Ethical Issues in Scarce Resource Allocation in COVID-19 Pandemic - PowerPoint Presentation

Slide1

Ethical Issues in Scarce Resource Allocation in COVID-19 Pandemic

Kenneth Prager, MD

Professor of Medicine at Columbia University Medical center

Director, Clinical Ethics

Chair, Medical Ethics Committee

How can the most lives be saved?

The greatest ethical challenge in the current pandemic is how to ethically allocate scarce life-saving resources to save the most lives when demand outpaces supply.

What are the scarce resources?

Human resources: physicians, nurses, respiratory therapists,

etc

Material resources

ICU beds

Ventilators

Dialysis machines and dialysate

Medications

Personal Protective Equipment (PPE)

COVID testing material

Options

First come, first serve, OR

Triage: favor those most likely to survive over those less likely, regardless of their places in the line

Utilitarianism: do the most good for the greatest number

How good are we at prognostication?

How can we avoid discrimination?

Ethical principles involved in triage

Patient autonomy: respecting patient’s wishes regarding access to life sustaining treatment

Request to receive life support even with poor prognosis

Beneficence: do the most good possible for our patients

Is the physician’s obligation to do what is best for his/her patient ever trumped by acting for the greater good of society?

Triage: ethical principles

Non-maleficence: first do no harm

Withholding or withdrawing life support against patient or family wishes is a major violation of this principle

Justice: fair allocation of scarce resources

Any triage policy must be vetted carefully to be fair to all patients regardless of race, ethnicity, income, immigration and insurance status

We have been triaging patients for receipt of organs for transplant for decades with societal acceptance

Triage policies: Basic features

Approximately 60 such policies across the country

Triage committee: decides who shall receive life support or have it withdrawn, based on a scoring system using objective medical data and +/- clinical judgment

Exclusion criteria: certain criteria will exclude patients from receiving life support

These severe medical conditions indicate remote likelihood of surviving to discharge even with life support

Sequential Organ Failure Assessment—SOFA score evaluation, calculated on admission and regularly thereafter; accuracy for Covid-19?

Triage policies: Basic features

Based on SOFA score patients placed in 4 categories:

Prognosis for survival too poor to justify ventilator

Patient status too good to need ventilator

Patient with favorable prognosis but in need of ventilator

Sicker patients with less favorable prognosis who may benefit from ventilator

Triage policies: Basic features

Exclusion criteria

Unwitnessed cardiac arrest

Irreversible hypotension

Severe traumatic or hypoxic brain injury

Any condition resulting in immediate or near immediate mortality even with aggressive therapy

Trial of ICU treatment

Assessed at regular intervals

Patients improving continue on ventilator

Patients not improving or deteriorating: ventilator withdrawn if needed for patient with favorable prognosis

Withholding or withdrawing ventilator

Decision not made by treating physician

Decision made by triage committee based on objective criteria applied fairly to all patients

Withholding ventilator—DNR/I--much easier emotionally for physicians and family than withdrawing

Need for rapid GOC discussion with family and role of palliative care

Concerns with triage policy

Disability community concerns re: discrimination

Intellectual disability

Dementia

Severe physical disability

Concerns that age may play inappropriate role in life support decisions

Is there bias against people with poorly treated medical conditions because of poor access to health care who have worse prognosis for survival?

Minority communities

How will public react to triage policies?

Public trust is essential if the policy will be implemented

Mistrust already exists in disability and minority communities

Needs legitimacy from governor/legislature to carry this out

Must not be perceived by public as being policy of certain hospitals only

Physicians must be guaranteed legal protection if they carry out policy

Must be transparent

Must treat all people, ethnicities, immigrants, uninsured and insured alike.

Controversial triage questions

Should patients requiring more intense care be disadvantaged?

Should patients with poorer long term prognosis be disadvantaged?

Should physicians, nurses, and other health care providers be favored in allocations?

If so how?

If not, how will this affect morale?

How would this be perceived by the public?

Potential legal liability

Major obstacle to implementing triage policy

“Existing federal and state statutes provide limited immunity to physicians and nurses in times of emergency

“But importantly, these laws do not clearly immunize decisions to withhold or withdraw ventilators, which might be seen as willful, reckless, or wanton conduct and thus beyond the scope of existing shields

“Moreover, only a small number of states extend immunity to criminal charges”

Potential legal liability for withdrawing or withholding ventilators during COVID-19; Cohen, Crespo, White;

Journal of the American Medical Association

, April 1, 2020

Potential legal liability

“Clinicians making triage decisions do so at the judgment of future juries.

“A clinician who intentionally withdraws a ventilator from a nonconsenting patient could conceivably be charged with criminal homicide.

“If the clinician knows that removing the ventilator will result in the death of the patient , the applicable charge would be murder.”

Cohen, et. al.;

op.cit

.

The need for urgent action by State Governments

“With potentially thousands of triage decisions on the horizon, clinicians should not be expected to move ahead with implementing triage protocols based on the hope that prosecutorial discretion or sympathetic juries will protect them in the future.

“…State legislatures must take action…[to] immunize all health care clinicians and health care entities from civil and criminal liability for ventilator triage decisions made in good faith compliance with mandatory or voluntary state-approved protocols…

Cohen, et.al.,

op.cit

.

Emergency Disaster Treatment Protection Act

Passed by NYS legislature April 7, 2020

Grants qualified immunity to hospitals, nursing homes, administrators, board members, physicians, nurses…from civil and criminal liability arising from decisions, acts, and omissions occurring from the beginning of the Governor’s emergency declaration on March 7 through its expiration, and covers liability stemming from the care of individuals with and without COVID-19.

The immunity will not apply to intentional criminal misconduct, gross negligence…but makes clear that acts, omissions, and decisions resulting from a resource or staffing shortage will be covered.

Reaction of NYC hospitals to COVID crisis

Instead of implementing triage policies, NYC hospitals have greatly expanded their ICU and ventilator capacities and the number of ICU physicians and nurses to accommodate vastly increased numbers of critically ill patients

Operating rooms,

cath

labs, and other spaces have been converted into ICUs

Toll on health care providers

Physicians, nurses and ancillary hospital personnel have performed heroically under the most stressful conditions

Threat of becoming infected

Threat of spreading infection to family members

Need to physically separate themselves from family at times

Enormous emotional toll of dealing with large numbers of dying patients who are separated from their families

Recent suicide of Allen Pavilion ER doctor after recovery from COVID, with no history of mental illness

Moral distress of physicians and nurses

Moral distress of having to continue life support for patients with no chance of survival whose families want “everything” done

Risk of becoming infected while treating these patients

Prolonging the dying process of such patients

Using scarce resources of ventilators, dialysis machines, PPE while treating these patients

Critical roll of palliative care physicians

The post COVID future

Will the way medicine is practiced be changed?

telemedicine

Will our approach to medical futility/unbeneficial medical care be altered?

Will the unethical situation of social determinants of medical inequality be addressed?

What can be done to prevent our lack of preparedness in case of future pandemics?