Integrating Ethical Reflection Into Practice
Micro Resource Allocation Exercise
Bashir Jiwani, PhD
Pandemic Preparedness
Allocation of Acute Care Resources
The task:
You are part of a working group that has been asked to make microallocation policy recommendations regarding who should receive scarce acute care resources in the event your community is affected by a global influenza pandemic. The first few sections of the process have been completed for the purpose of the exercise.
Your task is to:
1. Review the question and the facts sections, add salient bits missing and confirm agreement to proceed.
2. Discuss and agree on the values, in priority order, that should guide this decision
3. Based on these values, identify the specific criteria that should be used as filters to determine allocation of the resource
4. Where necessary, provide detail/elaboration of these criteria
5. Provide the justification that is used to defend the use of the criteria and their relative place in the list
6. Based on the values, identify specific criteria, if any, that should not be used as filters
What’s the question?
During a pandemic, what criteria should be used to determine who should receive scarce acute care resources, such as ventilators?
What are the facts?
- The following types of cases, corresponding to different pandemic phases, will be seen:
o Scenario 1: Early Pandemic
§ Despite being early in a pandemic, a large number of people have already been affected with the decision to cancel surgeries and services for conditions that would be treated under normal, operating conditions. In the next few days, there will be many more people requiring ICU beds and vents than what is available and it is a fact that others will suffer due to a lack of resources. The gap between what we have and those who need it will widen within a week. Currently, there are 100 people with unmet needs and within a week, over 1000 people all have critical unmet needs.
o Scenario 2: The Worst is Over
§ Many people have died from a pandemic, however from information obtained by experts, the pandemic crisis is decreasing even though people are still sick. Those who require critical care are rapidly falling however there are still people waiting for a constrained supply of vents. Planners are thinking about reinstating normal, standard care to areas such as ICU in an attempt to begin to address collateral damage.
o Scenario 3: Pre-Pandemic
§ A pandemic crisis is developing in another province in Canada. Confounding the emergency preparedness planning is the looming nurses’ strike. All regions in Alberta have begun to operationalize their pandemic plans and have begun to discharge patients and cancelling surgeries that will require long post-operative stay and resources. Currently, ICUs are full and all vents are being used. An individual arrives at the Royal Alex Hospital with respiratory disease. He is elderly, not an essential worker, and is not expected to recover. The decision needs to be made as to whether he is admitted to the ICU and isolated despite the future need there will be for the ventilator he will use.
o For each of these situations, possible outcomes for those receiving ventilator support include…
§ Outcome 1 – will fully recover for the long term
§ Outcome 2 – will physically recover, but will have significant cognitive deficit
§ Outcome 3 – will be physically disabled, but cognitively aware
§ Outcome 4 – will adequately recover for 2 months but is palliative
§ Outcome 5 – never gets off ventilator
- Most, if not all, ventilators will be in use throughout the pandemic phases
- Those individuals who do not receive the resource needed will have a higher likelihood of dying
- There will be a scarcity in technology and qualified human resources
- The option of securing more resources will have been exhausted
- Age by itself is not a determinant of outcome
- The public will have already seen a scaling down of services (i.e. elective surgeries, clinics, cancer treatments)
- Communication strategies are in place to share a broad ethical framework to guide decision makers and the general public
- The four goals of health care generally are saving life, curing disease, relieving suffering, and promoting & maintaining health
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Missing Information
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What are the values?
The Working Group suggests that in the context of the allocation of acute care resources during a pandemic, the following values, listed in priority order, should guide decision-making:
In allocating scarce acute care resources, it is important that… / Value/Theme / Priority (1=highest, 5=lowest)Example: We maximize the ability of the system to respond to situation / Social Utility
Policy Recommendations:
A) During a pandemic, the following criteria should be used in order to determine who should receive scarce acute care resources such as ventilators. Each criterion should be used as a filter. If the number of candidates that pass through the first filter still outweighs the resources available, the next filter should then be used. Resources should be allocated to those individuals…Filter / Criterion / Notes/Elaboration / Justification
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5
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B) In determining who will and will not receive scarce resources, there are certain criteria that ought never to be used. These criteria include…
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