PPE for care providers
Personal protective equipment (PPE) is essential for reducing risks to healthcare providers, patients and their families, though insufficient supplies continue to be a challenge.
Do I have an obligation to continue working in a setting where personal protective equipment (PPE) has not been provided or is inadequate (i.e. masks, gowns, gloves, eye protection, etc.)?
Physicians may be permitted in exceptional circumstances to refuse to practice if they reasonably believe that the work environment creates a legitimate unacceptable hazard that is not inherent to their ordinary work. A refusal to work due to inadequate protective gear, could put a health worker at risk of a hospital, health center or clinic complaint, the success of which will depend upon the context of the situation. The MESE is aware that health institutions are taking into account the current COVID-19 situation and would assess any complaint in that context. Health institutions also generally have an obligation to provide a safe work environment for their staff pursuant to occupational health and safety standards.
Health workers are encouraged to work with their institution in developing appropriate screening, triage, and infection prevention and control policies and procedures to deal with patients presenting with symptoms consistent with COVID-19 or patients who have recently travelled through affected regions.
Do Physicians have an obligation to attend to pronounce and certify the death of a patient at their home or long-term care facility if PPE is not available and it is suspected death may have been caused by COVID-19?
Generally, when a person dies at home, the persons who live with him shall be bound to declare his death. In default of such persons, such obligation shall devolve on his relatives by consanguinity or affinity, if they live in the same commune, and, in their default, on his nearest neighbors.
Death shall be ascertained when there is no sign of life as approved by a competent health professional based on examination of functions of brain, heart and breathing organs. Accordingly, there is no legal requirement that death be pronounced by a physician. Pronouncing a death means issuing an opinion that life has ceased based on a physical assessment of the patient. Often, another person, such as a nurse who was involved in caring for the deceased, could pronounce a patient’s death.
Certifying a death is not the same as pronouncing death. In general, any physician (or a nurse practitioner who was in attendance during the last illness of the deceased person or who has sufficient knowledge of the last illness has an obligation to complete the death certificate. Certifying a death is the legal process of attesting to the fact, cause, and manner of someone’s death, in writing, on the form prescribed by the local authority.
Health institutions and other health care facilities such as long-term care homes generally have an obligation to provide a safe work environment for their staff pursuant to occupational health and safety standards, which includes providing adequate PPE. Health workers should consult with long-term care homes regarding their policies for attending in person to pronounce a patient’s death and to complete the death certificate in circumstances where there is inadequate PPE.
If it becomes necessary to refuse to attend upon a patient to certify death because adequate PPE is not available, it is necessary to document the rationale and the steps taken to find an alternative means to certify the patient’s death, including by working with long-term care homes in developing reasonable approaches.
What should I do if I cannot obtain PPE for my department and/or my staff refuse to work out of fear of infection? Can I close my practice?
Health workers generally have an ethical and professional obligation to be available to provide medical services during pandemics. While a number of public health and regulatory authorities have issued guidance or in some cases directed that non-essential health services be postponed, few institutions and health workers has already stated that it is generally unacceptable to completely close clinical practice, unless there are legitimate reasons to do so.
Health institutions generally have an obligation to provide a safe environment for their patients and staff pursuant to occupational health and safety standards. In the absence of available PPE, health workers may wish to consider other measures to screen patients prior to arrival. For example, some countries health ministries have published guidance recommending, amongst other things, that patients be screened over phone before scheduling appointments; signage be posted on entry to the office and at reception areas for patients with symptoms to self-identify, perform hand hygiene, wear a procedure mask, and have access to tissue and a waste receptacle; and for staff conducting screenings to potentially be behind a barrier (e.g. plexiglass) to protect from droplet/contact spread.
Documentation of the facts and circumstances of care provided in these circumstances, including the steps taken to attempt to obtain PPE, will be invaluable in the event of medicolegal developments in the future when memories may have faded about working conditions at the time.
As with any resource constraint, health workers are expected to do the best they can for patients and act reasonably in the circumstances. Health workers may need to adapt and be resourceful in this rapidly changing and challenging environment.