<div>Amy Y. Chen, MD, MPH</div><div>Emory University</div><div>achen@emory.edu</div><div>Maisie Shindo, MD</div><div>Oregon Health Sciences University</div><div>shindom@ohsu.edu</div><div>Corresponding author:</div><div>Amy Y. Chen, MD, MPH</div><div>Emory Department of Otolaryngology Head and Neck Surgery</div><div>550 Peachtree St. MOT 1135</div><div>Atlanta, GA 30308</div><div>404-778-2178</div><div>achen@emory.edu</div><div>Short title: Ethics Endocrine Surgery COVID 19</div><div>Ethical Framework for Head and Neck Endocrine Surgery in the COVID 19
pandemic</div><div>The COVID-19 pandemic has halted all elective surgeries, allowing only
emergent surgeries, and in some hospitals time-sensitive urgent
surgeries to proceed. “Mr. X, This is Dr. I’m calling to discuss with
you your previously planned surgery. “ I’ve been having many
conversations like this with my patients over the past weeks. Surgeries
may be delayed or the patient and his/ her family may need to make a
heart wrenching decision whether to proceed with surgery in a hospital
filling with COVID patients, risking infection themselves, and without
any visitors. Endocrine surgery falls into this valley where it is
neither life threatening nor totally benign either. The American
Association of Endocrine Surgeons<sup>1</sup> as well as the
endocrine section of the American Head and Neck
Surgery<sup>2</sup> have put forth recommendations for thyroid
and parathyroid conditions that would be considered urgent
time-sensitive surgery. These include 1) high risk thyroid cancers such
as those with bulky central and lateral neck disease, concern for
tracheal or esophageal involvement, or short doubling time 2) Graves’
disease with thyrotoxicosis that cannot be controlled with anti-thyroid
medications, 3) compressive large goiters with dyspnea or significant
symptomatic vascular compression, 4) Primary hyperparathyroidism with
life-threatening hypercalcemia that cannot be managed medically, 5)
endocrine disorders in pregnant patient that are dangerous to the health
of the mother or fetus that cannot be controlled medically.</div><div>Certainly, there has been an international push to observe more well
differentiated thyroid cancer; however, what about those “smallish”
cancers that are near the isthmus, near the trachea/ esophagus, or with
extracapsular extension? Despite their small size, these can become
invasive to the degree that could result in the need to perform a more
morbid procedure if surgery is delayed, and thus should be considered in
the category of “time-sensitive surgery”. What about indeterminate
thyroid nodules with adverse molecular markers? If such nodules present
with ultrasound findings that are concerning for local invasion, even
though the cytologic diagnosis is not “malignant”, such lesions should
be treated as high risk cancer, and surgery should not be delayed.</div><div>If proceeding with surgery, the surgeon has an ethical responsibility to
discuss with the patient the potential risk of COVID-19 infection. We as
surgeons have a responsibility to reduce risk of infection not only to
the patient but the healthcare team who will be caring for the patient.
At the minimum COVID-19 testing should be performed preoperatively
within 2 days of surgery, and the patient should be educated on the
importance of self-isolation and necessary precautions.</div><div>If potential difficult airway is anticipated communication and planning
with anesthesia pre-procedure is important. Despite that fact that the
patient may test negative for COVID-19, the false negative rate is not
zero, and as such, precautions need to be taken to minimize exposure. A
difficult airway may result in manipulation of the airway that could
potentially be aerosolizing. Having the appropriate protective gear and
all necessary difficult airway equipment is essential in such a
situation. If the patient needs fiberoptic laryngoscopy or tracheoscopy,
nasal pledgets should be used in lieu of sprays. Surgery should
certainly be postponed in Covid-19 positive patients.</div><div>Scarcity of resources, surge planning, and public health mitigation
efforts have all combined in a perfect storm to delay and in some
situations, to deny treatment to head and neck surgery patients. Whereas
some of our patients may afford a delay in their treatment, others do
not have that luxury. It is incumbent upon us, as their clinicians, to
integrate competing priorities into an acceptable plan.</div><div>Justice, or to be just/ fair, must include a lens towards equity. One
way to honor this ethical principle is to incorporate both clinical and
non-clinical factors in risk assessment. Many papers have reported on
the profound effect of sociodemographic factors on patient outcomes. An
intersection between higher comorbidity burden and lower socioeconomic
status can worsen disparities of who gets treatment. For example,
algorithms that incorporate comorbidity are necessary so that resources
can be allocated for the “greater good;” however, these guidelines
risk heightening disparities and health inequity. Strategies to
ameliorate these disparities include flexibility of treatment options,
creative discharge planning, and thorough pre-operative conditioning.
Flexibility of treatment options include consideration of definitive
chemoradiation, induction chemotherapy prior to surgery (to buy time),
and resection with delayed reconstruction.</div><div>Beneficence, or to do good, is a guiding principle of ethics. With
limited resources, the “good” of society supersedes the “good’ of the
individual. Hence, the cancellation of elective, non-emergent cases is
instituted. So is the prioritization of surgical cases that are not
likely to need ICU care, blood products, extended inpatient stay, and
extensive ancillary laboratory/ radiology testing.</div><div>However, these cancellations/ delays in treatment/ changes in treatment
can cause anxiety for both the clinician and his/ her patient. Many of
our patients have been waiting for several weeks for their treatment to
start, only to have it be delayed or altered. How do we reassure the
patient that the new plan is the best plan, given the restrictions that
the COVID 19 pandemic places on systems? How do we, as clinicians,
resolve our inner turmoil in delaying/ denying/ altering treatment.</div><div>Early data already demonstrate that COVID 19 is affecting vulnerable
racial minorities at a higher disproportionate rate. To compound the
adverse effects, this cohort has more access issues due to
transportation, hourly job limitations, and lack of stable insurance.
The delay in surgery may result in the patient’s loss of insurance
status due to loss of income and/ or being furloughed. As we move into
the next phase of easing up restrictions, such factors need to be taken
into consideration in prioritizing whom we select for surgery.</div><div>1.
https://www.endocrinesurgery.org/assets/COVID-19/AAES-Elective-Endocrine-Surgery.pdf</div><div>2.
https://www.ahns.info/wp-content/uploads/2020/03/Endocrine-Surgery-during-the-Covid.pdf</div>