Transcript Slide 1

Applying Altered but Ethical
Standards of Care
David A. Fleming, M.D., MA, FACP
Professor of Clinical Medicine
Director, MU Center for Health Ethics
University of Missouri School of Medicine
573-882-2738
[email protected]
Objectives
Understand the ethical complexities of
emerging threats requiring emergent
responses with limited resources
Recognize that altered standards are still
evidence based standards deployed in
nontraditional ways and places
Ethical guidance in establishing standards
when all cannot be saved
Emerging Threats
Pandemic: H5N1 (“bird flu”), VRSA, SARS
– CDC estimates that the next influenza pandemic will
result in 89,000 to 207,000 lost lives and $71.3 Bil. to
$166.4 Bil. economic loss.
Terrorist attack: anthrax, radiation,
bombing
Natural: hurricane, earthquake, flood
Potential Problem
Many epidemic and bioterrorist agent
illnesses will overwhelm current health
care resources.
Current ethics-based criteria for
allocation of resources will not apply in
situations of mass casualty.
– Duty to Respond and Treat
– Allocation of scarce healthcare resources
Six Critical Challenges in Pandemic
Planning
The concept of preparedness is not clearly
defined.
Some preparedness efforts can’t be resolved
by individual hospitals.
Demand for healthcare will exceed capacity.
Staffing will be inadequate.
Funding is inadequate.
Hospital solvency may be threatened.
Center on Biosecurity, University of Pittsburg Medical Center
Impact of Past Influenza
Pandemics
Pandemic
Mortality
1918-19
Spanish Flu
1957-58
Asian Flu
1968-69
Hong Kong Flu
1977-78
Russian Flu
500,000
Those
Affected
<65 years
70,000
Infants, elderly
36,000
Infants, elderly
8,300
Young (<20)
Influenza Pandemic
90 Mil sick (~1/3 of population 303,824,640)
10 Mil hospitalized
1.5 Mil requiring ICU
1.9 Mil deaths
USDHHS. HHS Pandemic Influenza Plan. 2005
www.hhs.gov.pandemicflu/plan
Ventilators Needed
105,000 ventilators available in U.S.
– during a regular flu season, 100,000 are in use
(McNeil, 2006)
National Preparedness Plan indicates a
potential need for 742,500 ventilators in a
worst case scenario pandemic.
$3.8 billion authorized for flu preparedness
by Congress
– But to buy enough ventilators for a flu outbreak
similar to that of 1918 it is estimated that
$18 billion will be required.
Missouri Pandemic Estimates 2007
Hospital Industry Data Institute, CDC
If 35% attack rate (population 5.6 Mil)
>27,000 admissions
>5,500 deaths (500-800 a week)
Non ICU beds available (staffed) 21,890
ICU beds available (staffed) 1,629
– capacity exceeded by week 4
Ventilators available 386 (20% of 1,931)
– capacity will be exceeded by week 2 and
last over 8 weeks
Estimated Impact on Columbia
Columbia Area
population
10% affected
100,000 persons
20% of those too sick
to care for selves
2,000 persons
20% of those require
hospitalization
-no family to provide care, too
400 persons
sick to stay home
10,000 persons
Choosing an ethics
framework
Traditional focus on “respect for patient
autonomy” is ineffective for resource
poor environments
A Utilitarian or “distributive justice”
model is more effective for scarce
resource allocation.
Ethical Complexities
Challenges of professional obligation
– Selectively not treating those who otherwise might be saved
Meeting “altered” standards of care
– Moral discomfort … conscientious objection
– Work force integrity
Physical and emotional exhaustion
Personal risk
– Alternative providers
– Alternative sites of care
– Organizational integrity … loss of resources
Public trust
–
–
–
–
Many will not have access who once did
Unexpected questions of Futility
Questions of fairness, bias, and disparity
Questions of transparency, consistency, accountability
Ethical Options Considered
Utilitarian (White)
– Maximize lives saved
– Maximize “life years” saved
– Opportunity to life through all “life stages”
– Elderly and those with functional impairment
denied access
Values, virtues and duties (Tuohey)
Solidarity and duty (Brody)
Community (Berlinger)
Who Should Receive Life Support?
White et al. Ann Int Med 2009;150:132-138
Utilitarian perspective
Based on prognosis for survival to
discharge
Life, life years, life stages
Social value
Instrumental value (“multiplier effect”)
Public engagement
A Matrix for Ethical Decision Making in a Pandemic
John Tuohey, Ph.D., St. Vincent Med. Ctr. Portland OR
Ethical Considerations
Contextual realities—communities rather than
only hospitals and clinics
Solidarity within the profession
– Duty to treat even if at risk
– Same professional standards but in a different
context
Solidarity within and between institutions
Solidarity between providers and community
Social solidarity
Shared duty
Importance of the Context of the
Response
For Hospitals  resource centered
– ”altered standards protocols”
– unquestioned authority and objectivity
For first responders  person centered
– Viability (futility)
– Compassion and comfort (beneficence)
– Parity (Justice)
– Room for variability (regional, personal)
– Alternative sites available
Maintaining Integrity
Mission-goals-ideals
Hospital—objective criteria for
resource allocation
Community—person centered criteria
Professional—adapting competencies,
standards, and practices to contextual
changes
Futility
Do what is clinically indicated
Proportionate consideration of…
– Medical effectiveness (prognosis)
– Benefits/Burdens
Room for personal preference
Limits of autonomy (right to demand
and refuse treatment)
Guiding Principles
(obligations in a social context)
Consistency
Accountability
Transparency
Honesty
Reliability (safety)
Fairness
Guiding Values
(personal context)
Medical Effectiveness
Benefit/Burden (Quality of Life)
Urgency
Safety
Preferences
Compassion
Fairness
Healthcare resources are allocated fairly with a special
concern for the most vulnerable
With limited resources:
The fair distribution of scarce resources in an
emergency is governed not by what is best for the
individual, but rather “the greater good of the
community.”
Decisions will be made that result in certain people
getting some resources while others do not.
Not every need will be fulfilled in a disaster.
Respect
All, by nature, are worthy of esteem and respect.
All must know they will be cared for and treated with
dignity.
With limited resources:
some persons will receive treatment
some will receive limited treatment
some will receive palliative treatment
Missouri Altered Standards
Committee
MO DHSS (Nancie McAnaugh)
Ventilator Protocol
Pediatric subcommittee
Regional triage team for rural systems
Prehospital triage protocol
EMS engagement (first responders)
Just-in-time “grief training” for managers and
supervisors
Dialogue with trial attorneys association
Public feedback mechanism
Consortium
MU CHE and MO DHSS
Consortium of 4-5 ethics centers
Ethical guidelines of palliative care triage
for Missouri
Statewide network of ethical committees
Availability of ethics consults and
support
Thank You!