DOI: 10.1161/CIRCOUTCOMES.120.

006779

Code Blue During the COVID-19 Pandemic

Paul S. Chan, MD, MSc1; Robert A. Berg, MD2; Vinay M. Nadkarni, MD, MS2

1
Saint Luke’s Mid America Heart Institute and University of Missouri, Kansas City, MO; 2The

Children’s Hospital of Philadelphia and the University of Pennsylvania Perelman School of

Medicine, Philadelphia, PA
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Address for correspondence:

Paul S. Chan, MD, MSc

Saint Luke’s Mid America Heart Institute

9th Floor, 4401 Wornall Rd.

Kansas City, MO 64111

Email: pchan@saint-lukes.org

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 DOI: 10.1161/CIRCOUTCOMES.120.006779

The surging COVID-19 pandemic has raised ethical and moral dilemmas that Western

nations with first-rate medical care facilities rarely confront—how to best allocate standard life-

saving medical resources when escalating demand outstrips supply. Sadly, these quandaries are

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 U.S. has varied widely by region.

Already in certain areas of the U.S., hospitals have run out of intensive care unit (ICU) beds and

mechanical ventilators for patients and personal protective equipment (PPE) for healthcare
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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 (i.e., “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 U.S. 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

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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-Limited Circumstances”,1 the

Italian Scientific Society of Anesthesiologists, Intensivists, and Pain Therapists recommend

setting an age limit during this pandemic by which to deny a patient a ventilator and an ICU bed

so as to maximize the benefit of limited intensive care resources for the greatest number of

patients. Others in the U.S. have also advocated for a rationing approach in the setting of

ventilator and ICU bed scarcity.2-4 Critical to these policies is that these guidelines are set by

ethics teams and provide a framework by which physicians abide. Such guiding principles permit
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physicians during this pandemic to exit the deontological 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 U.S. annually in a non-pandemic year, is ever more important to

address. IHCA is a medical emergency where prompt response and treatment are critical. In

normal times, more than 1 in 5 patients with an IHCA survive to hospital discharge—a marked

improvement from just two 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 CPR during the first minutes after IHCA as healthcare

providers don PPE prior to initiating resuscitations. Given the expected shortage of ventilators

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and ICU beds for patients and PPE for providers in some U.S. regions, some have even

advocated Do-Not-Attempt-Resuscitate (DNAR)/Allow Natural Death (AND) orders for all

COVID-19 patients irrespective of patient preferences or progniosis.6 Other hospitals have

instituted policies delaying initiation 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-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 during the COVID-19 pandemic. Yet we believe there is a way to implement a
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more nuanced and contextualized approach to Code Blue responses for IHCA in order to balance

ethics, healthcare provider safety, and scarce resources. To start, we believe hospitals should

implement policies to clarify patients’ advanced directives and their COVID-19 status as soon as

possible. All admitted patients regardless of COVID-19 status should have meaningful

discussions about goals of care and DNAR/AND 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 moderate 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 disease, medical providers should don PPE prior to

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resuscitations. This is to protect healthcare providers as the Italian experience has shown that 1 in

6 hospitalized patients with COVID-19 are healthcare workers.7 However, initiation 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 providers in the resuscitation room

should be limited to essential 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 COVID-19 surge with an existing or

imminent shortage of ventilators, ICU beds, and PPE, we expect systems to consider instituting a

utilitarian approach to guide whether or not to resuscitate any patient with IHCA, irrespective of
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COVID-19 status. To accomplish this, each hospital may need to organize an ethics team

comprised of a physician, nurse, respiratory therapist, and ethicist to develop written protocols

and review all admitted patients who are not DNAR/AND during a hospitalization and determine

whether, in the event of cardiac arrest, the patient should undergo resuscitation efforts or be

made DNAR/AND. If the latter, the patient would be informed as to the decision and the

rationale. Allocation 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

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patients at highest risk for clinical decline and IHCA– e.g., 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—rationing 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 preclude such an approach due to manpower.

Even for patients who are already on a ventilator, hospitals’ allocation criteria in areas

with extreme resource scarcity could also recommend no resuscitative efforts if the likelihood of

survival is expected to be extremely low to make available resources for others. Within GWTG-

Resuscitation, we know that patients 80 years of age or older who have an IHCA while on a

ventilator with an initial rhythm or asystole or pulseless electrical activity and concurrent

pneumonia or sepsis have only a 3.7% likelihood of survival without severe neurological
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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 hospitals with

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extreme resource scarcity will lead to inefficient use of medical therapies and deplete PPE,

putting both patients’ and providers’ lives on the line.

Funding Sources: Dr. Chan is supported by an R01 grant (1R01HL123980) from the National

Heart Lung and Blood Institute.

Disclosures: None of the authors have any financial conflicts of interest to disclose. This

viewpoint reflects the personal opinions of the authors and do not represent 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
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