Karachi Bioethics Group Meetings 2020

Concise Minutes of the Karachi Bioethics Group (KBG) Meeting held in 2020

Date: Monday, February 03, 2020

Time: 8.30 am – 10.00 am 

1. Introduction to Indus Hospital, Clinical Ethics Committee and Karachi Bioethics Group: by Dr. Nuzhat Irfan Malik

Dr. Nuzhat Irfan Malik, Radiologist, The Indus Hospital, gave a presentation to update all participants, on how The Indus Hospital is aligning its vision and values in the provision of healthcare and the vital role CEC is playing. Activities like KBG meetings are also examples of such initiatives. It was heartening to note the active participation from the Nursing staff and students, and it was encouraged to involve residents for more active participation.

2. Case Discussion — CPR on children presenting with near-drowning / immersion in Pediatric Emergency.

Dr. Saba Laila, Consultant Pediatrician, and lead of the Pediatric ER at The Indus Hospital, presented a case of an eleven-month-old child who remained immersed in a bucket for 15 minutes and was brought to the ER by parents. He was unresponsive and cyanosed. After receiving cardiopulmonary resuscitation (CPR) for 20 minutes, the patient was revived and admitted to ICU on ventilator support. During hospitalization, he had 3 episodes of generalized tonic-clonic seizures with poor outcomes for the child due to neurological injury secondary to hypoxial insult to the brain. CT scan findings were consistent with global hypoxic-ischemic encephalopathy. Parents were concerned about the quality of life of their children. The questions disturbing the clinical team were as follows:

• Should we not have done CPR on this patient?
• The long-term neurological outcome is usually poor in such patients. So are we wasting our resources on such patients who have bad outcomes compared to those who have better?
• How can we counsel patients in a busy emergency regarding short and long-term complications?

3. Case Discussion – Challenges in long-term management of children with Critical Illness

Dr. Saba Shahid, Senior Pedestrian at The Indus Hospital, described a case of a 6-month-old male child who was admitted with complaints of fever, cough, and lethargy. Earlier, he was diagnosed as having Pneumonia, he was put on a mechanical ventilator and was discharged after 7 days. His parents kept him at home but realized that he was not taking feed, so they brought him to TIH. Father works in a garment factory. The parents recently got separated and the child was living with his phuppo. Examination showed that the child was hypotonic and a diagnosis of Spinal Muscular Atrophy (SMA) was made. During hospital stay. Phupu took care of the child. When arrangements for discharge were being made, the aunt wanted the mother to come but according to the father, she refused. On the evening before discharge father came to see the child, had an argument, and tried to strangulate the child. This was anecdotal and there was no witness. 

Ethical Concerns were: 

• Whom should the child be handed over to?
• What can the hospital do to safeguard the child’s security?
• To what extent should the doctor pursue?

*****

Date: Monday, June 8, 2020

Time: 8.45 am – 10.00 am 

1. Discussion on “The New Normal – Some Experiences from the Frontline”: by Dr. Robyna Khan

Dr. Robyna Khan, Anesthesiologist and Bioethicist at Aga Khan University deliberated on how life has changed during this COVID pandemic; there was an initial phase where everyone was mind-blocked and, now the second phase where our clinical and social approaches have changed and this is what defines the new normal. 

2. Presentation on “The Ethics of Care for Non-COVID Patients during a Pandemic – outpatient experience” by Dr. Ruhma Ashraf 

Dr. Ruhma Ashraf, Associate Consultant, Family Medicine at The Indus Health Network, explained how the dynamics of NON-COVID patient care have changed during this Pandemic. She shared her clinical and ethical experiences as a Family Physician at The Indus Hospital, working on the frontlines, and taking care of patients with problems other than COVID. She detailed the processes developed to cater to patient care from across the country for reasons other than COVID and issues faced at screening and during teleconsultations with the help of scenarios.

The first scenario was of the patient who despite not having any symptoms or contact with COVID and falling into the category of low risk, wanted herself and the entire family tested because the hype made it extremely difficult for the staff to explain how we were managing to function with limited kits available. Challenges highlighted were handling and communicating with anxious and angry patients as well as stress and anxiety in healthcare professionals, especially the residents and the junior doctors who are on the verge of quitting their jobs. Another challenge was the problem of referral because of patchy information and improper dissemination of SOPs and guidelines. The challenge of providing care or referring patients with problems other than COVID was also creating moral distress because the hospitals have restricted clinical activities and services other than COVID.

She then talked about another scenario where a patient was diagnosed with GI malignancy and was in the initial stages of management when due to lockdown the clinical services stopped and patient care got affected. Upon consulting the patient over the phone, the physician was informed by the son that the patient passed away a few days ago. This raised the question “Whether this death was avoidable?” The focus of managing only acutely ill patients, and Non-Covid patients being put to low priority is evidently challenging. Also, reluctance and delay in seeking medical care by the patients can have detrimental impacts on health and disease parameters because of fear of the virus. The teleconsultations being done on the phone were not providing the same therapeutic humane effect and the threat to autonomy and privacy is increasing. Dr Ruhma mentioned some strategies that have been adopted for tackling these issues like counselling sessions for healthcare providers to allay their anxiety, provision of stress-free zones, and putting systems in place for clinical services.

The questions disturbing the physicians were 

1. How do we ensure justice and equity for ALL patients during this pandemic?
2. Is restricting medical care to non-covid patients medically and ethically sustainable in the long run?

*****

Date: August 10, 2020

Time: 8.45 am – 10.20 am 

1. Scenario-Based Discussion on Access and Health Equity during a Pandemic  — Dr. Nuzhat Irfan Malik (Radiologist, Chair, CEC, The Indus Hospital) 

Dr. Nuzhat Irfan Malik’s topic was based on her experience with how we are internalizing and starting to take things in life differently during this COVID-19 pandemic. We all are in different phases according to our personal and professional experiences and these experiences have created new ethical questions about health access and equity with new contexts.

She started with a scenario where during the pandemic, there was availability of just one bed for two patients in the COVID emergency room of the hospital, and one of them was the father of the healthcare provider working at the hospital while the other was not. On request of Dr. Farhat Moazzam and Dr. Aamir Jafarey, she further elaborated to give more context; age, co-morbidities, and other medical parameters which were similar and both demanded immediate medical attention for COVID.

2. Case(s) Discussion on Ventilator Support … Whose preference should it be? Patient vs Family or Physician — Dr. Sohail Akhtar (Senior Consultant, Pulmonology, The Indus Hospital)

Dr. Sohail Akhtar, Senior Consultant, Pulmonology at The Indus Health Network, started by sharing his and his team’s experiences with real-life situations in the management of COVID patients. He presented 3 cases followed by questions and then invited members to initiate discussion. The cases had one thing in common and it was regarding the patient’s consent to be ventilated but the context differed. 

Cases 1 and 2: The patients refused ventilation (did not sign the DNI forms, refusal was verbal) but were ventilated due to family pressure. The clinical conditions were such that recovery seemed remote and the treating medical team was of the same opinion as the patients.

Case 3: The patient in full senses and with clear understanding, consented to intubation and was ventilated. However, the family thought that permission should have been sought from them and they were to decide rather than the patient.

Questions:

1. Whose right is it, to decide about ventilation, and similar critical issues?
2. If the family’s decision is different from the patient’s, can it be overrun?
3. If treating doctors’ assessment is opposite to the consent given (either patient or family), how justified are they to convince them to change?
4. If the family pressurizes the physician to remove the patient from ventilation because of different ideas, what should the treating physician do in a) if the prognosis is reasonably good b) if the prognosis is poor?

*****

Date: Monday October 05, 2020

Time: 8.50 am – 10.15 am 

1. Scenario-Based Presentation on Ethical Issues of Obstetric Care in COVID-19 by Dr. Ayesha Saba (Consultant, Obstetrics & Gynecology, The Indus Hospital, Karachi) 

The theme for this KBG meeting was related to maternal health issues faced during the COVID-19 Pandemic. In this background, based on her and her team’s experience with the management of patients during this critical time, Dr. Ayesha Saba shared a real-life scenario, and a discussion was held around the issues faced. She discussed a case of a 38-year-old woman, primigravida, unbooked at the hospital, who presented in ER with severe abdominal pain and vaginal bleeding. She was hemodynamically unstable but stabilized with immediate intervention. Diagnosis of placental abruption and COVID-19 pneumonia was made. To save the life of the mother, an emergency C-section was planned. The family was counseled regarding critical conditions and poor fetal and maternal outcomes. High-risk consent was taken from the family regarding anesthesia and surgery risk along with prolonged ICU stay and its sequelae. It was decided to shift the patient to the Operation Room. However, there were limitations in having a fully equipped OR with negative pressure ventilation and exposing the minimum number of healthcare providers. It was an IUD; the baby could not be saved but the mother was saved and kept on ventilator support in COVID-ICU. However, she also passed away on the 12^th day of surgery due to pulmonary embolism. So, the challenges were: the limitation of resources like not having a fully equipped negative pressure ventilation system for COVID patients and the moral pressure of exposing about 6-8 health care providers who may or may not be willing to risk themselves. There was no issue of PPE though.

2. Presentation on Ethical Challenges of Privacy, Confidentiality and Misinformation  around COVID-19 and its Effects on Quality  of Maternal Health Services by Neha Mankani (Senior Manager, Maternal Health, MNCH, Nutrition, Global Health Directorate, Indus Health Network)

In continuation of the theme related to Maternal Health, Ms. Neha Mankani spoke about the issues she handled in the community settings. She brought her diverse experience of women in various communities she and her team approached during the COVID outbreak. Ms. Neha described the impact of COVID-19 on outcomes of Maternal Health Services very comprehensively. Some of the pertinent points are as follows:

• Rumors around hospital management of Covid-19 leading to distrust of healthcare facilities
• Slow flow of information causing alteration of practices without evidence
• Fear among healthcare providers, refusing to accept women, separation of mother and baby
• Fear of testing pregnant women for fear of positive results
• Inequity in PPE and safety measures for staff causing low intrapartum surveillance, forcing women for C-sections, untrained staff managing labor rooms
• Reduced hours or closure of facilities without prior notice
• Increased interventions to speed up labor
• Neglect, abandonment, restriction. access to care 
• Acts curtailing women’s decision-making autonomy: unavailability of contraceptive devices, closure of Reproductive Health Service centers

3. Mobile Application for Bioethics

Dr. Tashfeen Ahmad, Chair-Bioethics Group, AKU, introduced an app for Bioethics developed by The Aga Khan University for Just-in-Time learning. People facing ethical dilemmas during their work and studies can post on the App anonymously, and a pool of facilitators can respond, thus generating a discussion. The app also has a list of resources. It was initially restricted to AKU, but it is open to external users now. The app was used for a research project, and the contents had to be deleted for confidentiality reasons, but it will be repopulated soon, as posts come in. KBG members are invited to download, use the app and give suggestions, and recommend it to trainees. AKU maintains anonymity, and a strict code of conduct is followed in the postings.

The links to download the app are:
https://play.google.com/store/apps/details?id=com.aku.bioethicsethakul&hl=en
https://apps.apple.com/az/app/ethakul/id1437160199
For problems, please write to bioethics.group@aku.edu

*****

Date: Monday December 14, 2020

Time: 8.45 am – 10.00 am 

1. Presentation on the Role of Nurses on the Frontline during the COVID-19 Pandemic by Ms. Rashida Merchant (Director, Nursing Services, Indus Health Network)

The theme for this KBG meeting was specifically related to Nurses…a very important yet overlooked section of healthcare professionals in Pakistan. With this context, Ms. Rashida Merchant was invited to present on the role of Nurses at The Indus Hospital (and beyond). She elaborately presented the medical, moral and administrative issues faced by the Nurses during the COVID-19 Pandemic. Based on her and her team’s experience, she discussed the critical role in managing not only patients and their families, but also how they handled their peers and themselves during this crucial time, and still are. With the help of real-life scenarios and situations, initially, she gave a background of administrative and clinical challenges the nursing teams were facing at the hospital in general and with COVID in particular. She explained how the team members gave continuous duties of 24-36 hours with COVID patients and covered for their peers’ absenteeism despite having internal fear and anxiety; supervisors handled personnel with those who were not experienced or skilled with the tasks in rapid turnover; managers who provided all possible support in terms of incentivizing, appreciating with gestures and gifts, creating spaces for destressing; and leadership in planning and mobilizing the resources, be it PPE, equipment, skilled human resource, or even food and clothes; hence, how all these things affected (perhaps may have helped) the moral values and motivation of the nursing staff.