Brigham and Women's Hospitals

Ethics

Updated: September 27, 2020

Resource Allocation and Triage

  1. Below are general considerations and references about resource allocation in the setting of scarcity. For a comprehensive framework for resource allocation, please see the model developed Douglas White and colleagues at the University of Pittsburgh.

Crisis Standards of Care

  1. A “crisis standard of care” is a set of principles to help guide triage when there are insufficient resources (including ICU beds, ventilators, dialysis machines, etc.) to meet medical needs (Institute of Medicine 2012).
  2. It is triggered by “a substantial change in usual healthcare operations and the level of care it is possible to deliver, which is made necessary by a pervasive (e.g. pandemic influenza) or catastrophic (e.g. earthquake, hurricane) disaster” (Institute of Medicine 2012)
  1. It must be formally declared by regional/state authorities and hospital leadership.
  2. It typically involves contingencies for different stages of a crisis
  1. It allows transparency. Transparency in decision making, particularly when resources are scarce and cannot be allocated to all who are in need, is essential (Biddison et al., Chest 2014)

Stages of crisis

(Christian et al. 2014)

Triage principles

  1. The goal of triage is to maximize population benefit while treating individuals fairly.
  1. This is different from the usual goal in medicine of promoting the wellbeing of individuals.
  1. The most widely endorsed strategies are to maximize lives saved or life-years saved:
  1. Lives saved (no explicit preference given based on age)
  2. Life-years saved (some explicit preference given to younger patients all else being equal)
  1. Several other strategies have been proposed to allocate scarce resources, but have been criticized for failing to maximize benefit (NY State Task Force 2015). These include:
  1. first-come first served
  2. lottery
  3. preferential allocation (e.g. for healthcare workers)
  1. Consensus statement policies (Biddison et al., Chest, 2014) suggest no ethical difference between withholding and withdrawing care.

Structure of triage teams

  1. Consensus guidelines suggest that all decisions about triage are made by a Triage Officer, not the bedside clinicians caring for patients (Christian, Chest, 2014).
  2. The Triage Officer should be a physician with critical care training.
  3. Decisions about triage should be made based on protocols established by the hospital. These protocols should be evidence based and nondiscriminatory (Gostin & Hanfling, JAMA, 2009)
  4. Bedside clinicians, patients, and families should have mechanisms for appealing triage decisions.
  5. An oversight committee should be established to review decisions made by Triage Officers to ensure consistent application of the triage protocol and to adjudicate appeals.

Duties of Health Care Workers

  1. Regardless of scarcity, clinicians have a duty to care for all patients—including by providing compassionate comfort-oriented to those who will benefit from it.
  1. The duty to care requires that clinicians accept a reasonable level of risk in the provision of care, founded in the principles of fidelity, respect for persons, and non-abandonment.
  2. There is a corollary obligation of organizations to ensure risk is minimized to clinicians as much as possible through, for example, the provision of personal protective equipment (Veterans Health Administration 2010).
  3. It is critical to extend the same level of care and resources to all healthcare workers regardless of title, especially those such as environmental services that have increased exposure to potentially infectious materials and environments (Tyan and Evans, Annals of IM 2020, Himmelstein and Woolhandler, Annals of IM 2020).
  1. Unlike other staff, healthcare trainees are uniquely positioned to have high rates of exposure to COVID-19 with variable ability to contribute to patient care that justify this risk.
  1. This section is still in progress