Patients who need to see their neurologists in non-emergency situations should be offered telehealth appointments to limit potential exposure to COVID-19, according to a new position statement issued by the American Academy of Neurology (AAN) late Friday.
Telemedicine appointments are especially important because some drugs prescribed for neurologic conditions, like corticosteroids or immunomodulating therapies for multiple sclerosis or myasthenia gravis, may weaken patients’ immune systems and increase COVID-19 infection risk, wrote Michael Rubin, MD, of UT Southwestern Medical Center in Dallas, and coauthors, in Neurology.
The new position paper offered ethics guidance on inpatient care, outpatient care, and neurology training during the pandemic. “Now is one of the most challenging times of our careers as neurologists,” AAN president James Stevens, MD, said in a statement.
“Clinics and hospitals are adapting to caring for the most ill, managing scarce resources, and trying to protect people without the disease,” Stevens continued. “As neurologists, we must continue to adapt our daily practice, continue to care for our most ill neurology patients, and help contribute to the care of those afflicted with COVID-19.”
The paper was developed by the Ethics, Law, and Humanities Committee of the AAN, American Neurological Association, and Child Neurology Society, in collaboration with the Neurocritical Care Society ethics committee. It addressed:
Telemedicine allows outpatient care to continue while limiting COVID-19 exposure. “Telehealth can be particularly problematic to neurologists, as it limits the physical examination with more emphasis on observation than our traditional ‘hands on’ approach,” the committee wrote. In recent years, telemedicine has expanded beyond stroke care, but research is limited and knowledge gaps remain. Routine EEGs, EMGs, sleep studies, and some MRIs may be postponed during the pandemic; clinicians should discuss risks of delaying diagnostics and limitations of telehealth with patients.
Advance care planning
Neurologists should know their community’s COVID-19 burden and discuss advance care planning with some patients. “In the event that hospitals have to triage limited resources, it’s possible that people with advanced neurologic disease may not be offered certain elements of lifesaving care, such as ventilators and ICU beds,” Rubin said in a statement. “To ensure more control in the treatments they receive, people with advanced disease and their loved ones should discuss with their neurologist how reduced resources may impact their care and communicate their care preferences if they were to become seriously ill.”
Competing clinical care
Inpatient neurologists may be asked to help with non-neurology patients if a COVID-19 surge occurs. “While neurologists still have an obligation to manage the patients for whom they were trained, as time permits, they should help manage the surge of respiratory failure,” the committee wrote. “While becoming a specialist does require taking responsibility for a focused patient population, it does not obviate the duty we have as physicians to support the greater community.”
Neurology education is grounded in neurological examinations and exercises in lesion localization and differential diagnosis, the committee pointed out. “To replace these bedside-teaching opportunities, we should increase didactics via remote-access-learning and make a conscious effort to include video demonstrations of examination findings and facilitate interactive discussions,” Rubin and coauthors advised. Caring for COVID-19 patients can provide rich educational opportunities, but must be balanced with patient care and trainee well-being.
Decisions about allocating scarce resources should be based on need, potential benefit, best medical evidence, and the balance of personal freedoms with the interests of the entire community, the authors observed. “Triage is not novel for the medical profession, but rationing and abrupt change to this extent are likely beyond the experience of many current neurologists,” they wrote.
Medical and ethics communities have reached a consensus that the goal of allocation policies during a public health crisis should be a fair distribution of resources with emphasis placed on maximizing the survival of the most number of patients, they noted. African Americans and other groups with a high presence of comorbidities have shown high COVID-19 infection and mortality rates and “there is some concern about these disparities being passed forward into scarce resource allocation protocols,” they wrote.
The committee also voiced concerns about disability discrimination: “We do not support protocols that would exclude patients because of a spinal-cord injury leading to paralysis, a stroke inhibiting movement or language, or a neuromuscular or movement disorder that may limit level of activity,” the authors stated. “These patients may have a different quality of life, but they can still adapt to a different existence.”
During the pandemic, neurologists can make the most ethically appropriate decisions “by standing by our core principles of advocating for the wellness of our patients while also fulfilling our obligations to the rest of society,” Rubin and colleagues emphasized.
“We must adapt our daily practice and consider how we can care for our most ill neurology patients while contributing to the care of all patients afflicted with COVID-19,” they wrote. “We must consider the needs of the entire community and the role we are obligated to play during the crisis.”