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Butler CR, Webster LB, Diekema DS. Staffing crisis capacity: a different approach to healthcare resource allocation for a different type of scarce resource. JOURNAL OF MEDICAL ETHICS 2024; 50:647-649. [PMID: 35777960 PMCID: PMC9844994 DOI: 10.1136/jme-2022-108262] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 06/24/2022] [Indexed: 06/15/2023]
Abstract
Severe staffing shortages have emerged as a prominent threat to maintaining usual standards of care during the COVID-2019 pandemic. In dire settings of crisis capacity, healthcare systems assume the ethical duty to maximise aggregate population-level benefit of existing resources. To this end, existing plans for rationing mechanical ventilators and intensive care unit beds in crisis capacity focus on selecting individual patients who are most likely to survive and prioritising these patients to receive scarce resources. However, staffing capacity is conceptually different from availability of these types of discrete resources, and the existing strategy of identifying and prioritising patients with the best prognosis cannot be readily adapted to fit this real-world scenario. We propose that two alternative approaches to staffing resource allocation offer a better conceptual fit: (1) prioritise the worst off: restrict access to acute care services and hospital admission for patients at relatively low clinical risk and (2) prioritise staff interventions with high near-term value: universally restrict selected interventions and treatments that require substantial staff time and/or energy but offer minimal near-term patient benefit. These strategies-while potentially resulting in care that deviates from usual standards-support the goal of maximising the aggregate benefit of scarce resources in crisis capacity settings triggered by staffing shortages. This ethical framework offers a foundation to support institutional leaders in developing operationalisable crisis capacity policies that promote fairness and support healthcare workers.
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Affiliation(s)
- Catherine R Butler
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington, USA
- Hospital and Speciality Medicine, VA Puget Sound Health Care System Seattle Division, Seattle, Washington, USA
| | - Laura B Webster
- Bioethics Progam, Virginia Mason Medical Center, Seattle, Washington, USA
- Bioethics and Humanities, University of Washington School of Medicine, Seattle, Washington, USA
| | - Douglas S Diekema
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Trueman Katz Center for Pediatric Bioethics, Seattle Children's Research Institure, Seattle, Washington, USA
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Riggan KA, Nguyen NV, Ennis JS, DeBruin DA, Sharp RR, Tilburt JC, Wolf SM, DeMartino ES. Behind the Scenes: Facilitators and Barriers to Developing State Scarce Resource Allocation Plans for the COVID-19 Pandemic. Chest 2024:S0012-3692(24)00541-5. [PMID: 38710464 DOI: 10.1016/j.chest.2024.04.006] [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: 10/11/2023] [Revised: 03/22/2024] [Accepted: 04/03/2024] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND In response to COVID-19, many states revised, developed, or attempted to develop plans to allocate scarce critical care resources in the event that crisis standards of care were triggered. No prior analysis has assessed this plan development process, including whether plans were successfully adopted. RESEARCH QUESTION How did states develop or revise scarce resource allocation plans during the COVID-19 pandemic, and what were the barriers and facilitators to their development and adoption at the state level? STUDY DESIGN AND METHODS Plan authors and state leaders completed a semi-structured interview February to September 2022. Interview transcripts were qualitatively analyzed for themes related to plan development and adoption according to the principles of grounded theory. RESULTS Thirty-six participants from 34 states completed an interview, from states distributed across all US regions. Among participants' states with plans that existed prior to 2020 (n = 24), 17 were revised and adopted in response to COVID-19. Six states wrote a plan de novo, with the remaining states failing to develop or adopt a plan. Thirteen states continued to revise their plans in response to disability or aging bias complaints or to respond to evolving needs. Many participants expressed that urgency in the early days of the pandemic prevented an ideal development process. Facilitators of successful plan development and adoption include: coordination or support from the state department of health and existing relationships with key community partners, including aging and disability rights groups and minoritized communities. Barriers include lack of perceived political interest in a plan and development during a public health emergency. INTERPRETATION To avoid repeating mistakes from the early days of the COVID-19 response, states should develop or revise plans with community engagement and consider maintaining a standing committee with diverse membership and content expertise to periodically review plans and advise state officials on pandemic preparedness.
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Affiliation(s)
| | | | - Jackson S Ennis
- Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN
| | - Debra A DeBruin
- Center for Bioethics, University of Minnesota, Minneapolis, MN
| | - Richard R Sharp
- Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN
| | - Jon C Tilburt
- Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN; Division of General Internal Medicine, Mayo Clinic, Scottsdale, AZ
| | - Susan M Wolf
- University of Minnesota Medical School, Minneapolis, MN; University of Minnesota Law School, Minneapolis, MN
| | - Erin S DeMartino
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
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Jose S, Geller G, Bollinger J, Mathews D, Kahn J, Garibaldi BT. The ethics of using COVID-19 host genomic information for clinical and public health decision-making: A survey of US health professionals. HGG ADVANCES 2024; 5:100255. [PMID: 37978805 PMCID: PMC10746522 DOI: 10.1016/j.xhgg.2023.100255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 11/09/2023] [Accepted: 11/09/2023] [Indexed: 11/19/2023] Open
Abstract
Several genetic variants linked to COVID-19 have been identified by host genomics researchers. Further advances in this research will likely play a role in the clinical management and public health control of future infectious disease outbreaks. The implementation of genetic testing to identify host genomic risk factors associated with infectious diseases raises several ethical, legal, and social implications (ELSIs). As an important stakeholder group, health professionals can provide key insights into these ELSI issues. In 2021, a cross-sectional online survey was fielded to US health professionals. The survey explored how they view the value and ethical acceptability of using COVID-19 host genomic information in three main decision-making settings: (1) clinical, (2) public health, and (3) workforce. The survey also assessed participants' personal and professional experience with genomics and infectious diseases and collected key demographic data. A total of 603 participants completed the survey. A majority (84%) of participants agreed that it is ethically acceptable to use host genomics to make decisions about clinical care and 73% agreed that genetic screening has an important role to play in the public health control of COVID-19. However, more than 90% disagreed that it is ethically acceptable to use host genomics to deny resources or admission to individuals when hospital resources are scarce. Understanding stakeholder perspectives and anticipating ELSI issues will help inform policies for hospitals and public health departments to evaluate and perhaps adopt host genomic technologies in an ethically and socially responsible manner during future infectious disease outbreaks.
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Affiliation(s)
- Sheethal Jose
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD 21205, USA; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.
| | - Gail Geller
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD 21205, USA; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA; Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
| | - Juli Bollinger
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Debra Mathews
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD 21205, USA; Department of Genetic Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
| | - Jeffrey Kahn
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD 21205, USA; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Brian T Garibaldi
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
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Ishizaki S, Jindai K, Saito H, Oshitani H, Kulstad Gonzalez T. Patient Admission and Mechanical Ventilator Allocation Decision-Making Processes by Frontline Medical Professionals in a Japanese ICU During the COVID-19 Pandemic: A Qualitative Study. QUALITATIVE HEALTH RESEARCH 2023; 33:1291-1304. [PMID: 37846588 PMCID: PMC10666510 DOI: 10.1177/10497323231201026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Abstract
During the COVID-19 pandemic, the need to triage COVID-19 patients in ICUs emerged globally. Triage guidelines were established in many countries; however, the actual triage decision-making processes and decisions themselves made by frontline medical providers may not have exactly reflected those guidelines. Despite the need to understand decisions and processes in practice regarding patient ICU admission and mechanical ventilator usage to identify areas of improvement for medical care provision, such research is limited. This qualitative study was conducted to identify the decision-making processes regarding COVID-19 patient ICU admissions and mechanical ventilator allocation by frontline medical providers and issues associated with those processes in an ICU during the COVID-19 pandemic. Semi-structured, in-depth interviews were conducted with ICU physicians and nurses working at an urban tertiary referral hospital in Japan between February and April 2022. Patient characteristics that influenced triage decisions made by physicians and the interaction between physicians, nurses, and senior management staff upon making such decisions are discussed in this article. An implicated issue was the lack of legal support for Japanese physicians to practice withdrawal of life-sustaining treatments even during emergencies. Another issue was the impact of non-clinical forces-likely specific to health emergencies-on physicians' decisions regarding mechanical ventilator allocation, where such forces imposed a significant mental burden on the medical providers. We consider public policy and legal implications for future pandemics.
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Affiliation(s)
- Sakura Ishizaki
- Department of Anthropology, Grinnell College, Grinnell, IA, USA
- Department of Biological Chemistry, Grinnell College, Grinnell, IA, USA
| | - Kazuaki Jindai
- Department of Virology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroki Saito
- Department of Emergency and Critical Care Medicine, St Marianna University School of Medicine, Kawasaki, Japan
| | - Hitoshi Oshitani
- Department of Virology, Tohoku University Graduate School of Medicine, Sendai, Japan
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Harlan EA, Mubarak E, Firn J, Goold SD, Shuman AG. Inter-hospital Transfer Decision-making During the COVID-19 Pandemic: a Qualitative Study. J Gen Intern Med 2023; 38:2568-2576. [PMID: 37254008 PMCID: PMC10228431 DOI: 10.1007/s11606-023-08237-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 05/09/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND Inter-hospital patient transfers to hospitals with greater resource availability and expertise may improve clinical outcomes. However, there is little guidance regarding how patient transfer requests should be prioritized when hospital resources become scarce. OBJECTIVE To understand the experiences of healthcare workers involved in the process of accepting inter-hospital patient transfers during a pandemic surge and determine factors impacting inter-hospital patient transfer decision-making. DESIGN We conducted a qualitative study consisting of semi-structured interviews between October 2021 and February 2022. PARTICIPANTS Eligible participants were physicians, nurses, and non-clinician administrators involved in the process of accepting inter-hospital patient transfers. Participants were recruited using maximum variation sampling. APPROACH Semi-structured interviews were conducted with healthcare workers across Michigan. KEY RESULTS Twenty-one participants from 15 hospitals were interviewed (45.5% of eligible hospitals). About half (52.4%) of participants were physicians, 38.1% were nurses, and 9.5% were non-clinician administrators. Three domains of themes impacting patient transfer decision-making emerged: decision-maker, patient, and environmental factors. Decision-makers described a lack of guidance for transfer decision-making. Patient factors included severity of illness, predicted chance of survival, need for specialized care, and patient preferences for medical care. Decision-making occurred within the context of environmental factors including scarce resources at accepting and requesting hospitals, organizational changes to transfer processes, and alternatives to patient transfer including use of virtual care. Participants described substantial moral distress related to transfer triaging. CONCLUSIONS A lack of guidance in transfer processes may result in considerable variation in the patients who are accepted for inter-hospital transfer and in substantial moral distress among decision-makers involved in the transfer process. Our findings identify potential organizational changes to improve the inter-hospital transfer process and alleviate the moral distress experienced by decision-makers.
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Affiliation(s)
- Emily A Harlan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI, USA.
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA.
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA.
| | - Eman Mubarak
- University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Janice Firn
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
- University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Susan D Goold
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Andrew G Shuman
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
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Butler CR, Wightman AG, Taylor JS, Hick JL, O’Hare AM. Experiences of US Clinicians Contending With Health Care Resource Scarcity During the COVID-19 Pandemic, December 2020 to December 2021. JAMA Netw Open 2023; 6:e2318810. [PMID: 37326986 PMCID: PMC10276299 DOI: 10.1001/jamanetworkopen.2023.18810] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 05/02/2023] [Indexed: 06/17/2023] Open
Abstract
Importance The second year of the COVID-19 pandemic saw periods of dire health care resource limitations in the US, sometimes prompting official declarations of crisis, but little is known about how these conditions were experienced by frontline clinicians. Objective To describe the experiences of US clinicians practicing under conditions of extreme resource limitation during the second year of the pandemic. Design, Setting, and Participants This qualitative inductive thematic analysis was based on interviews with physicians and nurses providing direct patient care at US health care institutions during the COVID-19 pandemic. Interviews were conducted between December 28, 2020, and December 9, 2021. Exposure Crisis conditions as reflected by official state declarations and/or media reports. Main Outcomes and Measures Clinicians' experiences as obtained through interviews. Results Interviews with 23 clinicians (21 physicians and 2 nurses) who were practicing in California, Idaho, Minnesota, or Texas were included. Of the 23 total participants, 21 responded to a background survey to assess participant demographics; among these individuals, the mean (SD) age was 49 (7.3) years, 12 (57.1%) were men, and 18 (85.7%) self-identified as White. Three themes emerged in qualitative analysis. The first theme describes isolation. Clinicians had a limited view on what was happening outside their immediate practice setting and perceived a disconnect between official messaging about crisis conditions and their own experience. In the absence of overarching system-level support, responsibility for making challenging decisions about how to adapt practices and allocate resources often fell to frontline clinicians. The second theme describes in-the-moment decision-making. Formal crisis declarations did little to guide how resources were allocated in clinical practice. Clinicians adapted practice by drawing on their clinical judgment but described feeling ill equipped to handle some of the operationally and ethically complex situations that fell to them. The third theme describes waning motivation. As the pandemic persisted, the strong sense of mission, duty, and purpose that had fueled extraordinary efforts earlier in the pandemic was eroded by unsatisfying clinical roles, misalignment between clinicians' own values and institutional goals, more distant relationships with patients, and moral distress. Conclusions and Relevance The findings of this qualitative study suggest that institutional plans to protect frontline clinicians from the responsibility for allocating scarce resources may be unworkable, especially in a state of chronic crisis. Efforts are needed to directly integrate frontline clinicians into institutional emergency responses and support them in ways that reflect the complex and dynamic realities of health care resource limitation.
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Affiliation(s)
- Catherine R. Butler
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle
- Nephrology Section, Hospital and Specialty Medicine and Seattle-Denver Health Services Research and Development Center of Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Aaron G. Wightman
- Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Hospital, Seattle, Washington
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Janelle S. Taylor
- Department of Anthropology, University of Toronto, Toronto, Ontario, Canada
| | - John L. Hick
- Hennepin Healthcare, University of Minnesota, Minneapolis
| | - Ann M. O’Hare
- Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle
- Nephrology Section, Hospital and Specialty Medicine and Seattle-Denver Health Services Research and Development Center of Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
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Howe EG. When Should Providers Defer versus Impose Their Views? THE JOURNAL OF CLINICAL ETHICS 2023; 34:289-295. [PMID: 37991734 DOI: 10.1086/727439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
AbstractThis piece discusses perhaps the most agonizing ethical decision ethics consultants and other providers encounter. This is the extent to which providers should defer decisions to patients or to their proxy decision makers as opposed to imposing their own views as to what they think is ethically right. It discusses the most difficult issues these providers may encounter, especially when they wish to depart from authoritative bodies' standards or guidelines, and it presents initial steps providers may take to help patients and their families work together to resolve these dilemmas more harmoniously. It highlights how providers may inadvertently impose flawed biases on patients and families. Finally, it discusses how providers should take initiative with both parties to offer to help appeal when these avenues already exist and seek to establish the appellate procedures when they are absent.
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Preparing for the Worst-Case Scenario in a Pandemic: Intensivists Simulate Prioritization and Triage of Scarce ICU Resources. Crit Care Med 2022; 50:1714-1724. [PMID: 36222541 PMCID: PMC9668365 DOI: 10.1097/ccm.0000000000005684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Simulation and evaluation of a prioritization protocol at a German university hospital using a convergent parallel mixed methods design. DESIGN Prospective single-center cohort study with a quantitative analysis of ICU patients and qualitative content analysis of two focus groups with intensivists. SETTING Five ICUs of internal medicine and anesthesiology at a German university hospital. PATIENTS Adult critically ill ICU patients ( n = 53). INTERVENTIONS After training the attending senior ICU physicians ( n = 13) in rationing, an impending ICU congestion was simulated. All ICU patients were rated according to their likelihood to survive their acute illness (good-moderate-unfavorable). From each ICU, the two patients with the most unfavorable prognosis ( n = 10) were evaluated by five prioritization teams for triage. MEASUREMENTS AND MAIN RESULTS Patients nominated for prioritization visit ( n = 10) had higher Sequential Organ Failure Assessment scores and already a longer stay at the hospital and on the ICU compared with the other patients. The order within this worst prognosis group was not congruent between the five teams. However, an in-hospital mortality of 80% confirmed the reasonable match with the lowest predicted probability of survival. Qualitative data highlighted the tremendous burden of triage and the need for a team-based consensus-oriented decision-making approach to ensure best possible care and to support professionals. Transparent communication within the teams, the hospital, and to the public was seen as essential for prioritization implementation. CONCLUSIONS To mitigate potential bias and to reduce the emotional burden of triage, a consensus-oriented, interdisciplinary, and collaborative approach should be implemented. Prognostic comparative assessment by intensivists is feasible. The combination of long-term ICU stay and consistently high Sequential Organ Failure Assessment scores resulted in a greater risk for triage in patients. It remains challenging to reliably differentiate between patients with very low chances to survive and requires further conceptual and empirical research.
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Different Pathways to the Most Difficult Decisions. Crit Care Med 2022; 50:1824-1827. [PMID: 36394399 PMCID: PMC9668360 DOI: 10.1097/ccm.0000000000005691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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