Transcript Triage of Mechanical Ventilation in an Epidemic: Ethical

The Ethics of Pandemic
Influenza Planning and Response
in Missouri
Lea Brandt, OTD, MA, OTR/L
MHPC OTA Program Director
Clinical Assistant Professor
School of Health Professions
Faculty, MU Center for Health Ethics
Objectives

Review the ethical implications of pandemic
from a community health perspective.

Provide foundation for discussion regarding
community-based response efforts.
Potential Problem

In the event of a pandemic current health care
resources will be overwhelmed.

More importantly the community itself!
◦ Every community is unique.

Current ethics-based criteria for allocation of
resources does not apply in situations of
pandemic.
Preparing for Pandemic Influenza
Barriers to Provision of Care
Ventilator shortages.
 Decreased Capacity

◦ ED overcrowding reported by 91% of ED
directors
◦ Decrease of inpatient bed capacity by 4.4%
nationwide.
◦ Shortage of trained and qualified healthcare
professionals
◦ Lack of “surge capacity”
◦ >10 day LOS for ICU patients with acute
respiratory syndrome

Public Response
Whose life is more valuable?
Decision Maker?
Healthcare Organizations and Public Health
Agencies must plan for the fair distribution of
resources


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Rationale: Must ensure that there is a process in place at
their healthcare organization for the fair distribution of
resources.
Includes both the educational opportunities for clinicians
to be informed of the guidelines for ethical decisionmaking
A process for making ethical decisions accomplished
through a vehicle such as an “Ethics Committee” with
clinical input that meets to review criteria for admission,
discharges, procedures, allocation of scarce resources.
Organizations and Communities must
be non-competitive

Rationale: To achieve “the greater good for the
community” leaders must set aside competitive
goals and do what is best for the community.
Leaders must ensure that there are agreements
in place for the sharing of supplies, equipment
and personnel and also for the triaging and
acceptance of patients, based on what is best
for the patients and the community.
Ethical Discussion

We need a regional plan.
◦ Should facilities be able to abstain from
participation?
◦ Does the plan need to be consistent between
facilities?
◦ Who should decide which patients receive
mechanical ventilation?
◦ Who can decide whether on patient’s life is
more valuable than another’s?
◦ Who should develop the criteria?
Disaster Ethics is a set of principles and values
that direct:
• Duties
• Obligations
• Parameters
Disaster Ethics is the study of what ought to
be done in a disaster situation.
Post Katrina, we need to reset our expectations.
We need to realize that, in a disaster, things will
not always go well; people will die; some people
may not get treatment
Choosing an ethics model

Traditional focus on patient autonomy
was deemed ineffective for resource
poor environments

Utilitarian or “distributive justice” model
is more effective for scarce resource
allocation
Fundamental Ethical Values
Fairness
 Respect
 Solidarity
 Limiting Harm

Fairness:
Healthcare resources are allocated fairly with a special
concern for the most vulnerable
With limited resources:

The fair distribution of resources is governed not by
what is best for the individual, but rather by the principle
of “the greater good of the community”

Decisions will be made that result in certain people
getting these resources and others not getting these
resources

Not every need will be able to be addressed in a
disaster.
Respect

*Each person must know that they will always be
cared for and will be treated with dignity.

A person is, by nature, worthy of esteem and respect

They should be assured that they will be provided
with dignified comfort care
With limited resources:



some persons will receive treatment
some will receive limited treatment
some will receive palliative treatment
Solidarity
Each individual must consider the needs of others
 Each person makes a commitment not only to family
and loved ones but also to the community

With Limited resources:

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Each person has an obligation to care for the other
Each person must consider the greater good of the
community rather than one’s own self-interest.
Nonmaleficence: Limiting Harm
Do No Harm
With limited resources:
•
Healthcare professionals may not be able to meet the
needs of all patients
•
Healthcare professionals will do as much good as possible
for each patient, which means “limiting harm done to
patients” because of the lack of necessary resources.
Example, with hospitals filled with patients, patients, who
would normally be hospitalized, may need to be cared for
at home. In this case, there will be public messages
available to help family members take care of sick persons
at home.
Procedural Values
Reasonableness
 Transparency/ Openness
 Inclusiveness
 Responsiveness
 Responsibility

Reasonableness

Reasonableness is the quality of being believable and
acceptable by the average person
With Limited Resources:

Treatment decisions are to be based on science,
evidence, practice, experience and principles and be
guided by the values that are identified in this
document

Both healthcare workers and the public should at
least understand that science, evidence, practice,
experience and principles are being used for
addressing healthcare decisions in a disaster
Transparency/Openness:

The process of discussing the guidelines
in this document and how these
guidelines will be applied in a disaster is
open to public discussion and scrutiny

This period of discussion is an
opportunity for both healthcare workers
and the public to provide their
recommendations about editing the
guidelines and to have their
recommendations recognized and acted
upon.
Inclusiveness

Health Ethics Considerations:
Planning for and Responding to
Pandemic Influenza in Missouri

Community Engagement
Responsiveness

There are to be opportunities to revisit
and revise guidelines as new information
emerges, especially throughout the actual
crisis

There are to be mechanisms to address
comments, recommendations, disputes
and complaints
Duty to Care
The “duty to care” is a duty incumbent upon
healthcare professionals. However, all healthcare
workers provide essential functions and all
contribute to patient care.
Thus, this “duty” is incumbent upon all
healthcare workers. Especially in high-risk
incidents, all healthcare workers along with
other critical infrastructure workers will be
faced with conflicting obligations.
Duty to Care
This same “duty” applies to everyone,
because, in a disaster, when there are
limited resources, each person has an
obligation to care for others, knowing
that with limited resources, all must all
think of the greater good rather than
think only of themselves.
Moving Forward

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Identify and acknowledge health system limitations
at a regional level.
Identify if there are current related policies
developed by community hospitals and public
health agencies and if there are conflicts between
policies of the organizations.
Identify potential champions in communities that
are willing to assist in standardizing criteria.
Organize focus groups including community
leaders and representatives from local health
related organizations.
Ultimately develop a contingency plan to address
such a situation in advance.
Moving Forward

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Provide guidelines for individual physicians with
regard to withdrawal, which will improve
consistency and decrease need for defense of
position.
Implemented on a regional not institutional basis
Include liability protections for providers and
institutions
Special attention should be paid to vulnerable
populations and representatives affiliated with
these groups should be involved in decisionmaking.
Restrictions should apply equally to those
infected and those hospitalized for other
reasons.
Altered Standards of Care????

The term "altered standards" has not
been definitively defined, but generally
is assumed to mean a shift to providing
care and allocating scarce equipment,
supplies, and personnel in a way that
saves the largest number of lives in
contrast to the traditional focus on
saving individuals
References
2008, Corneliuson, E. Ethical Decisions in a Mass Casualty or Biological Incident.
Region 7 Wisconsin Hospital Emergency Preparedness Program Presentation.
2006, State Expert Panel, Inpatient/Outpatient Surge Capacity: HRSA Wisconsin
Hospital Preparedness Program
2005, Upshur, R.; Faith, K.; Gibson, J.; Thompson, A.; Tracy, C.; Wilson, K.; Singer ,P.
Stand on Guard For Thee, Ethical considerations in preparedness planning for
pandemic influenza; A report of the University of Toronto Joint Centre of
Bioethics Pandemic Influenza Working Group
2005, Agency for Healthcare Research and Quality and the Office of the Assistant
Secretary for Public Health Emergency Preparedness, U.S. Department of
Health and Human Services, Altered Standards of Care in Mass Casualty
Events, Bioterrorism and Other Public Health Emergencies
2006, 7:5 Ruderman, C.; Tracy, S.; Bensimon,C.; Bernstein,M.; Hawryluck,L.; Zlotnik,
R; Shaul2, 5 and Ross EG ; Upshur,S.; Upshur,R.; On pandemics and the duty
to care: whose duty? who cares? Published: 20 April BMC Medical Ethics
2007, Roberts, M.; Hodge, J.; Gabreil, E.: Hick, J.; Cantrill, S.; Wilkinson, A.; Matzo,
M.; Mass Medical Care with Scarce Resources Published: February Agency
for Healthcare Research and Quality