Overview

Severe Acute Respiratory Distress Syndrome is when the lungs have trouble supplying enough oxygen to the blood. In treating it, healthcare teams use ventilation to protect the lungs and avoid more damage. If the patient’s condition worsens, more advanced life support may be needed. This can lead to ethical challenges for healthcare teams, such as making decisions about life-support treatments, obtaining patient consent, and managing end-of-life care. This article will explore these ethical issues in detail.

Resource allocation and prioritisation 

Ensuring fair distribution of life-saving resources

Equal access to life-saving resources such as extracorporeal membrane oxygenation (ECMO), Intensive Care Unit (ICU) bed, or pharmacology therapeutics¹⁹ can often depend on the geographic location and socio-economics concerning the healthcare provider.¹⁴ Healthcare institutions therefore have to triage and prioritise accordingly to ensure all patients are treated fairly, and that no patients are being denied life-saving resources unjustly.¹³

ICU bed availability 

When there is a short supply of ICU beds, healthcare teams have to determine which patients are allocated an ICU bed, and which patients are either relocated or moved to an alternative ward.¹² This decision involves an assessment of a patient’s medical needs, severity of the condition, and likelihood of recovery and quality of life.¹³ 

Ventilator availability 

During the COVID-19 pandemic, there was a shortage of ventilators.¹⁵ If hospitals are overwhelmed with cases of Severe Acute Respiratory Distress Syndrome, medical teams have to assess how to manage limited resources. This involves making sure ventilators are distributed fairly, ensuring patients aren’t harmed, and acting in their best interest.¹⁴ To help with these tough decisions, healthcare teams often follow specific guidelines and protocols for prioritizing care.^1,16

Prioritizing patients with high chances of survival vs. immediate need

Often, the processes and protocols that healthcare teams utilize to support the triage and prioritization of patients can cause tension.¹⁷ These processes and protocols support maximizing the number of lives saved. Healthcare teams often have to review patients regarding their respect for survival and the urgency of care required.¹⁸ Evidence from the pandemic suggests that triage protocols can prioritize younger patients, those with fewer comorbidities, or those with a better overall prognosis.²⁰

Furthermore, a patient with Severe Acute Respiratory Distress Syndrome and multiple comorbidities may have a low chance of survival but require immediate intervention. In contrast, a healthier patient with Severe Acute Respiratory Distress Syndrome may have a better chance of recovery but is not in immediate danger.²¹

Patient Autonomy vs. Medical Necessity

Informed consent 

Acute Respiratory Distress Syndrome can often require urgent interventions like mechanical ventilation or ECMO.¹ When a patient is incapacitated due to the severity of Acute Respiratory Distress Syndrome, obtaining informed consent for these life-saving treatments becomes a significant ethical challenge.² Although healthcare teams must act swiftly, obtaining consent is key. This can be fulfilled via consent from family members or legal proxies who are able to provide surrogate consent.

However, it should be noted that due to the complexities of Acute Respiratory Distress Syndrome, and the invasive nature of treatments, life-dependent decisions can be difficult for families who do not understand the implications of the decision.³ Healthcare teams have to balance surrogate consent against what is in their patient's best interest.²

Refusal of care 

Ethical dilemmas can arise when a patient, a family member, or a proxy refuses or delays life-saving treatment (e.g., invasive mechanical ventilation or ECMO). Refusal or delay in care, especially in Acute Respiratory Distress Syndrome, can lead to irreversible organ damage or death.¹ In scenarios such as these, healthcare teams must ensure that the family member or proxy fully understands the risks and benefits of the decision to refuse or delay life-saving treatment.⁷ Although refusal of care can conflict with healthcare team policies and processes, healthcare teams are required to engage with family members or proxies with compassion while respecting the decision.^6,7 

Advanced care planning

Some patients can present with advanced, do-not-resuscitate (DNR) orders, and/ or guiding treatment decisions pre-planned for healthcare teams.¹⁰ These documents allow healthcare teams to honor patient preferences regarding invasive treatments and end-of-life care.⁹ Advanced directives can play a pivotal role in Acute Respiratory Distress Syndrome care, particularly in intensive care settings where patients may require mechanical ventilation or ECMO. 

End-of-life decisions

Withdrawing or withholding life support: ethical challenges in end-of-life care

Patients with Severe Acute Respiratory Distress Syndrome may need life-supporting interventions like ventilators or ECMO.^1,21 However, if these options are no longer likely to help the patient recover, healthcare teams will discuss whether life-supporting interventions can cease. In cases where it’s unclear if the patient will recover, the healthcare teams will also have to decide when it might be appropriate to stop life-supporting interventions.⁸ Healthcare teams often face the challenge of assessing when invasive or aggressive treatments may not improve quality of life or survival rate. These discussions and decisions are delicate and must be aligned with the patient’s wishes and best interest.^4,7,8

Balancing comfort and life-prolonging measures 

In Severe Acute Respiratory Distress Syndrome, when patients can’t recover normal lung function and more treatments may do more harm than good, palliative care can be considered. Palliative care focuses on keeping the patient comfortable, easing pain, and improving their well-being. Aggressive treatments for this condition can sometimes cause more harm and discomfort.^1,5 Deciding between palliative care and continuing life-prolonging treatments means considering the patient’s condition, wishes, and quality of life.⁸ Healthcare teams need to have open, honest conversations with patients or their families and or proxies to make sure any decisions reflect the patient's values and preferences.^{6,7, 8}

Family or proxy involvement in decision-making

In the instance where a patient is critically ill with Severe Acute Respiratory Distress Syndrome and unable to make decisions for themselves, and there is a lack of documentation regarding a patient’s advance directives, family members or proxies are crucial to make a shared decision with the healthcare teams regarding treatment options. However, as this is a delicate situation, difficulties can arise when there is disagreement between family members, or between the family and the medical team about whether to continue aggressive treatment or transition to palliative care.^6,11 Family members may struggle with the emotional burden of deciding to withdraw life support.^6,7,11 Healthcare teams are required to help families and/or proxies understand the medical situation, prognosis, and potential outcomes, empowering them to make informed decisions.⁶

Summary

To conclude, treating Severe Acute Respiratory Distress Syndrome can bring many ethical dilemmas for healthcare teams to resolve. These include; deciding how to fairly use limited resources (e.g. ventilators and ICU beds), consent in the instance where a patient is unable to make decisions about their own care, and utilizing healthcare protocols to support patient prioritisatioprioritizationAlthough processes and protocols are in place to support decision-making, healthcare teams can still face challenges when family members or legal representatives often need to step in, which can sometimes lead to disagreements, particularly around end-of-life care. Lastly, healthcare teams have to undertake detailed assessments to find the right balance between invasive, aggressive treatment and comfort through palliative care while honouring the patient’s wishes.