With the holiday season upon us, in the US and globally, ICUs (Intensive Care Units) are still struggling with the deadly COVID-19 pandemic. For the first time in our history, hospital systems are forced to scramble to allocate scarce resources such as nursing, respiratory therapists, ICU beds, oxygenation, and drug treatments that lack adequate amount of literature support.

COVID-19 has drastically changed how end-of-life care is practiced in the intensive care unit (ICU). Safety concerns for society limits family visitation but is contrary to patient and family-oriented care. This article provides an ethical analysis of the pros and cons of having family members present at the death of a critically ill patient with COVID-19 and provides a framework that can be used in future surges.

She was breathing laboriously and had all but lost consciousness. In the subcutaneous tissues of her right arm, a syringe pump was delivering morphine and midazolam to help her breathe more easily and prevent the seizures she had been having earlier. Her right cheek still twitched periodically. She was in her daughter’s home surrounded by her grandsons and daughter. Just yesterday she had opened her eyes and smiled at her loved ones, tracking their movements.

COVID-19 has caused immense stress on physicians. Anesthesiologists and critical care physicians have been at the forefront of pandemic response, whether caring for critically ill patients or facilitating surgical procedures amidst significant uncertainty. Health care providers are particularly vulnerable to mental health issues amidst risk of exposure, longer work hours, shortages of personal protective equipment (PPE), challenging resource allocation decisions, stress of caring for their loved ones, threatened financial and job security, and an overall decrease in social interactions.

The biting cold winter in Minnesota did not feel any different in January, 2020, but for the news wildly circulating over the internet, television, radio, and social media of a novel coronavirus spreading in the Chinese city of Wuhan, which would later be termed SARS-CoV-2. Everywhere else, people continued their life with minimal worry. In the new millennium, other potential pandemic threats related to SARS (2003), H1N1 (2009), MERS (2012), and Ebola (2014-2016) were readily managed with routine infectious disease principles and did not disrupt our life to any significant extent.

The risk to healthcare providers of intubating patients with COVID-19 is a global concern, but data are scarce despite the presumably high risks. Surprisingly, the results of a recent study published in Anaesthesia by El-Boghadadly et al. suggest that the risk of transmission, hospitalization, and/or self-quarantine may be slightly higher than 10%!

The COVID-19 pandemic created a unique crisis in healthcare across the world. Due to the shortage of staff to cover surge intensive care units in many hospitals, the Society of Critical Care Medicine, among other organizations, recommended a tiered approach to forming surge capacity teams for coverage of additional critical care beds. These models seek to extend the expertise and oversight of intensivists, and other critical care professionals, to a greater number of patients via a multidisciplinary team.

Given the extraordinary disruption to training and medical practice caused by COVID-19, the American Board of Anesthesiology (ABA) has taken swift action to relax policies, offering increased flexibility for anesthesiologists. The Board has also worked to provide seamless access to educational and mental health resources for impacted physicians.

Natalia Ivascu, MD (Weill Cornell Medicine) and Jonathan Hastie, MD (Columbia University Vagelos College of Physicians and Surgeons) are critical care and adult cardiothoracic anesthesiologists in New York City. Their leadership of a coordinated COVID-19 pandemic response across the New York-Presbyterian health care system was recently featured in NEJM Catalyst.

Among its many impacts, COVID-19 has spawned a plethora of early data and literature. That which is not high-quality may hinder progress toward our understanding of the disease. Critical care and, more broadly, perioperative medicine are clinical arenas that generate massive volumes of data. As we routinely care for patients with COVID-19 in those settings, these data hold promise to further our understanding of the disease.

Nicole King is an anesthesiologist and critical care physician at the University of Cincinnati. She is currently obtaining her Executive Masters in Clinical Quality, Patient Safety and Leadership at Georgetown University. She answered a call for volunteers in New York and staffed a repurposed operating room intensive care unit for a month. While there, she chronicled her experience via e-mail. Excerpts from those e-mails are reproduced below. Only minor edits have been made where necessary for readability and to guard privacy.

The COVID-19 pandemic has raised many ethical and moral dilemmas in the realm of public health, social order, duty of care, and fair distribution of resources. Difficult decisions must be made about how, where, when, and to whom resources should be allocated. Physicians and health care workers are bound by a duty of care, therefore, obligations to the patient’s well-being are generally considered to be primary. This is grounded in the principle of beneficence, among others. There is also a reciprocal obligation placed on health systems to provide the best possible infection control modalities at the disposal of healthcare workers, to provide them preferential access to care should they become ill, and to consider the well-being of the families as critical to supporting healthcare workers.

Telework, or telecommuting, is an alternative work arrangement where “employees perform tasks elsewhere that are normally done in a primary or central workplace”. According to the US Bureau of Labor Statistics, more than 25 million people were telecommuting in 2018, and the number of telecommuters increased 115% between 2005 and 2015. Workplace social distancing, including telework, has been considered a possible mitigation strategy during influenza pandemics, and a number of companies and governments have encouraged workers to telecommute because of the current COVID-19 pandemic.

Of all the disruption created by Coronavirus Disease 2019 (COVID-19), nothing remains more constant than its enormous uncertainty. How the immediate and long-term future of the pandemic will play out remains unclear. Yet, it is certain that the world is now fundamentally different. COVID-19 has and will continue to adversely impact individual and population health, both directly and indirectly.