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Garrett JR, McNolty LA, Wolfe ID, Lantos JD. Our Next Pandemic Ethics Challenge? Allocating "Normal" Health Care Services. Hastings Cent Rep 2020; 50:79-80. [PMID: 32596905 DOI: 10.1002/hast.1145] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The pandemic creates unprecedented challenges to society and to health care systems around the world. Like all crises, these provide a unique opportunity to rethink the fundamental limiting assumptions and institutional inertia of our established systems. These inertial assumptions have obscured deeply rooted problems in health care and deflected attempts to address them. As hospitals begin to welcome all patients back, they should resist the temptation to go back to business as usual. Instead, they should retain the more deliberative, explicit, and transparent ways of thinking that have informed the development of crisis standards of care. The key lesson to be learned from those exercises in rational deliberation is that justice must be the ethical foundation of all standards of care. Justice demands that hospitals take a safety-net approach to providing services that prioritizes the most vulnerable segments of society, continue to expand telemedicine in ways that improve access without exacerbating disparities, invest in community-based care, and fully staff hospitals and clinics on nights and weekends.
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Silberzweig J, Ikizler TA, Kramer H, Palevsky PM, Vassalotti J, Kliger AS. Rationing Scarce Resources: The Potential Impact of COVID-19 on Patients with Chronic Kidney Disease. J Am Soc Nephrol 2020; 31:1926-1928. [PMID: 32669321 DOI: 10.1681/asn.2020050704] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
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Farrell TW, Ferrante LE, Brown T, Francis L, Widera E, Rhodes R, Rosen T, Hwang U, Witt LJ, Thothala N, Liu SW, Vitale CA, Braun UK, Stephens C, Saliba D. AGS Position Statement: Resource Allocation Strategies and Age-Related Considerations in the COVID-19 Era and Beyond. J Am Geriatr Soc 2020; 68:1136-1142. [PMID: 32374440 PMCID: PMC7267615 DOI: 10.1111/jgs.16537] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 04/30/2020] [Indexed: 01/14/2023]
Abstract
Coronavirus disease 2019 (COVID-19) continues to impact older adults disproportionately, from severe illness and hospitalization to increased mortality risk. Concurrently, concerns about potential shortages of healthcare professionals and health supplies to address these needs have focused attention on how resources are ultimately allocated and used. Some strategies misguidedly use age as an arbitrary criterion, inappropriately disfavoring older adults. This statement represents the official policy position of the American Geriatrics Society (AGS). It is intended to inform stakeholders including hospitals, health systems, and policymakers about ethical considerations to consider when developing strategies for allocating scarce resources during an emergency involving older adults. Members of the AGS Ethics Committee collaborated with interprofessional experts in ethics, law, nursing, and medicine (including geriatrics, palliative care, emergency medicine, and pulmonology/critical care) to conduct a structured literature review and examine relevant reports. The resulting recommendations defend a particular view of distributive justice that maximizes relevant clinical factors and deemphasizes or eliminates factors placing arbitrary, disproportionate weight on advanced age. The AGS positions include (1) avoiding age per se as a means for excluding anyone from care; (2) assessing comorbidities and considering the disparate impact of social determinants of health; (3) encouraging decision makers to focus primarily on potential short-term (not long-term) outcomes; (4) avoiding ancillary criteria such as "life-years saved" and "long-term predicted life expectancy" that might disadvantage older people; (5) forming and staffing triage committees tasked with allocating scarce resources; (6) developing institutional resource allocation strategies that are transparent and applied uniformly; and (7) facilitating appropriate advance care planning. The statement includes recommendations that should be immediately implemented to address resource allocation strategies during COVID-19, aligning with AGS positions. The statement also includes recommendations for post-pandemic review. Such review would support revised strategies to ensure that governments and institutions have equitable emergency resource allocation strategies, avoid future discriminatory language and practice, and have appropriate guidance to develop national frameworks for emergent resource allocation decisions. J Am Geriatr Soc 68:1136-1142, 2020.
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Farrell TW, Francis L, Brown T, Ferrante LE, Widera E, Rhodes R, Rosen T, Hwang U, Witt LJ, Thothala N, Liu SW, Vitale CA, Braun UK, Stephens C, Saliba D. Rationing Limited Healthcare Resources in the COVID-19 Era and Beyond: Ethical Considerations Regarding Older Adults. J Am Geriatr Soc 2020; 68:1143-1149. [PMID: 32374466 PMCID: PMC7267288 DOI: 10.1111/jgs.16539] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 04/30/2020] [Indexed: 12/11/2022]
Abstract
Coronavirus disease 2019 (COVID‐19) continues to impact older adults disproportionately with respect to serious consequences ranging from severe illness and hospitalization to increased mortality risk. Concurrently, concerns about potential shortages of healthcare professionals and health supplies to address these issues have focused attention on how these resources are ultimately allocated and used. Some strategies, for example, misguidedly use age as an arbitrary criterion that disfavors older adults in resource allocation decisions. This is a companion article to the American Geriatrics Society (AGS) position statement, “Resource Allocation Strategies and Age‐Related Considerations in the COVID‐19 Era and Beyond.” It is intended to inform stakeholders including hospitals, health systems, and policymakers about ethical considerations that should be considered when developing strategies for allocation of scarce resources during an emergency involving older adults. This review presents the legal and ethical background for the position statement and discusses these issues that informed the development of the AGS positions: (1) age as a determining factor, (2) age as a tiebreaker, (3) criteria with a differential impact on older adults, (4) individual choices and advance directives, (5) racial/ethnic disparities and resource allocation, and (6) scoring systems and their impact on older adults. It also considers the role of advance directives as expressions of individual preferences in pandemics. J Am Geriatr Soc 68:1143–1149, 2020. See related paper by Farrell et al.
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Dudzinski DM, Hoisington BY, Brown CE. Ethics Lessons From Seattle's Early Experience With COVID-19. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:67-74. [PMID: 32552455 DOI: 10.1080/15265161.2020.1764137] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Ethics consultants and critical care clinicians reflect on Seattle's early experience as the United States' first epicenter of COVID-19. We discuss ethically salient issues confronted at UW Medicine's hospitals and provide lessons for other health care institutions that may soon face what we have faced.
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Haward MF, Janvier A, Moore GP, Laventhal N, Fry JT, Lantos J. Should Extremely Premature Babies Get Ventilators During the COVID-19 Crisis? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:37-43. [PMID: 32400291 DOI: 10.1080/15265161.2020.1764134] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
In a crisis, societal needs take precedence over a patient's best interests. Triage guidelines, however, differ on whether limited resources should focus on maximizing lives or life-years. Choosing between these two approaches has implications for neonatology. Neonatal units have ventilators, some adaptable for adults. This raises the question of whether, in crisis conditions, guidelines for treating extremely premature babies should be altered to free-up ventilators. Some adults who need ventilators will have a survival rate higher than some extremely premature babies. But surviving babies will likely live longer, maximizing life-years. Empiric evidence demonstrates that these babies can derive significant survival benefits from ventilation when compared to adults. When "triaging" or choosing between patients, justice demands fair guidelines. Premature babies do not deserve special consideration; they deserve equal consideration. Solidarity is crucial but must consider needs specific to patient populations and avoid biases against people with disabilities and extremely premature babies.
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Auriemma CL, Molinero AM, Houtrow AJ, Persad G, White DB, Halpern SD. Eliminating Categorical Exclusion Criteria in Crisis Standards of Care Frameworks. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:28-36. [PMID: 32420822 PMCID: PMC7387214 DOI: 10.1080/15265161.2020.1764141] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
During public health crises including the COVID-19 pandemic, resource scarcity and contagion risks may require health systems to shift-to some degree-from a usual clinical ethic, focused on the well-being of individual patients, to a public health ethic, focused on population health. Many triage policies exist that fall under the legal protections afforded by "crisis standards of care," but they have key differences. We critically appraise one of the most fundamental differences among policies, namely the use of criteria to categorically exclude certain patients from eligibility for otherwise standard medical services. We examine these categorical exclusion criteria from ethical, legal, disability, and implementation perspectives. Focusing our analysis on the most common type of exclusion criteria, which are disease-specific, we conclude that optimal policies for critical care resource allocation and the use of cardiopulmonary resuscitation (CPR) should not use categorical exclusions. We argue that the avoidance of categorical exclusions is often practically feasible, consistent with public health norms, and mitigates discrimination against persons with disabilities.
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Li Q, Tian L, Jing X, Chen X, Li J, Chen H. Efficiency and scale effect of county public hospitals in Shandong Province, China: a cross-sectional study. BMJ Open 2020; 10:e035703. [PMID: 32540890 PMCID: PMC7299019 DOI: 10.1136/bmjopen-2019-035703] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To evaluate the efficiency of county public hospitals in Shandong Province following China's new medical reform and compare the efficiency of hospitals with different bed sizes for improving efficiency. DESIGN AND SETTING This was a cross-sectional study on the efficiency and size of 68 county public hospitals in China in 2017. OUTCOME MEASURES Data envelopment analysis was used to calculate the efficiency scores of hospitals and to analyse the slack values of inefficient hospitals. The actual number of open beds, doctors, nurses and total expenditure were selected as inputs, and the total number of annual visits, discharges and total income were selected as outputs. The Kruskal-Wallis H test was employed to compare the efficiency of hospitals with different bed sizes. The χ2 test was used to compare the returns to scale (RTS) of hospitals with different bed sizes. RESULTS Twenty (29.41%) hospitals were efficient. There were 27 hospitals with increasing returns to scale, 23 hospitals with constant returns to scale and 18 hospitals with decreasing returns to scale (DRS). The differences in technical efficiency (p=0.248, p>0.05) and pure technical efficiency (p=0.073, p>0.05) were not statistically significant. However, the differences in scale efficiency (p=0.047, p<0.05) and RTS (p<0.001) were statistically significant. Hospitals with DRS began to appear at 885 beds. All sample hospitals with more than 1100 beds were already saturated and some hospitals even had a negative scale effect. CONCLUSIONS The government and hospital managers should strictly control the bed size in hospitals and make hospitals resume operating in the interests of public welfare. Interventions that rationally allocate health resources and improve the efficiency of medical workers are conducive to solving redundant inputs and insufficient outputs.
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Gwynne-Jones DP, Wilson R, McEwan C. National Referral Prioritization tool for first specialist assessment: results of a pilot study in orthopaedic surgery. ANZ J Surg 2020; 90:1738-1742. [PMID: 32455480 DOI: 10.1111/ans.16002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 04/15/2020] [Accepted: 05/03/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Most public hospitals are receiving more referrals for first specialist assessment than they have capacity to see. Traditional priority categories are too broad for effective discrimination. In New Zealand (NZ) explicit prioritization is required by legislation and supported by the Medical Council of NZ. A new generic National Referral Prioritization tool (NRPT) has been developed which includes a patient impact on life score. This study reports its trial implementation in orthopaedic surgery in a single centre. METHODS Four months of referrals to the orthopaedic department were prioritized using the new NRPT and traditional clinical priority categories. Scores and acceptances were compared across conditions, surgeons and against the traditional categories. RESULTS The mean NRPT was 60.1 (range 23-99). The correlation with impact on life was 0.59. There was good consistency of scores between surgeons. The NRPT score was significantly different across clinical priority categories (urgent, semi-urgent, routine). A total of 305 referrals (49%) were accepted using the NRPT compared with 493 (79%) if the traditional tool had been used. Patients with foot and ankle, carpal tunnel syndrome and upper limb conditions had the lowest scores and were more likely to be declined. CONCLUSIONS The NRPT is the first tool designed to prioritize referral letters. It is more discriminating than the clinical priority categories used previously. It allows fine-tuning of a threshold score to balance acceptances and capacity.
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Abstract
There is no agreed minimum standard with regard to what is considered safe, competent nursing care. Limited resources and organizational constraints make it challenging to develop a minimum standard. As part of their everyday practice, nurses have to ration nursing care and prioritize what care to postpone, leave out, and/or omit. In developed countries where public healthcare is tax-funded, a minimum level of healthcare is a patient right; however, what this entails in a given patient’s actual situation is unclear. Thus, both patients and nurses would benefit from the development of a minimum standard of nursing care. Clarity on this matter is also of ethical and legal concern. In this article, we explore the case for developing a minimum standard to ensure safe and competent nursing care services. Any such standard must encompass knowledge of basic principles of clinical nursing and preservation of moral values, as well as managerial issues, such as manpower planning, skill-mix, and time to care. In order for such standards to aid in providing safe and competent nursing care, they should be in compliance with accepted evidence-based nursing knowledge, based on patients’ needs and legal rights to healthcare and on nurses’ codes of ethics. That is, a minimum standard must uphold a satisfactory level of quality in terms of both professionalism and ethics. Rather than being fixed, the minimum standard should be adjusted according to patients’ needs in different settings and may thus be different in different contexts and countries.
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Sandman L, Hofmann B, Bognar G. Rethinking patient involvement in healthcare priority setting. BIOETHICS 2020; 34:403-411. [PMID: 32333687 DOI: 10.1111/bioe.12730] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 11/05/2019] [Accepted: 11/19/2019] [Indexed: 06/11/2023]
Abstract
With healthcare systems under pressure from scarcity of resources and ever-increasing demand for services, difficult priority setting choices need to be made. At the same time, increased attention to patient involvement in a wide range of settings has given rise to the idea that those who are eventually affected by priority setting decisions should have a say in those decisions. In this paper, we investigate arguments for the inclusion of patient representatives in priority setting bodies at the policy level. We find that the standard justifications for patient representation, such as to achieve patient-relevant decisions, empowerment of patients, securing legitimacy of decisions, and the analogy with democracy, all fall short of supporting patient representation in this context. We conclude by briefly outlining an alternative proposal for patient participation that involves patient consultants.
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Abstract
In recent months, Covid-19 has devastated African American communities across the nation, and a Minneapolis police officer murdered George Floyd. The agents of death may be novel, but the phenomena of long-standing epidemics of premature black death and of police violence are not. This essay argues that racial health and health care disparities, rooted as they are in systemic injustice, ought to carry far more weight in clinical ethics than they generally do. In particular, this essay examines palliative and end-of-life care for African Americans, highlighting the ways in which American medicine, like American society, has breached trust. In the experience of many African American patients struggling against terminal illness, health care providers have denied them a say in their own medical decision-making. In the midst of the Covid-19 pandemic, African Americans have once again been denied a say with regard to the rationing of scarce medical resources such as ventilators, in that dominant and ostensibly race-neutral algorithms sacrifice black lives. Is there such thing as a "good" or "dignified" death when African Americans are dying not merely of Covid-19 but of structural racism?
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Savulescu J, Cameron J, Wilkinson D. Equality or utility? Ethics and law of rationing ventilators. Br J Anaesth 2020; 125:10-15. [PMID: 32381261 PMCID: PMC7167543 DOI: 10.1016/j.bja.2020.04.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 04/09/2020] [Accepted: 04/10/2020] [Indexed: 11/19/2022] Open
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Tønnessen S, Christiansen K, Hjaltadóttir I, Leino-Kilpi H, Scott PA, Suhonen R, Öhlén J, Halvorsen K. Visibility of nursing in policy documents related to health care priorities. J Nurs Manag 2020; 28:2081-2090. [PMID: 32037639 DOI: 10.1111/jonm.12977] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 01/18/2020] [Accepted: 02/06/2020] [Indexed: 12/01/2022]
Abstract
AIM To explore the visibility of nursing in policy documents concerning health care priorities in the Nordic countries. BACKGROUND Nurses at all levels in health care organisations set priorities on a daily basis. Such prioritization entails allocation of scarce public resources with implications for patients, nurses and society. Although prioritization in health care has been on the political agenda for many years, prioritization in nursing seems to be obscure in policy documents. METHODOLOGY Each author searched for relevant documents from their own country. Text analyses were conducted of the included documents concerning nursing visibility. RESULTS All the Nordic countries have published documents articulating values and criteria relating to health care priorities. Nursing is seldom explicitly mentioned but rather is included and implicit in discussions of health care prioritization in general. CONCLUSION There is a need to make priorities in nursing visible to prevent missed nursing care and ensure fair allocation of limited resources. IMPLICATIONS FOR NURSING MANAGEMENT To highlight nursing priorities, we suggest that the fundamental need for nursing care and what this implies for patient care in different organisational settings be clarified and that policymakers explicitly include this information in national policy documents.
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Egan M, Murar F, Lawrence J, Burd H. Identifying the predictors of avoidable emergency department attendance after contact with the NHS 111 phone service: analysis of 16.6 million calls to 111 in England in 2015-2017. BMJ Open 2020; 10:e032043. [PMID: 32152158 PMCID: PMC7066618 DOI: 10.1136/bmjopen-2019-032043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To measure the frequency of patients making avoidable emergency department (ED) attendances after contact with NHS 111 and to examine whether these attendances can be predicted reliably. DESIGN Analysis of 16 563 946 calls made to 111, where each call was linked with a record of whether the patient attended ED within 24 hours. SETTING All regions of England from March 2015 to October 2017. PARTICIPANTS AND DATA Our main regression model used a sample of 10 954 783 calls, each with detailed patient-level information. MAIN OUTCOME Whether patients made an unadvised, non-urgent type 1 ED ('avoidable') attendance within 24 hours of calling 111. RESULTS Of 16 563 946 calls to 111, 12 894 561 (77.8%) were not advised to go to ED (ie, they were advised to either attend primary care, attend another non-ED healthcare service or to self-care). Of the calls where the patient was not advised to go to the ED, 691 783 (5.4%) resulted in the patient making an avoidable ED attendance within 24 hours. Among other factors, calls were less likely to result in these attendances when they received clinical input (adjusted OR 0.52, 95% CI 0.51 to 0.53) but were more likely when the patient was female (OR 1.07, 95% CI 1.06 to 1.08) or aged 0-4 years (OR 1.34, 95% CI 1.33 to 1.35). CONCLUSIONS For every 20 calls where 111 did not advise people to attend the ED, 1 resulted in avoidable ED attendance within 24 hours. These avoidable attendances could be predicted, to a certain extent, based on call characteristics. It may be possible to use this information to help 111 call handlers identify which callers are at higher risk of these attendances.
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Hughes D, Doheny S. Constructing 'exceptionality': a neglected aspect of NHS rationing. SOCIOLOGY OF HEALTH & ILLNESS 2019; 41:1600-1617. [PMID: 31219173 DOI: 10.1111/1467-9566.12976] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
In the British NHS the principle of exceptionality involves assessing whether a patient is sufficiently different from the generality of patients to justify providing a treatment, such as an expensive cancer drug, not approved for routine funding. In England, individual requests for certain high-cost treatments are considered by local panels that examine exceptionality alongside treatment efficacy and cost as the main criteria for funding. This was also the case in Wales until September 2017. Our paper draws on audio recordings of panel meetings and interviews in a Welsh Health Board to investigate how exceptionality was constructed in discussions. It focuses on the problematic combination of different decision criteria in meeting talk, particularly regarding the discourses associated with efficacy and exceptionality. Exceptionality is a fluid category that raised questions about the evidence-based nature of panel decision making. In particular, the paper discusses the use of subgroup data from RCTs and the difficulty of deciding how small a subgroup of patients should be before it is deemed exceptional. Determining exceptionality has been an important mechanism for deciding that a minority of NHS patients can still receive high-cost treatments not routinely provided for all. As a neglected rationing mechanism it warrants sociological examination.
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Gaydarov GM, Apkhanova NS, Tolstykh AS, Dushina EV. [On the issue of work time measurement in phthisiatricians rendering ambulatory polyclinic care to adult and children population]. PROBLEMY SOT︠S︡IALʹNOĬ GIGIENY, ZDRAVOOKHRANENII︠A︡ I ISTORII MEDIT︠S︡INY 2019; 27:464-469. [PMID: 31465667 DOI: 10.32687/0869-866x-2019-27-4-464-469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 04/30/2019] [Indexed: 11/06/2022]
Abstract
The formation of the number of medical personnel, the establishment of labor standards, the rational distribution and use of personnel are the most significant components of the system of labor rationing in health care. Standard norms of working time for TB doctors are not developed. There is an uneven workload and a plan implementation indicator in different offices and cabinets. The timing of the working process of phthisiatricians providing outpatient care to adults and children was carried out; work time was spent on individual elements of the labor process of district phthisiatricians accepting adults and children and a phthisiatrician without district work receiving patients in the office tuberculosis care for HIV patients. The concept of "visitation" is defined as applied to the working conditions of the TB service. According to the results of time-keeping observations, technological operations performed by TB doctors, including additional sections of work that are not related to the admission of patients, are highlighted; the normative indicator of the function of the medical post of the district TB specialist and the normative indicator of the time spent on one visit are determined.
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Kottow M. Intergenerational healthcare inequities in developing countries. Dev World Bioeth 2019; 20:122-129. [PMID: 31475438 DOI: 10.1111/dewb.12244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 07/17/2019] [Accepted: 07/26/2019] [Indexed: 11/28/2022]
Abstract
Concern about the rapid ageing of all societies reaches alarming proportions as healthcare inequities are steeply rising, prompting the elderly to live longer but subject to insufficient social protection and healthcare in the wake of dwindling public resources. The aged population of developing nations are facing additional hardships due to the growing gap between needs and the financial reductions of public institutions, retirement funds, and the trend towards privatization of essential services turned into commodities. Current approaches to allocation of insufficient resources without ageist discrimination are briefly discussed: individual self-care aimed at successful, active and healthy ageing based on resourcefulness of the privileged elderly; utilitarian approaches founded on QALY and fair innings, and human rights focused on the plights of the elderly. These approaches cannot apply to resources poor nations, who need to engage in context-bound bioethics dealing with the realities of their exposed ageing population. A developing world bioethics is needed to face the plights of the elderly in countries with low and middle-income and insufficient social capital. Suggested are: 1) a phenomenological approach based on the interaction of bioethics and ethnology, furthering grass-roots input from the elderly; 2) Create small communities -campus-like boroughs- to simplify accessibility to social services and healthcare facilities, as an alternative to the high-cost WHO proposal of age-friendly large cities.
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Scott PA. Niven and Scott (2003): Sixteen years of hindsight. Nurs Philos 2019; 20:e12250. [PMID: 31136085 DOI: 10.1111/nup.12250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 04/15/2019] [Accepted: 04/18/2019] [Indexed: 11/30/2022]
Abstract
This paper revisits a 2003 publication in Nursing Philosophy: The need for accurate perception and informed judgement in determining the appropriate use of the nursing resource: hearing the patient's voice. The author suggests that the basic ideas and focus of this 16-year-old paper are still topical and relevant in considerations of nursing care. However, it is also suggested that greater attention to the importance of the nurse-patient relationship in considerations of resource allocation, and potential rationing of nursing care, would have strengthened the original paper.
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Taylor C, Joolay Y, Buckle A, Lilford R. Prioritising allocation of donor human breast milk amongst very low birthweight infants in middle-income countries. MATERNAL & CHILD NUTRITION 2018; 14 Suppl 6:e12595. [PMID: 30592164 PMCID: PMC6865934 DOI: 10.1111/mcn.12595] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 12/02/2017] [Accepted: 01/07/2018] [Indexed: 01/28/2023]
Abstract
The use of donor human breast milk instead of formula reduces the risk of necrotising enterocolitis in preterm infants when their mother's own milk is insufficient. Use of donor milk is limited by the cost of establishing a milk bank and a lack of donors, but the optimal rationing of limited donor milk is unclear. This paper uses an economic model to explore how a limited donor milk supply should be allocated across very low birthweight infants in South Africa considering 2 outcomes: maximising lives saved and minimising costs. We developed a probabilistic cohort Markov decision model with 10,000 infants across 4 birthweight groups. We evaluated allocation scenarios in which infants in each group could be exclusively formula-fed or fed donor milk for 14 or 28 days and thereafter formula until death or discharge. Prioritising infants in the lowest birthweight groups would save the most lives, whereas prioritising infants in the highest birthweight groups would result in the highest cost savings. All allocation scenarios would be considered very cost-effective in South Africa compared to the use of formula; the "worst case" was $619 per Disability Adjusted Life Year averted. There is a compelling argument to increase the supply of donor milk in middle-income countries. Our analysis could be extended by taking a longer term perspective, using data from more than one country and exploring the use of donor milk as an adjunct to mother's own milk, rather than a pure substitute for it.
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Johannessen LEF. Narratives and gatekeeping: making sense of triage nurses' practice. SOCIOLOGY OF HEALTH & ILLNESS 2018; 40:892-906. [PMID: 29664118 DOI: 10.1111/1467-9566.12732] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
It is well documented that emergency service staff consider some patients to be 'inappropriate attenders'. A central example is 'trivia', denoting patients with medical problems considered too 'trivial' to warrant attention. Although research has repeatedly shown that frontline staff violate guidelines in turning away 'trivial' patients, existing research has paid insufficient attention to why staff are willing to engage in guideline-violating gatekeeping, which may put both themselves and 'trivial' patients at risk. To address this issue, the present article explores nurses' narratives about 'trivial' patients - referred to in this context as 'GP patients' - drawing on fieldwork data from a Norwegian emergency service. The article reconstructs three narrative clusters, showing that nurses' gatekeeping is motivated by concerns for the patient being turned away, for nurses and more critically ill patients, and for the service they work for. Some of the issues embedded in these narratives have been under-analysed in previous research - most importantly, the role of identity and emotion in nurses' gatekeeping, and how patient narratives can function as 'social prognoses' in nurses' assessments. Analysis of these narratives also reveals an antagonistic relationship between nurses and 'trivial' patients that contradicts nurses' ethical guidelines and indicates a need for healthcare reform.
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Abstract
The number of patients requiring dialysis by 2030 is projected to double worldwide, with the largest increase expected in low- and middle-income countries (LMICs). Dialysis is seldom considered a high priority by health care funders, consequently, few LMICs develop policies regarding dialysis allocation. Dialysis facilities may exist, but access remains highly inequitable in LMICs. High out-of-pocket payments make dialysis unsustainable and plunge many families into poverty. Patients, families, and clinicians suffer significant emotional and moral distress from daily life-and-death decisions imposed by dialysis. The health system's obligation to provide financial risk protection is an important component of global and national strategies to achieve universal health coverage. An ethical imperative therefore exists to develop transparent dialysis priority-setting guidelines to facilitate public understanding and acceptance of the realistic limits within the health system, and facilitate fair allocation of scarce resources. In this article, we present ethical challenges faced by patients, families, clinicians, and policy makers where dialysis is not universally accessible and discuss the potential ethical consequences of various dialysis allocation strategies. Finally, we suggest an ethical framework for use in policy development for priority setting of dialysis care. The accountability for reasonableness framework is proposed as a procedurally fair decision-making, priority-setting process.
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Walker AJ, Curtis HJ, Bacon S, Croker R, Goldacre B. Trends, geographical variation and factors associated with prescribing of gluten-free foods in English primary care: a cross-sectional study. BMJ Open 2018; 8:e021312. [PMID: 29661914 PMCID: PMC5905743 DOI: 10.1136/bmjopen-2017-021312] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES There is substantial disagreement about whether gluten-free foods should be prescribed on the National Health Service. We aim to describe time trends, variation and factors associated with prescribing gluten-free foods in England. SETTING English primary care. PARTICIPANTS English general practices. PRIMARY AND SECONDARY OUTCOME MEASURES We described long-term national trends in gluten-free prescribing, and practice and Clinical Commissioning Group (CCG) level monthly variation in the rate of gluten-free prescribing (per 1000 patients) over time. We used a mixed-effect Poisson regression model to determine factors associated with gluten-free prescribing rate. RESULTS There were 1.3 million gluten-free prescriptions between July 2016 and June 2017, down from 1.8 million in 2012/2013, with a corresponding cost reduction from £25.4 million to £18.7 million. There was substantial variation in prescribing rates among practices (range 0 to 148 prescriptions per 1000 patients, IQR 7.3-31.8), driven in part by substantial variation at the CCG level, likely due to differences in prescribing policy. Practices in the most deprived quintile of deprivation score had a lower prescribing rate than those in the highest quintile (incidence rate ratio 0.89, 95% CI 0.87 to 0.91). This is potentially a reflection of the lower rate of diagnosed coeliac disease in more deprived populations. CONCLUSION Gluten-free prescribing is in a state of flux, with substantial clinically unwarranted variation between practices and CCGs.
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Scott PA, Harvey C, Felzmann H, Suhonen R, Habermann M, Halvorsen K, Christiansen K, Toffoli L, Papastavrou E. Resource allocation and rationing in nursing care: A discussion paper. Nurs Ethics 2018; 26:1528-1539. [PMID: 29607703 PMCID: PMC6681425 DOI: 10.1177/0969733018759831] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Driven by interests in workforce planning and patient safety, a growing body of literature has begun to identify the reality and the prevalence of missed nursing care, also specified as care left undone, rationed care or unfinished care. Empirical studies and conceptual considerations have focused on structural issues such as staffing, as well as on outcome issues - missed care/unfinished care. Philosophical and ethical aspects of unfinished care are largely unexplored. Thus, while internationally studies highlight instances of covert rationing/missed care/care left undone - suggesting that nurses, in certain contexts, are actively engaged in rationing care - in terms of the nursing and nursing ethics literature, there appears to be a dearth of explicit decision-making frameworks within which to consider rationing of nursing care. In reality, the assumption of policy makers and health service managers is that nurses will continue to provide full care - despite reducing staffing levels and increased patient turnover, dependency and complexity of care. Often, it would appear that rationing/missed care/nursing care left undone is a direct response to overwhelming demands on the nursing resource in specific contexts. A discussion of resource allocation and rationing in nursing therefore seems timely. The aim of this discussion paper is to consider the ethical dimension of issues of resource allocation and rationing as they relate to nursing care and the distribution of the nursing resource.
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Anticipating uncertainty and irrevocable decisions: provider perspectives on implementing whole-genome sequencing in critically ill children with heart disease. Genet Med 2018; 20:1455-1461. [PMID: 29493583 DOI: 10.1038/gim.2018.25] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 01/30/2018] [Indexed: 12/21/2022] Open
Abstract
PURPOSE To investigate the potential impacts of whole-genome sequencing (WGS) in the pediatric critical-care context, we examined how clinicians caring for critically ill children with congenital heart disease (CHD) anticipate and perceive the impact of WGS on their decision-making process and treatment recommendations. METHODS We conducted semistructured in-person and telephone interviews of clinicians involved in the care of critically ill children with CHD at a high-volume pediatric heart center. We qualitatively analyzed the transcribed interviews. RESULTS In total, 34 clinicians were interviewed. Three themes emerged: (i) uncertainty about the accuracy of WGS testing and adequacy of testing validation; (ii) the use of WGS to facilitate life-limiting decisions such as futility, rationing, and selective prenatal termination; and (iii) moral distress over using WGS with a lack of decision support. CONCLUSION Despite uncertainty about WGS testing, the interviewed clinicians were using, and anticipated expanding the use of, WGS results to justify declarations of futility, withdrawal of care, and rationing in critically ill children with CHD. This situation is causing moral distress in providers who have to make high-stakes decisions involving WGS results, with only partial understanding of them. Decision support for clinicians, and discussion with families of the risks of using WGS for rationing or withdrawal, is needed.
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