COVID-19 resources: Leadership/Ethics

In this article published in the Australian Financial Review (April 2, 2020), Dr Michelle Mulligan, FANZCA reflects on her leadership role in pandemic planning at a major Sydney hospital in the lead up to the anticipated surge in affected patients and staff.

Summary.
Replete with both complexity and change, crises require executives to both lead and manage effectively. But more often than not, leaders tend to focus their efforts on management, rather than leadership.The most effective leaders in crises ensure that someone else is managing the present well while focusing their attention on leading beyond the crisis toward a more promising future. The authors identify four traps that most leaders fall into: 1) taking a narrow view; 2) getting seduced by managing; 3) over-centralizing the response; and 4) forgetting the human factor

Summary.
When contending with a crisis like the ongoing pandemic, leaders can easily fall into the traps of waiting for the situation to clarify how to act and downplaying the threat in order to reassure people. It turns out that these instincts mean failing the coronavirus leadership test. Passing that test requires leaders to act in an urgent, honest, and iterative fashion, recognizing that mistakes are inevitable and correcting course — not assigning blame.

Summary.
Leaders are under extraordinary pressure right now. They are expected to make decisions quickly with incomplete and rapidly evolving information. And unfortunately, being in crisis mode can cause even the most intentional and well-meaning leaders to fall into patterns of bias and exclusion. Research shows that when we’re stressed, we often default to heuristics and gut instincts, rather than making deliberate and goal-oriented decisions

The New Yorker Magazine is providing free open access to all articles published on the COVID 19 pandemic. In this article Atul Gawande appraises leadership in countries recognised for success in Keeping the Coronavirus from Infecting Health-Care Workers.

Abstract.
We describe an evidence-based approach to enhancing the resilience of healthcare workers in preparation for an influenza pandemic, based on evidence about the stress associated with working in healthcare during the SARS outbreak. SARS was associated with significant long-term stress in healthcare workers, but not with increased mental illness. Reducing pandemic-related stress may best be accomplished through interventions designed to enhance resilience in psychologically healthy people. Applicable models to improve adaptation in individuals include Folkman and Greer's framework for stress appraisal and coping along with psychological first aid. Resilience is supported at an organizational level by effective training and support, development of material and relational reserves, effective leadership, the effects of the characteristics of "magnet hospitals," and a culture of organizational justice. Evidence supports the goal of developing and maintaining an organizational culture of resilience in order to reduce the expected stress of an influenza pandemic on healthcare workers. This recommendation goes well beyond the provision of adequate training and counseling. Although the severity of a pandemic is unpredictable, this effort is not likely to be wasted because it will also support the health of both patients and staff in normal times.

When I ask groups of managers what makes a good leader, I seldom have to wait long before someone says, “Vision!” and everyone nods. I have asked that question countless times for the past 20 years, to cohorts of senior executives, middle managers, and young students from many different sectors, industries, backgrounds, and countries. The answer is always the same: A vision inspires and moves people. Expansion, domination, freedom, equality, salvation — whatever it is, if a leader’s vision gives us direction and hope, we will follow. If you don’t have one, you can’t call yourself a leader.

Central tenets of clinical management include consultation with colleagues, patients and families, establishment of goals of care with the consideration of treatment options and potential outcomes, respect for individual autonomy and shared decision making. Intensive care treatments in critically ill children should promote the child’s best interests and the parents or guardians have broad, but not absolute, autonomy in determining this. Similarly, for adult patients who lack decision making capacity, decisions must generally be made in the patient’s interests by doctors and substitute decision makers.

Intensive care requires significant resources, particularly in relation to highly skilled staff. Intensive care quality is closely monitored in Australia and New Zealand against professional standards (including those created by ANZICS, the College of Intensive Care Medicine, and the Australian College of Critical Care Nurses), while the ANZICS and ANZPICR registries allow the determination of trends over time as well as benchmarking across units and countries.

The scale of the COVID-19 pandemic is uncharted territory and is expected to cause significant strain on a finite resource. Intensive care specialists, in partnership with other specialist colleagues, are required to make decisions
about the ethical allocation of critical resources, especially when demand exceeds capacity. Decisions should be made fairly, consistently, transparently and in accordance with policy to the extent this is possible.

Abstract
Background: Planning for the next pandemic influenza outbreak is underway in hospitals across the world. The global SARS experience has taught us that ethical frameworks to guide decision-making may help to reduce collateral damage and increase trust and solidarity within and between health care organisations. Good pandemic planning requires reflection on values because science alone cannot tell us how to prepare for a public health crisis.

Discussion: In this paper, we present an ethical framework for pandemic influenza planning. The ethical framework was developed with expertise from clinical, organisational and public health ethics and validated through a stakeholder engagement process. The ethical framework includes both substantive and procedural elements for ethical pandemic influenza planning. The incorporation of ethics into pandemic planning can be helped by senior hospital administrators sponsoring its use, by having stakeholders vet the framework, and by designing or identifying decision review processes. We discuss the merits and limits of an applied ethical framework for hospital decision-making, as well as the robustness of the framework.

Summary: The need for reflection on the ethical issues raised by the spectre of a pandemic influenza outbreak is great. Our efforts to address the normative aspects of pandemic planning in hospitals have generated interest from other hospitals and from the governmental sector. The framework will require re-evaluation and refinement and we hope that this paper will generate feedback on how to make it even more robust.

Abstract
In the event of an influenza pandemic, many ethical issues will arise in terms of health risks, resource allocation, and management decisions. Planning decisions may be controversial, such as rationing of antivirals, resource allocation (including hospital beds and vaccinations), occupational risk, rostering of staff, responsibilities of health care workers, quarantine measures, and governance issues. A clear ethical framework is needed to enable understanding of the decision-making process and optimise acceptance of decisions by health care workers and other members of an affected community. Planning decisions need to start being examined now, and will require input from a broad group of experts: health care providers, infrastructure managers, lawyers, ethicists, public health physicians, and community members. The process will need to be open, honest and dynamic.