
May 2020 262
 Chan et al; Code Blue in the COVID-19 Pandemic
or asystole or pulseless electrical activity and concur-
rent pneumonia or sepsis have only a 3.7% likelihood
of survival without severe neurological disability. If they
are also on an intravenous vasopressor, that likelihood
decreases to 2.7%. That translates to a number needed
to resuscitate of 27 and 37, respectively. And in patients
with COVID-19, these rates are expected to be lower
as significant delays in initiating CPR are likely. Such
considerations in a setting of extreme resource scarcity
during a COVID-19 surge will ensure what limited ICU
resources exist are maximized for the greatest societal
benefit.
These are unprecedented times, and we must plan
for the challenges ahead. When confronted with
extreme resource scarcity, rationing will occur regardless
of whether one approaches the current COVID-19 crisis
with a deontological or a utilitarian ethics framework.
We are hopeful that hospitals can avoid the extreme
policy of not performing resuscitations on any patient
with IHCA regardless of prognosis, as some hospitals
are envisioning. In any case, the lack of a systematic
approach with clearly defined allocation criteria at hos-
pitals with extreme resource scarcity will lead to ineffi-
cient use of medical therapies and deplete PPE, putting
both patients’ and providers’ lives on the line.
ARTICLE INFORMATION
Correspondence
Downloaded from http://ahajournals.org by on February 14, 2021
Paul S. Chan, MD, MSc, St Luke’s Mid America Heart Institute, 9th Floor, 4401
Wornall Rd, Kansas City, MO 64111. Email pchan@saint-lukes.org
Affiliations
Saint Luke’s Mid America Heart Institute and University of Missouri, Kansas City
(P.S.C.). The Children’s Hospital of Philadelphia, University of Pennsylvania Perel-
man School of Medicine, Philadelphia (R.A.B., V.M.N.).
Circ Cardiovasc Qual Outcomes. 2020;13:e006779. DOI: 10.1161/CIRCOUTCOMES.120.006779
Sources of Funding
Dr Chan is supported by an R01 grant (1R01HL123980) from the National
Heart Lung and Blood Institute.
Disclosures
This viewpoint reflects the personal opinions of the authors and do not repre-
sent the committees or organizations for which they serve as volunteers, such
as the American Heart Association, the American College of Cardiology, ILCOR,
the Society of Critical Care Medicine, or the Citizen CPR Foundation.
REFERENCES
1. Vergano M, Bertolini G, Giannini A, Gristina G, Livigni S, Mistraletti G,
Petrini F. Clinical ethics recommendations for allocation of care of inten-
sive-care treatments in exceptional resource-limited circumstances. Italian
Scientific Society of Anesthesiologists, Intensivists, and Pain Therapists.
2020. Available at: http://www.siaarti.it/SiteAssets/News/COVID19%20
-%20documenti%20SIAARTI/SIAARTI%20-%20Covid-19%20-%20Clin-
ical%20Ethics%20Reccomendations.pdf. Accessed March 26, 2020.
2. Daugherty Biddison EL, Faden R, Gwon HS, Mareiniss DP, Regenberg AC,
Schoch-Spana M, Schwartz J, Toner ES. Too many patients…A framework
to guide statewide allocation of scarce mechanical ventilation during di-
sasters. Chest. 2019;155:848–854. doi: 10.1016/j.chest.2018.09.025
3. White DB, Lo B. A framework for rationing ventilators and critical care
beds during the COVID-19 pandemic [published online March 27, 2020].
JAMA. doi: 10.1001/jama.2020.5046
4. Emanuel EJ, Persad G, Upshur R, Thome B, Parker M, Glickman A,
Zhang C, Boyle C, Smith M, Phillips JP. Fair allocation of scarce medical
resources in the time of Covid-19 [published online March 23, 2020]. N
Engl J Med. 2020. doi: 10.1056/NEJMsb2005114
5. Girotra S, Nallamothu BK, Spertus JA, Li Y, Krumholz HM, Chan PS;
American Heart Association Get with the Guidelines–Resuscitation Inves-
tigators. Trends in survival after in-hospital cardiac arrest. N Engl J Med.
2012;367:1912–1920. doi: 10.1056/NEJMoa1109148
6. Cha AE. Hospitals consider universal do-not-resuscitate orders for coro-
navirus patients. The Washington Post. 2020. Available at: https://www.
washingtonpost.com/health/2020/03/25/coronavirus-patients-do-not-
resucitate/. Accessed April 1, 2020.
7. International Council of Nurses. High proportion of healthcare workers
with COVID-19 in Italy is a stark warning to the world: protecting nurses
and their colleagues must be the number one priority. Available at: https://
www.icn.ch/news/high-proportion-healthcare-workers-covid-19-italy-
stark-warning-world-protecting-nurses-and. Accessed April 1, 2020.
May 2020 263