Statement on Pandemics and Disasters: Practicing with Risk to Self

“Cure sometimes, comfort always”

Background

Registrants may occasionally have to practice in times and places of personal risk. Such risk may be the result of infectious disease,and may also include natural disasters and man-made disasters. The College has been asked by some to provide guidance to its members as to what their responsibility is in situations, such as a pandemic, in which their health may be put at some risk.

Introduction

A patient has a right to expect a registrant to provide competent, ethical medical care when called upon to do so, and if able, the registrant has a duty to comply. This patient expectation extends during the time of a pandemic or disaster, when there is the potential for personal risk to the registrant. Registrants will be judged by patients and society on the nature of their care and the degree of altruism exhibited.

CMA Code of Ethics and Professionalism (2018)

Fundamental Commitments of the Medical Profession:

• Consider first the well-being of the patient; always act to benefit the patient and promote the good of the patient.
• Provide appropriate care and management across the care continuum.
• Promote the well-being of communities and populations by striving to improve health outcomes and access to care, reduce health inequities and disparities in care, and promote social accountability.
  Practice medicine competently, safely, and with integrity; avoid any influence that could undermine your professional integrity.

Professional Responsibilities

1. Accept the patient without discrimination (such as on the basis of age, disability, gender identity or expression, genetic characteristics, language, marital and family status, medical condition, national or ethnic origin, political affiliation, race, religion, sex, sexual orientation, or socioeconomic status). This does not abrogate the right of the registrant to refuse to accept a patient for legitimate reasons.
2. Having accepted professional responsibility for the patient, continue to provide services until they are no longer required or wanted, or until another suitable physician has assumed responsibility for the patient, or until after the patient has been given reasonable notice that you intend to terminate the relationship.
3. Provide whatever appropriate assistance you can to any person who needs emergency medical care.
4. Engage in respectful communications in all media.
5. Support the profession’s responsibility to act in matters relating to public and population health, health education, environmental determinants of health, legislation affecting public and population health, and judicial testimony.
6. Contribute, where appropriate, to the development of a more cohesive and integrated health system through inter-professional collaboration and, when possible, collaborative models of care.
7. Contribute, individually and in collaboration with others, to improving health care services and delivery to address systemic issues that affect the health of the patient and of populations, with particular attention to disadvantaged, vulnerable, or underserved communities.

Legal Framework

Public Health Act

• Part III – Public Health Emergency;
  • Section 49. Public health emergency
  • Section 52. Emergency Measures Act prevails
  • Section 53. Limited license

Emergency Measures Act – STATES OF EMERGENCY

• Section 9. Declaration, state of emergency
• Section 11. Powers exercisable when state of emergency declared
• Section 14. Termination by the Minister
• Section 15. Termination conditions
• Section 20. Regulations

Medical Act

• Section 4. (g)
• Section 9. (3)
• Section 9. (4)

Regulations under the Medical Act:

• Regulation 1(a), (b).
• Regulation 3.

CPSPEI Telemedicine Policy April, 2020

This policy is relevant to licensing during a pandemic or other state of emergency such as a natural disaster or man-made disaster.

Discussion

In a pandemic or a disaster, registrants have an obligation, as in all patient care, to remain current in the recommended investigation and management.

In an established registrant-patient relationship, the ethical principles of practice should allow a patient to expect competent care by a caring ethical registrant. Whereas a registrant cannot discriminate against a patient because of the nature of the patient’s illness, e.g. influenza, there should not be any issue during a pandemic or a disaster. However, physician services may be restricted and patients may be required to attend a specified clinic, hospital or other site.

During a pandemic or a disaster, the usual standard of care may not be applicable depending on clinical and operational realities; the standard of care will be contingent on contextual considerations, such as scarcity of resources and obligatory departures from “normal” care standards. Previously established standards may evolve with changes to the clinical environment.

Some patients do not have the benefit of an established relationship with a primary care provider. Because of that fact, and because of the expected increase in volume of illness in the community during a pandemic or a disaster, there is likely to be a strain on the system, on the emergency rooms, on needed equipment and on individual registrants. Furthermore, ill registrants should not expose their patients to illness, and this will increase the workload for those who remain well and able to work. The increased number of patients requiring admission due to serious illness, and perhaps ICU care, will sometimes demand difficult ethical decisions in that context.

Such excessive workload will be borne by special clinics, and by hospitals, as well as registrants’ offices, but probably always involving registrants. To help to ease this burden, additional resources may be required. This could mean that retired registrants, registrants working in other areas of health care or administration, medical students and residents may need to be pressed into service. The College of Physicians and Surgeons, and Health Care Institutions must be prepared, when safe and when appropriate, to allow, in the interest of patient care, such deviation from normal practice patterns. Registrants may find themselves faced with practising outside their usual scope of practice. To do this safely, registrants will need to use their professional judgment and work with their colleagues to determine the appropriate care to provide. The CPSPEI supports registrants temporarily practising outside their scope of practice where urgent medical care is needed, another registrant is not available to provide the care, and patients are not being put at unreasonable risk. Registrants must always be mindful of the limits of their training and experience. Where a registrant’s training or experience does not allow them to treat patients directly, they may wish to perform administrative or other activities that support the pandemic response effort.

During a pandemic or a disaster there may be an influx of registrants from other jurisdictions into our province and there will likely be an increase in registrants applying from other jurisdictions to do telemedicine here. Military medical staff, including physicians and physician assistants, may be deployed to our province to assist during a pandemic or disaster. In these instances, extra licenses may need to be issued, and the CPSPEI may consider less stringent requirements for emergency registration and licensure. Should the College Office Staff become reduced due to illness, other measures (including the appointment of an Emergency Acting Registrar) will be put in place to ensure that registration and licensing can continue during a pandemic or disaster.

Under the Medical Act, there are no provisions to limit the placing of complaints that arise about medical care provided during the time of a pandemic, a disaster or a state of emergency. Such complaints will be assessed with careful consideration of the circumstances in which registrants must practice during this time. It would be naïve to think that registrants will not have concerns: concerns with regard to their own safety; concerns with regard to their families’ safety and security, and the care of their families, should illness or death occur. However, one can only mitigate the risk; one cannot eliminate it. Even if one wished not to participate in the care of ill patients (which is not really an option for a registrant), one would remain at risk of acquiring the illness in the community. Ways to mitigate the risk include: washing and cleansing hands appropriately; appropriate social/physical distancing; appropriate use of and wearing of properly fitted personal protective equipment; visiting one’s own care provider if one gets flu-like symptoms or other illness; accepting any treatment or vaccination when/if available.

Conclusion

“Cure sometimes, comfort always”

A patient has a right to expect a registrant to provide competent, ethical medical care when called upon to do so, and if able, the physician has a duty to comply. Registrants will be judged by patients and society on the nature of their care and the degree of altruism exhibited. The College of Physicians and Surgeons of Prince Edward Island endorses and expects this high standard from its members.

References

• Canadian Medical Protective Association Public Health Emergencies and Catastrophic Events – the CMPA will Help, CMPA 2008
• CMA Code of Ethics and Professionalism, Canadian Medical Association (2018)
• CMA Policy Caring in a Crisis: the Ethical Obligations of Physicians and Society During a Pandemic, Canadian Medical Association, 2008
• College of Physicians and Surgeons of Nova Scotia, An Ethical Framework: Health Emergencies and the Physician, March 27, 2009
• Consultation of Draft Policy Physicians and Health Emergencies, College of Physicians and Surgeons, Sept. 2009
• Emergency Measures Act PEI, 2017
• Medical Act PEI, 2019
• Medical Act Regulations, 2014
• Public Health Act of PEI, 2018

Document History

Approval Date: July 10, 2020

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