Applying Lessons from the COVID-19 Pandemic to Everyday Crises: The Role of Policy, Innovation, and Stewardship in...

During the COVID-19 pandemic, supply chain disruptions and resource shortages-such as limited intensive care unit (ICU) beds, COVID-19 testing, and personal protective equipment (PPE)-placed significant burdens on emergency departments (EDs). These constraints contributed to high levels of moral distress among front-line clinicians.

To address these challenges, one health system implemented a two-physician resuscitation policy for changing code status to "do not resuscitate" (DNR) during the COVID-19 public health emergency. This policy aimed to support clinician decision-making around potentially non-beneficial care, promote responsible resource utilization, and mitigate the ethical and psychological burdens faced by clinicians. The current study sought to evaluate frontline clinicians' awareness, use, and experiences with this contingency policy, focusing on its ethical and psychological impact.

This mixed-methods quality improvement study included clinicians from emergency medicine, critical care, and other specialties who managed COVID-19-positive patients. Data were collected through an online survey assessing awareness and acceptance of the two-physician DNR policy and its impact on moral distress. Correlation analyses were performed to examine relationships between resource shortages and moral distress. Qualitative data were gathered through open-ended survey responses and interviews thematically coded to elucidate clinicians' experiences with policy implementation and its influence on care delivery.

Over half of participants (53%) reported moral distress, which was significantly correlated with the severity of resource shortages (p < 0.05). ED staff in particular attributed distress to inadequate ICU bed capacity (64%), limited COVID-19 tests (64%), and insufficient (63%). Most respondents (70.2%) felt supported by the policy, especially in emergency medicine (79%) and critical care (79%). Qualitative findings indicated that the policy supported difficult decision-making around nonbeneficial care, reinforced resource stewardship, and enabled flexibility to reverse DNR status if patients' clinical conditions improved.

These findings underscore the value of contingency policies in reducing moral distress and facilitating resource allocation during crises. By providing a clear framework for end-of-life decisions, the two-physician DNR policy was perceived by most clinicians as fostering shared accountability and prudent use of scarce resources. The flexibility inherent in this policy-such as the option to revise code status-was particularly important as patient conditions evolved. Notably, EDs continue to face "everyday crises" marked by supply shortages (e.g., IV fluids, blood culture bottles) and boarding. This study highlights the need for proactive stewardship and robust contingency planning beyond pandemic settings. Integrating lessons learned from the COVID-19 pandemic will help hospital systems and EDs better navigate ongoing shortages and enhance preparedness for future public health emergencies.