This article by Ehmann et al. provides operational recommendations to address resource allocation during a public health emergency. The recommendations were developed through a consortium of five health systems in Maryland, representing over half of all hospital in the state. Building on the foundation of existing ethical guidance, the recommendations focus on practical application. Finding that no single algorithm was universally applicable for all resource types, the authors include operational algorithms for several different potentially scarce resources:
- mechanical ventilators
- ICU resources
- blood components
- novel therapeutics
- extracorporeal membrane oxygenations (ECMO)
- renal replacement therapies.
Recommendations vary considerably between resource types, reflecting factors such as the presence or absence of evidence-based guidelines. However, all of the recommendations are informed by well-established bioethical principles including a duty to provide care, a duty to steward resources, distributive and procedural justice, equitable and standardized practices, and transparency. The recommendations primarily center principles of maximizing benefit and patient survival, with emphasis on fair chance and short-term and long-term survival.
This commentary by Supady, Brodie & Curtis identifies 10 key elements for clinicians, administrators, and society at large that must be considered in implementing guidelines for rationing scarce resources during a pandemic. The elements seek to harmonize available principles and processes for triage guidelines and critiques that have arisen during the COVID-19 pandemic related to legal issues, equity concerns, and practical challenges. The key elements identified are:
- Scarce Resources: Identify resources that are scarce using a thorough needs assessment, and update as circumstances evolve. All reasonable avenues to supplement resources must be exhausted before rationing begins, including repurposing of resources, personnel, or structures not traditionally designated for such use.
- Transparency and Public Participation: Different moral principles may lead to different and conflicting recommendations. Each community or society should agree on prioritization of the principles that form the basis for rationing decisions, ideally through a transparent public debate before a crisis occurs, and every effort should be made to engage key stakeholders.
- Patient Age: Patient age is a relevant parameter but may be considered unacceptable discrimination by some or essential to ensure equal opportunity to pass through different life stages by others. Incorporating age is inevitable, so it is crucial to come to explicit agreement regarding its appropriate role in rationing.
- Prognostication and Scores: It is not self-evident that outcome maximization should be the primary guiding principle for rationing, but when scores are used toward this end, they should be applicable and validated for the specific clinical context, which may be challenging in a novel pandemic.
- Responsibility for Decisions: Triage committees have been proposed to relieve bedside clinicians of the burden of rationing decisions, but such teams may be overwhelmed during a prolonged pandemic due to complexity, duration, and the time-sensitive nature of the decisions required. The authors recommend that triage committees be responsible for setting standards and developing guidelines and structures, leaving individual bedside decisions within these frameworks as the responsibility of treating clinicians.
- Patient Goals and Preferences: Rationing guidelines must attend to the early collection of patients’ goals and preferences, including advance directives and other expressions regarding treatment limitations, especially for the elderly and those with chronic life-limiting illnesses. Involvement of surrogate decision-makers should be considered at an early stage for patients lacking decisional capacity.
- Disabled and Disadvantaged Patients, Poverty, and Structural Racism: Rationing decisions must consider the perspective of vulnerable populations. A variety of structural factors lead to associations between poorer health status and poverty, low formal education levels, categorization as racial or ethnic minority, and disability. Because of these associations, focusing rationing decisions on long-term health outcomes could further disadvantage persons from these communities. Rationing decisions should be adjusted to address these disparities, and a process for mitigating inequities through triage decisions should be considered.
- Prioritization of Specific Person Groups: Prioritization of specific groups (e.g., HCW priority for vaccination) must be thoroughly justified and transparent, and prioritization based on perceived instrumental value must not be abused to the disproportionate detriment of other groups.
- Applicable Law and Legal Protection: Rationing decisions must comply with applicable law in the relevant jurisdiction, but legal frameworks may be incomplete in many instances. Triage guidelines cannot replace legal regulation, and such legal gaps must be addressed to enable health care workers engaged in rationing decisions under crisis standards of care to rely on societal and legal support for appropriate decisions.
- Role and Mental Wellbeing of Clinicians: When rationing of life-sustaining treatments is required, those participating in triage are likely to suffer mental health impacts due to bearing witness to the suffering and death of many patients. Guidelines should account for this and incorporate provisions for the support and assistance of health care workers involved in the process.