This article compares the ventilator allocation policies of hospitals that are associated with members of the Association of Bioethics Program Directors (ABPD), finding that at the time of survey over half of these hospitals did not have a ventilator triage policy in place, policies varied substantially between institutions, and many policies lacked guidance on fair implementation.
Many states and other groups have issued guidelines for the allocation of scarce resources during a public health emergency, but these guidelines are generally advisory. Polices at the hospital or health system level may vary due to jurisdictional differences and local norms, but, as the authors of the article argue, “unjustified variation could exacerbate structural inequities, squander valuable resources, and undermine public trust.”
The authors received responses from 67 program directors, with some providing information from multiple institutions. Among the responding directors, 36 (50%) reported that their affiliated institutions either did not have ventilator triage policies or had policies in development as of March 2020, and 7 (9.7%) had policies but could not share them.
The policies available expressed multiple ethical perspectives, the most frequent being justice, transparency, resource stewardship, duty to care, and duty to prevent unnecessary loss of life. The most common explicit triage criteria were benefit, need, conservation of resources, and lottery. Only a minority included a first-come, first-served allocation, and no policy used either lottery or first-come, first-served as the sole criteria. A minority of policies prioritized health care workers. Most policies used a form of scoring system, with Sequential Organ Failure Assessment (SOFA) score or modified SOFA score by far the most common type of system. Almost half of the policies included specific clinical exclusion criteria (e.g., cardiac arrest or severe burns). Policies took various approaches to the composition of a triage team charged with making allocation decisions, and approximately half either required or recommended that individuals providing direct patient care be excluded from these bodies.
The authors note that many institutions engaged in substantial contingency planning efforts following the 2009 H1N1 influenza pandemic, making the absence of existing allocation policies at a number of institutions notable. The authors also note that the rapid development of new policies may substantially limit stakeholder engagement and that policy heterogeneity and inconsistent implementation may have adverse consequences for patient health outcomes.