Researchers outlined a set of 6 recommendations detailing what strategies medical institutions should implement in the event that medical resources become scarce during the COVID-19 pandemic.
In a paper published in The New England Journal of Medicine, researchers outlined a set of 6 recommendations detailing what strategies medical institutions should implement in the event that medical resources become scarce during the coronavirus disease 2019 (COVID-19) pandemic.
The recommendations are intended to be used by healthcare centers in order to develop guidelines that can be applied fairly and consistently across cases.
“Such guidelines can ensure that individual doctors are never tasked with deciding unaided which patients receive life-saving care and which do not,” the authors wrote. “Instead, we believe guidelines should be provided at a higher level of authority, both to alleviate physician burden and to ensure equal treatment.”
According to the researchers, in the context of a pandemic, the value of maximizing benefits is most important. Moreover, priority for limited resources should aim at both saving the most lives and at maximizing improvements in the post-treatment length of life for individuals. Overall, this directive means that people who are sick but could recover if treated should be given priority over those who are unlikely to recover even if treated and those who are likely to recover without treatment.
For example, removing a patient from a ventilator or an ICU bed to provide it to those in need is considered justifiable by the researchers, and patients should be made aware of the possibility at admission. Though this would undoubtedly be psychologically traumatic for clinicians, and some may refuse to do so, many guidelines agree that the decision to withdraw a scarce resource to save others is not an act of killing and does not require the patient’s consent.
“Initially allocating beds and ventilators according to the value of maximizing benefits could help reduce the need for withdrawal,” the authors wrote.
Furthermore, essential COVID-19 interventions, such as testing, PPE, ICU beds, ventilators, therapeutics, and vaccines, should be given first to front-line healthcare workers and others who are for ill patients, especially those who face a high risk of infection and whose training makes them difficult to replace. The researchers indicated that this is not because these workers are somehow more worthy, but because they offer instrumental value.
“If physicians and nurses are incapacitated, all patients – not just those with COVID-19 – will suffer greater mortality and years of life lost,” the authors wrote. “Whether health workers who need ventilators will be able to return to work is uncertain, but giving them priority for ventilators recognizes their assumption of the high-risk work of saving others, and it may also discourage absenteeism.”
Of note, priority for critical workers must not be abused by prioritizing wealthy or famous persons or even those politically powerful above first responders or medical staff, as has already been seen with testing. Doing so would undermine trust in the allocation framework.
For patients who have a similar prognosis, treatment should be operationalized through an equal and randomized allocation, such as a lottery, rather than on a first-come, first-served basis, according to the authors. First-come, first-served distribution of medications or vaccines would not only encourage crowding but could also encourage violence at a time when social distancing is crucial.
Prioritization guidelines should also differ by intervention and should correlate with changing scientific evidence. For instance, COVID-19 outcomes have been significantly worse thus far in older persons and those with chronic conditions, suggesting that older persons should be given vaccines immediately after health care workers and first responders.
“Determining the benefit-maximizing allocation of antivirals and other experimental treatments, which are likely to be most effective in patients who are seriously but not critically ill, will depend on scientific evidence,” the authors wrote. “These treatments may produce the most benefit if preferentially allocated to patients who would fare badly on ventilation.”
Additionally, those who participate in research to prove the safety and effectiveness of vaccines and therapeutics should receive some priority for COVID-19 interventions. The researchers suggested that their assumption of risk during their participation in research helps future patients and they should be reward for that contribution. Such rewards would also encourage other patients to participate in clinical trials. However, research participation should only be used as a tiebreaker among patients who have a similar diagnosis.
Should the pandemic lead to absolute scarcity, the researchers indicated that scarcity will affect all patients, including those with heart failure, cancer, and other serious life-threatening conditions that require prompt medical attention. Should this occur, fair allocation of resources that prioritizes the value of maximizing benefits would apply across all patients who need resources.
“The need to balance multiple ethical values for various interventions and in different circumstances is likely to lead to differing judgments about how much weight to give each value in particular cases,” the authors wrote. “To help clinicians navigate these challenges, institutions may employ triage officers, physicians in roles outside direct patient care, or committees of experienced physicians and ethicists, to help apply guidelines, to assist with rationing decisions, or to make and implement choices outright – relieving the individual front-line clinicians of that burden.”
With the rapidly growing imbalance between supply and demand for medical resources presenting the question of how to allocate such resources, it is crucial that governments and policy makers do all they can to prevent the scarcity of medical resources. However, should resources become scarce, the researchers indicated that these recommendations are fair and consistent allocation procedures that include clinicians, patients, public officials, and others.
Emanuel EJ, Persad G, Upshur R, et al. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. N Engl J Med. doi:10.1056/NEJMsb2005114.