How to express concern with an unsafe practice in a hospital setting if quitting is not feasible?

Question

I am asking this question on behalf of my wife, who works in respiratory care, in a hospital. Her position involves direct patient care.

Due to recent spikes in the more contagious delta strain of the Covid 19 virus, the resources, such as ventilators, at the hospital in which she works is becoming more strained. Unfortunately, we live in a state in which spread is high,and vaccination rates below average.

She recently said that if the current spike gets worse, ventilators and other patient care resources may need to be tightened to include sharing such as co-ventililation. However, she has discussed with me how she has serious concerns of such practices being unsafe. Back in March of last year, a joint statement was made by organizations representing physicians in anesthesia and respiratory care professionals, strongly advising against sharing, as sharing of equipment may endanger patients due to differing needs of the individual patient.

If I were in her shoes, I understand the need to be resourceful with equipment use in a public health crisis, but would be similarly uncomfortable due to endangering patients wellbeing, and my state license.

Edit

@Ertai, yes she is basing her reluctance on medical best practices and expert knowledge. The cited article is an example and the professional organization representing her profession for which she belongs is another example. Respiratory therapists are considered experts in ventilator management and can intervene for patients in respiratory distress. From our conversation, her primary concern is that sharing of ventilators ignores unique needs of an individual patient , worsening their care, possibly with serious injury or, God forbid, death as result.

Update The situation has worsened and triage started. There is probably need to resort to coventilation. My wife along with her other colleagues in critical care will meet with hospital administration later next week. As unsafe as this may be, Hilmar probably gave the best answer

How does one communicate reluctance to engage in an potentially unsafe practice when quitting is not feasible due to other peoples health being on the line?

How can my wife communicate her concerns while protecting her job?

Answer 1

First things first: Please THANK your wife for doing a very difficult but desperately needed job in this pandemic. It's hard and sometimes very thankless work but we all appreciate it very much.

This is a tough situation but not uncommon. It's probably a case of Triage, which is painful but a well understood medical practice.

In medicine, triage (/ˈtriːɑːʒ, triˈɑːʒ/) is a process done when the immediate demand for medical resources exceeds their availability. It is the process of assigning priority to patients' treatments based on the severity of their condition, the urgency of them to receive immediate treatment, and their likelihood of recovery with and without treatment. This rations patient treatment efficiently when resources are insufficient for all to be treated immediately; influencing the order and priority of emergency treatment, emergency transport, or transport destination for the patient.

If there are more patients than ventilators, SOMETHING has to be done. There is no perfect solution so the medical team needs to find a good outcome for most patients even if that means a bad outcome for a small number of patients.

If your wife has a better (and more practical/feasible) idea how to mitigate the shortage then by all means she should strongly advocate for this. If not, it's probably best (if painful) to make her peace with it: Yes, it's unsafe, but it might give you a decent chance to save both Alice and Bob, instead of giving up on one of them.

And again: please thank your wife from all of us for what she does.

Answer 2

If your wife has concerns, she should raise them with her superior, as that is her duty as a medical practitioner.

The joint statement came out a year ago. A relevant quote form the joint statement:

It is better to purpose the ventilator to the patient most likely to benefit than fail to prevent, or even cause, the demise of multiple patients.

It is likely hospital administration has already taken in the advice, and considered the relevant risk factors.

Due to this crisis, it is no doubt there has been a lot of research done in order to mitigate the risks of shared ventilation. It is unclear if this has changed the opinion of AARC.

In any case, they have published research covering the use of shared ventilation (no doubt they are resigned to the fact that some jurisdictions may need to use shared ventilation anyway.) I am sure your wife has already started reading in preparation.

Answer 3

Consider this situation from the perspective of the hospital. If they have X ventilators, and Y people need them, and Y > X, then some number of people will not have a ventilator. Those people will probably asphyxiate and die. If ventilators are shared, then there is a possibility that all Y people can survive with X ventilators, but there is also a possibility that some number Z > (Y - X) will die due to the concerns your wife has raised. So basically you have 3 possibilities:

Hospital doesn't share ventilators, (Y - X) people will die. In this case, the hospital will likely face some kind of class-action lawsuit from the families of those people, claiming "why didn't you share ventilators?". The hospital will have to go to court, defend itself, bring in witnesses, and so on, all of which costs money, and that's even if they win the case which is not guaranteed (the science on anything covid-related is far from settled at this point, there's no telling what might happen in the future). This is at best a huge pain in the ass for the hospital administration and at worst a huge legal liability.

Hospital shares ventilators, Z < (Y - X) people die. There may still be a lawsuit, but the lawsuit will be smaller. Additionally, the hospital has in their defence that, if they didn't share ventilators then more people (Y - X people) would have died, so they can show the judge that even if Z people died, then it could have been worse, which helps them in court, because they "overall" did the right thing. It's less likely for the hospital to be found liable in this case, and if they are found liable then the settlement amount overall will be less.

Hospital shares ventilators, Z > (Y - X) people die. Then there will be a bigger lawsuit than in the first case, and in addition the plaintiffs (the families of the deceased) will have the medical documentation to show that the hospital acted negligently (this is assuming nothing changes on the covid-science front, and there is no supporting documentation to support sharing of ventilators that your wife doesn't know about and/or that you are not sharing with me here; personally speaking I find the likelihood of one or more of those things being true to be non-negligible, but that's just my opinion). This is the worst-case scenario for the hospital, clearly; they have a weaker defence in court and the settlement will be more than if they didn't share the ventilators at all.

Now, if you're the hospital administration, who has many doctors, nurses, other health professionals such as your wife, not to mention lawyers and so on, on staff, chances are you know all of this already, and you know the latest research and don't need someone telling you something you already know. You've calculated all of these scenarios and determined what your plan of action should be given the various factors, and come to the decision that the sharing of ventilators is appropriate, and that's what you decided.

So this is the position of the people against whom you are arguing; it's important to know this so you can prepare what you want to say and how you want to say it, and to temper your own expectations to not get yourself in hot water. Given all of this, here's my suggestion:

Your wife should go to whoever is responsible for these decisions and make a case: Show the documentation, explain it in medical terms, and say that she strongly believes this is not the way things should be done based on XYZ research. After she makes her case, she has to keep in mind that everything she said is certainly something the person she is talking to already knows and none of this is news. Based on the fact that none of this is new information, it's already been taken into account when the initial decision was made, and therefore it's very highly likely for the response from the hospital administration to be something like: "Yeah, we already know all of that, and even despite that we decided to do it this way; let us know if you have any new news, but until then, do what we say". At which point, you live with it or you find another job.

Answer 4

How can my wife communicate her concerns while protecting her job?

Depending on the particular hospital's culture, she could discuss her concerns with her boss, the hospital's ombudsman, or chief medical officer.

She should be prepared to have her concerns heard, but she should not expect the hospital to change its practices.

Answer 5

How does one communicate reluctance to engage in an potentially unsafe practice when quitting is not feasible due to other peoples health being on the line?

This is a non problem, quitting is always feasible.

How can my wife communicate her concerns while protecting her job?

By discussing with her superiors or any regulating body for the specific problem she see's. This does not endanger her job, taking action such as refusing to follow procedures or divulging confidential information to third parties is different from voicing a concern.