Resource Allocation

This ethics roundtable by Baumrucker et al. discusses the difficult case of critical care resource priority in the context of COVID-19, presenting a case in which an otherwise healthy 59-year-old and a 17-year-old both require ventilator care with only one machine available. The roundtable provides assessments of the case from:

• Medical perspective (including prognosis and co-morbidities)
• Legal perspective (including age discrimination)
• Case management perspective (including crisis standards of care)
• Ethics perspective (including benefit maximization and individualized consideration)
• Medical/Ethics perspective (including implementation of rationing protocols and ensuring fairness for already marginalized groups).

This commentary by a task force commissioned by the Alzheimer Society of Canada addresses allocation of scarce critical care resources as applied to persons with dementia. Dementia predominantly affects older persons, the group that has generally been at highest risk from COVID-19. The task force provides 7 principles for resource planning intended to ensure respect for dignity of persons with dementia:

• Decisions on access to lifesaving resources for persons with dementia should be individualized
• Persons with dementia should be provided the opportunity to indicate their wishes regarding goals of care
• Decisions on resource allocation should respect the personhood of people with dementia
• Decisions on access to lifesaving resources should be based on expected survival, not presumptions about individual quality of life
• Prognostications should be based on an objective, validated assessment of mortality risk, frailty, or functional disease stage
• The presence of mild cognitive impairment should not be used as a criterion for assessing suitability for lifesaving care.
• Persons with dementia who are denied potentially lifesaving care are entitled to an explanation and best alternative care, including palliative care, if appropriate.

These principles are consistent with ethical frameworks that govern most resource allocation and triage plans in the U.S. and elsewhere, which generally prioritize maximization of benefits. Some allocation frameworks have been criticized for, among other concerns, categorical exclusionary criteria and approaches that may disproportionately affect marginalized populations, including persons with disabilities and older persons.

Closely related, this commentary by Rockwood and Theou addresses the use of the Clinical Frailty Scale (CFS) in allocating scarce resources. The paper updates and refines components of the CFS and provides guidance on appropriate use of frailty assessments in this context for those who are less experienced with use of this approach. Among other points, the authors emphasize that assessing baseline state is crucial and that the CFS should not be used for younger persons or persons with stable single-system disabilities.