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Calderon Ramirez C, Farmer Y, Frolic A, Bravo G, Gaucher NO, Payot A, Opatrny L, Poirier D, Dahine J, L'Espérance A, Downar J, Tanuseputro P, Rousseau LM, Dumez V, Descôteaux A, Dallaire C, Laporte K, Bouthillier ME. What are the views of Quebec and Ontario citizens on the tiebreaker criteria for prioritizing access to adult critical care in the extreme context of a COVID-19 pandemic? BMC Med Ethics 2024; 25:31. [PMID: 38504267 PMCID: PMC10949716 DOI: 10.1186/s12910-024-01030-2] [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: 09/12/2023] [Accepted: 02/26/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND The prioritization protocols for accessing adult critical care in the extreme pandemic context contain tiebreaker criteria to facilitate decision-making in the allocation of resources between patients with a similar survival prognosis. Besides being controversial, little is known about the public acceptability of these tiebreakers. In order to better understand the public opinion, Quebec and Ontario's protocols were presented to the public in a democratic deliberation during the summer of 2022. OBJECTIVES (1) To explore the perspectives of Quebec and Ontario citizens regarding tiebreakers, identifying the most acceptable ones and their underlying values. (2) To analyze these results considering other public consultations held during the pandemic on these criteria. METHODS This was an exploratory qualitative study. The design involved an online democratic deliberation that took place over two days, simultaneously in Quebec and Ontario. Public participants were selected from a community sample which excluded healthcare workers. Participants were first presented the essential components of prioritization protocols and their related issues (training session day 1). They subsequently deliberated on the acceptability of these criteria (deliberation session day 2). The deliberation was then subject to thematic analysis. RESULTS A total of 47 participants from the provinces of Quebec (n = 20) and Ontario (n = 27) took part in the online deliberation. A diverse audience participated excluding members of the healthcare workforce. Four themes were identified: (1) Priority to young patients - the life cycle - a preferred tiebreaker; (2) Randomization - a tiebreaker of last resort; (3) Multiplier effect of most exposed healthcare workers - a median acceptability tiebreaker, and (4) Social value - a less acceptable tiebreaker. CONCLUSION Life cycle was the preferred tiebreaker as this criterion respects intergenerational equity, which was considered relevant when allocating scarce resources to adult patients in a context of extreme pandemic. Priority to young patients is in line with other consultations conducted around the world. Additional studies are needed to further investigate the public acceptability of tiebreaker criteria.
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Affiliation(s)
- Claudia Calderon Ramirez
- Biomedical Sciences Program, Clinical Ethics, Faculty of Medicine, Université de Montréal, Pavillon Roger-Gaudry 2900 Bd Édouard-Montpetit, Montréal, Québec, H3T 1J4, Canada
| | - Yanick Farmer
- Department of Social and Public Communication, Faculty of Communication, succursale Centre-Ville, Université du Québec à Montréal, Montréal, Québec, C.P 8888, H3C 3P8, Canada
| | - Andrea Frolic
- Program for Ethics and Care Ecologies (PEaCE), Hamilton Health Sciences - King West, P.O. Box 2000, Hamilton, ON, L8N 3Z5, Canada
| | - Gina Bravo
- Department of Community Health Sciences, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 2500 Bd de l'Université, Sherbrooke, Québec, J1K 2R1, Canada
| | - Nathalie Orr Gaucher
- Research Centre of the Sainte-Justine University Hospital, 3175 Chem. de la Côte-Sainte- Catherine, Québec, Montreal, H3T 1C5, Canada
- Office of Clinical Ethics, Faculty of Medicine, Université de Montréal, Pavillon Roger-Gaudry, 2900 Bd Édouard-Montpetit, Montréal, Québec, H3T 1J4, Canada
| | - Antoine Payot
- Office of Clinical Ethics, Faculty of Medicine, Université de Montréal, Pavillon Roger-Gaudry, 2900 Bd Édouard-Montpetit, Montréal, Québec, H3T 1J4, Canada
| | - Lucie Opatrny
- Executive Office Administration, Faculty of Medicine, McGill University Health Centre, Site Glen 1001 boul. Décarie, Montréal, Québec, H4A 3J1, Canada
| | - Diane Poirier
- CIUSSS du Centre-Sud-de-l'Île-de-Montréal, 1560, rue Sherbrooke Est, Montréal, Québec, H2L 4M1, Canada
| | - Joseph Dahine
- Department of Medicine and Medical Specialties, Faculty of Medicine, Université de Montréal, Pavillon Roger-Gaudry 2900 boulevard Édouard-Montpetit, Montréal, Québec, H3T 1J4, Canada
| | - Audrey L'Espérance
- École nationale d'administration publique (ENAP), 4750 Av. Henri-Julien, Montréal, Québec, H2T 2C8, Canada
| | - James Downar
- Division of Palliative Care, Department of Medicine, University of Ottawa, 43 Rue Bruyere St. 268J, Ottawa, ON, K1N 5C8, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, 501 Smyth Rd, Box 511, Ottawa, ON, K1H 8L6, Canada
| | - Louis-Martin Rousseau
- Faculty of Engineering, Montreal Polytechnic, Chem. de Polytechnique, Montréal, Québec, 2500, H3T 1J4, Canada
| | - Vincent Dumez
- Centre d'Excellence sur le Partenariat avec les Patients et le Public (CEPPP) CRCHUM -, Pavillon S 850, rue St-Denis, porte S03.900, Montréal, Québec, H2X 0A9, Canada
| | - Annie Descôteaux
- Bureau du Patient Partenaire, Faculté de médecine, Université de Montréal, Pavillon Roger- Gaudry 2900 boulevard Édouard-Montpetit, bureau R-815, Montréal, Québec, H3T 1J4, Canada
| | - Clara Dallaire
- Bureau du Patient Partenaire, Faculté de médecine, Université de Montréal, Pavillon Roger- Gaudry 2900 boulevard Édouard-Montpetit, bureau R-815, Montréal, Québec, H3T 1J4, Canada
| | - Karell Laporte
- Medical residency program, Faculty of Medicine, Université de Montréal, Pavillon Roger- Gaudry 2900 boulevard Édouard-Montpetit, Montréal, Québec, H3T 1J4, Canada
| | - Marie-Eve Bouthillier
- Office of Clinical Ethics, Faculty of Medicine, Université de Montréal, Pavillon Roger-Gaudry, 2900 Bd Édouard-Montpetit, Montréal, Québec, H3T 1J4, Canada.
- Department of Family and Emergency Medicine, Faculty of Medicine, Université de Montréal, 2900 Bd Édouard-Montpetit, Montréal, Québec, H3T 1J4, Canada.
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Le Fort M, Demeure Dit Latte D, Perrouin-Verbe B, Ville I. Organizational ethics in urgent transfers of severely disabled people to intensive care units - a qualitative study. Disabil Rehabil 2023; 45:3852-3860. [PMID: 36369957 DOI: 10.1080/09638288.2022.2140847] [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: 09/08/2022] [Revised: 10/20/2022] [Accepted: 10/23/2022] [Indexed: 11/15/2022]
Abstract
PURPOSE Urgent transfers of severely impaired patients with chronic neurological disability (PwND) from a neurological physical and rehabilitation medicine (nPRM) to an intensive care unit (ICU) or an emergency room (ER) served as the basis for this study. We hypothesized that human and structural factors interfered with but were not directly related to the acute context. METHODS We decided to use a qualitative methodology, based on in-depth interviews with 16 ICU/ER physicians. We used mixed bottom-up and top-down methods. We interpreted our data using a thematic approach based on the key principles of grounded theory, which were modified with consideration of the literature. RESULTS Three main domains emerged. The impact of the clinical setting notably implied the patient's clinical typology between the acute event and the chronic background, but also bed availability. Key elements of the telephone negotiation were confidence and perceived usefulness of the transfer. Finally, the otherness of some categories of patients, transferred with more difficulty, involved those with cognitive impairment. CONCLUSIONS The existence of healthcare pathways for many years has created an organizational culture between departments of nPRM and ICUs. But urgent transfers also imply organizational ethics, as a balance should be struck between utility and equity. IMPLICATIONS FOR REHABILITATIONStructural and human factors interfere in urgent transfers, involving the settings within health pathways, the key elements of negotiation to get confidence and a perceived utility of transfer, and certain categories of people, especially those with cognitive impairment.Transfers that imply negotiation between practitioners from physical and rehabilitation medicine and intensive care unit departments, lead to a need of organizational ethics, as a balance should be struck between the principles of utility and equity.The development of facilitating tools such as a commitment charter is of paramount importance as it can support ethical decision-making.
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Affiliation(s)
- Marc Le Fort
- Nantes Université, Centre Hospitalier Universitaire de Nantes, Service universitaire de Médecine Physique et de Réadaptation neurologique, Hôpital Saint-Jacques, Nantes, France
- Institut national de la santé et de la recherche médicale (INSERM-CERMES3), Ecole des hautes études en sciences sociales (EHESS-PHS), Paris, France
| | - Dominique Demeure Dit Latte
- Nantes Université, Centre Hospitalier Universitaire de Nantes, Service de Réanimation chirurgicale, Hôtel-Dieu, Nantes, France
| | - Brigitte Perrouin-Verbe
- Nantes Université, Centre Hospitalier Universitaire de Nantes, Service universitaire de Médecine Physique et de Réadaptation neurologique, Hôpital Saint-Jacques, Nantes, France
| | - Isabelle Ville
- Institut national de la santé et de la recherche médicale (INSERM-CERMES3), Ecole des hautes études en sciences sociales (EHESS-PHS), Paris, France
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Ramirez CC, Farmer Y, Bouthillier ME. Public voices on tie-breaking criteria and underlying values in COVID-19 triage protocols to access critical care: a scoping review. DISCOVER HEALTH SYSTEMS 2023; 2:16. [PMID: 37206881 PMCID: PMC10169297 DOI: 10.1007/s44250-023-00027-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 03/14/2023] [Indexed: 05/21/2023]
Abstract
Background To reduce the arbitrariness in the allocation of rare resources in intensive care units (ICU) in the context of the pandemic, tiebreakers were considered in some COVID-19 triage algorithms. They were also contemplated to facilitate the tragic decisions of healthcare workers when faced with two patients with similar prognosis and only one ICU bed available. Little is known about the public's perspective on tiebreakers. Objectives To consolidate the available scientific literature on public consultations, particularly on tiebreakers and their underlying values. Also, to obtain an overview of the key arguments presented by the participating public and to identify potential gaps related to this topic. Methods The steps described by Arksey and O'Malley was the preferred method to our approach. Seven electronic databases were searched from January 2020 to April 2022, using keywords for each database: PubMed, Medline, EMBASE, Web of Science, PsycINFO, EBM reviews, CINAHL complete. We also searched in Google and Google Scholar, and in the references of the articles found. Our analysis was mainly qualitative. A thematic analysis was performed to consider the public's perspectives on tiebreakers and their underlying values, according to these studies. Results Of 477 publications found, 20 were selected. They carried out public consultations through various methods: surveys (80%), interviews (20%), deliberative processes (15%) and others (5%) in various countries: Australia, Brazil, Canada, China, France, Germany, India, Iran, Italy, Japan, Korea, Netherlands, Portugal, Spain, Switzerland, Thailand, United Kingdom, and United States. Five themes emerged from our analysis. The public favored the life cycle (50%) and absolute age (45%) as a tiebreaker. Other values considered important were reciprocity, solidarity, equality, instrumental value, patient merit, efficiency, and stewardship. Among the new findings were a preference for patient nationality and those affected by COVID-19. Conclusions There is a preference for favoring younger patients over older patients when there is a tie between similar patients, with a slight tendency to favor intergenerational equity. Variability was found in the public's perspectives on tiebreakers and their values. This variability was related to socio-cultural and religious factors. More studies are needed to understand the public's perspective on tiebreakers. Supplementary Information The online version contains supplementary material available at 10.1007/s44250-023-00027-9.
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Affiliation(s)
- Claudia Calderon Ramirez
- Biomedical Sciences Program, Clinical Ethics, Faculty of Medicine, Université de Montréal, 2900 Bd Édouard-Montpetit, Montréal, Québec H3T 1J4 Canada
| | - Yanick Farmer
- Department of Social and Public Communication, Faculty of Communication, Université du Québec à Montréal, C.P 8888, Succursale Centre-Ville, Montréal, Québec H3C 3P8 Canada
| | - Marie-Eve Bouthillier
- Department of Family and Emergency Medicine and Office of Clinical Ethics, Faculty of Medicine, Université de Montréal, 2900 Bd Édouard-Montpetit, Montréal, Québec H3T 1J4 Canada
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Martins MS, Lourenção DCDA, Pimentel RRDS, de Oliveira JM, Manganoti LTDCN, Modesto RC, Silva MSDS, Dos Santos MJ. Recommendations for the safety of hospitalised patients in the context of the COVID-19 pandemic: a scoping review. BMJ Open 2022; 12:e060182. [PMID: 36123068 PMCID: PMC9485646 DOI: 10.1136/bmjopen-2021-060182] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 01/09/2023] Open
Abstract
OBJECTIVE To map the recommendations for hospitalised patient safety in the context of the COVID-19 pandemic. DESIGN Scoping review using the method recommended by the Joanna Briggs Institute. DATA SOURCES Databases: Medline, SCOPUS, EMBASE, ScienceDirect, LILACS, CINAHL and IBECS; grey literature platform: Google Scholar; and 11 official websites of leading healthcare institutions were searched on 27 April 2021 and updated on 11 April 2022. ELIGIBILITY CRITERIA We included documents that present recommendations for the safety of hospitalised patients in the context of the COVID-19 pandemic, published in any language, from 2020 onwards. DATA EXTRACTION AND SYNTHESIS Data extraction was performed in pairs with consensus rounds. A descriptive analysis was carried out to present the main characteristics of the articles. Qualitative data from the extraction of recommendations were analysed through content analysis. RESULTS One hundred and twenty-five documents were included. Most papers were identified as expert consensus (n=56, 44.8%). Forty-six recommendations were identified for the safety of hospitalised patients: 17 relating to the reorganisation of health services related to the flow of patients, the management of human and material resources and the reorganisation of the hospital environment; 11 on the approach to the airways and the prevention of the spread of aerosols; 11 related to sanitary and hygiene issues; 4 about proper use of personal protective equipment and 3 for effective communication. CONCLUSIONS The recommendations mapped in this scoping review present the best practices produced so far and serve as a basis for planning and implementing good practices to ensure safe hospital care, during and after COVID-19. The engagement of everyone involved in the care of hospitalised patients is essential to consolidate the mapped recommendations and provide dignified, safe and quality care.
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Affiliation(s)
| | | | | | - Janine Melo de Oliveira
- Escola de Enfermagem, Universidade Federal de Alagoas, Maceio, Brazil
- Curso de Enfermagem, Universidade Estadual de Ciências da Saúde de Alagoas, Maceio, Brazil
| | | | | | | | - Marcelo José Dos Santos
- Career Guidance Department, Universidade de São Paulo Escola de Enfermagem, Sao Paulo, Brazil
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Evaluation of Minnesota Score in the Allocation of Venovenous Extracorporeal Membrane Oxygenation During Resource Scarcity. Crit Care Res Pract 2022; 2022:2773980. [PMID: 35402045 PMCID: PMC8985705 DOI: 10.1155/2022/2773980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 03/15/2022] [Indexed: 11/18/2022] Open
Abstract
Background In this study, we evaluate the previously reported novel Minnesota Score for association with in-hospital mortality and allocation of venovenous extracorporeal membrane oxygenation in patients with acute respiratory distress syndrome with or without SARS-CoV-2 pneumonia. Methods This was a retrospective cohort study across four extracorporeal membrane oxygenation centers in Minnesota. Logistic regression was used to assess the relationship between the scores and in-hospital mortality, duration of ECMO cannulation, and discharge disposition. Priority groups were established statistically by maximizing the sum of sensitivity and specificity and compared to the previous qualitatively established priority groups. Results Of 124 patients included in the study, 38% were treated for COVID-19 acute respiratory distress syndrome. The median age was 48 years, and 73% were male. The in-hospital mortality rate was 38%. The Minnesota Score was significantly associated with in-hospital mortality only (OR 1.13, p=0.02). Statistically determined cut points were similar to qualitative cut points. SARS-CoV-2 status did not change the findings. Conclusions In our patient cohort, the Minnesota Score is associated with increased mortality. With further validation, proposed priority groups could be utilized for allocation of ECMO in times of increasing scarcity.
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Frontline Healthcare Professionals’ Views Regarding the Impact of COVID-19 on Ethical Decision-Making: A Multicentre Mixed-Methods Study from Estonia. Healthcare (Basel) 2022; 10:healthcare10040711. [PMID: 35455888 PMCID: PMC9032527 DOI: 10.3390/healthcare10040711] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/09/2022] [Accepted: 04/09/2022] [Indexed: 12/21/2022] Open
Abstract
Background: The objective of the study was to investigate frontline healthcare professionals’ experiences and attitudes in relation to the COVID-19 pandemic’s ethical and psychosocial aspects in Estonia. There were two research foci: first, ethical decision-making related to treating patients in the context of potential medical resource scarcity, and second, other psychosocial factors for healthcare professionals pertaining to coping, role conflicts, and the availability of institutional support. Methods: An online survey was conducted in the fall of 2020 amongst the frontline healthcare professionals working in the three most impacted hospitals; respondents were also drawn from two ambulance services. The focus of the survey was on the first wave of COVID-19 (spring 2020). A total of 215 respondents completed the quantitative survey and qualitative data were gathered from open comments. Results: Over half of the surveyed healthcare professionals in Estonia expressed confidence in their roles during the pandemic. More than half cited the complex ethical aspects related to their decisions as their main source of doubt and uncertainty. In response to this uncertainty, Estonian healthcare professionals drew on their previous training and experience, the policies and guidelines of their institution, and support from their colleagues, to aid their decision-making during the pandemic. Conclusions: Although frontline healthcare professionals faced difficult decisions during the first wave of the pandemic, overall, most agreed that experiencing the pandemic reconfirmed that their work mattered greatly.
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Géa LP, Upfold C, Qureshi A, Moulden HM, Mamak M, McDonald Wilson Bradford J, Chaimowitz GA. Public perceptions of psychiatric, justice-involved, and elderly populations during the COVID-19 pandemic. J Psychiatr Res 2022; 146:67-76. [PMID: 34954362 PMCID: PMC8689415 DOI: 10.1016/j.jpsychires.2021.12.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 11/02/2021] [Accepted: 12/10/2021] [Indexed: 12/23/2022]
Abstract
The novel coronavirus disease (COVID-19) has had a significant global impact, with all countries facing the challenge of mitigating its spread. An unprecedented shortage of medical resources has raised concerns regarding allocation and prioritization of supplies, which may exacerbate social discrepancies for already vulnerable populations. As public opinion can impact healthcare policies, we aimed to characterize perceptions of psychiatric, forensic psychiatry, correctional, and elderly populations regarding COVID-19-related issues. This web-based study recruited participants (n = 583) from the general population in North America. The survey included perceptions of the pandemic, hypothetical scenarios on resource prioritization, and Likert scale questions. The majority of participants were cisgender female (72.7%), aged 31-74 years (80.0%), married (48.0%), retired (52.7%), resided in Canada (73.9%), had a college/university degree (50.9%) and had never worked in healthcare (66.21%). Most respondents reported not having a criminal history (95.88%), or a psychiatric disorder (78.73%). Perceptions of vulnerable populations were significantly different for resource allocation and prioritization (e.g., ventilator and vaccine resources, all p < 0.001). Healthcare workers and the elderly were commonly ranked the highest priority for resources, while forensic psychiatry and correctional populations were given the lowest priority. A high rate of disagreement was found for the more stigmatizing questions in the survey (all p < 0.0001). Our results suggest that perception from members of the general public in North America is aligned with current practices for resource allocation. However, individuals that already face social and health disparities may face additional opposition in decision-making for COVID-19 resources.
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Affiliation(s)
- Luiza Paul Géa
- Forensic Psychiatry Program, St. Joseph's Healthcare Hamilton – West 5th Campus, 100 West 5th Street, Hamilton, ON, L8N3K7, Canada,Department of Psychiatry and Behavioural Neurosciences, McMaster University, 1280 Main Street West, Hamilton, ON, L8S4L8, Canada
| | - Casey Upfold
- Forensic Psychiatry Program, St. Joseph's Healthcare Hamilton – West 5th Campus, 100 West 5th Street, Hamilton, ON, L8N3K7, Canada
| | - Aamna Qureshi
- Forensic Psychiatry Program, St. Joseph's Healthcare Hamilton – West 5th Campus, 100 West 5th Street, Hamilton, ON, L8N3K7, Canada
| | - Heather Marie Moulden
- Forensic Psychiatry Program, St. Joseph's Healthcare Hamilton – West 5th Campus, 100 West 5th Street, Hamilton, ON, L8N3K7, Canada,Department of Psychiatry and Behavioural Neurosciences, McMaster University, 1280 Main Street West, Hamilton, ON, L8S4L8, Canada
| | - Mini Mamak
- Forensic Psychiatry Program, St. Joseph's Healthcare Hamilton – West 5th Campus, 100 West 5th Street, Hamilton, ON, L8N3K7, Canada,Department of Psychiatry and Behavioural Neurosciences, McMaster University, 1280 Main Street West, Hamilton, ON, L8S4L8, Canada
| | - John McDonald Wilson Bradford
- Forensic Psychiatry Program, St. Joseph's Healthcare Hamilton – West 5th Campus, 100 West 5th Street, Hamilton, ON, L8N3K7, Canada,Department of Psychiatry and Behavioural Neurosciences, McMaster University, 1280 Main Street West, Hamilton, ON, L8S4L8, Canada
| | - Gary Andrew Chaimowitz
- Forensic Psychiatry Program, St. Joseph's Healthcare Hamilton - West 5th Campus, 100 West 5th Street, Hamilton, ON, L8N3K7, Canada; Department of Psychiatry and Behavioural Neurosciences, McMaster University, 1280 Main Street West, Hamilton, ON, L8S4L8, Canada.
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Ghamari SH, Abbasi-Kangevari M, Zamani N, Hassanian-Moghaddam H, Kolahi AA. Priorities Towards Fair Allocation of Ventilators During COVID-19 Pandemic: A Delphi Study. Front Med (Lausanne) 2022; 8:769508. [PMID: 35141240 PMCID: PMC8818721 DOI: 10.3389/fmed.2021.769508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 12/31/2021] [Indexed: 11/29/2022] Open
Abstract
Background COVID-19 pandemic has resulted in severe shortage in vital resources, including invasive mechanical ventilators. The current imbalance between demand and supply of mechanical ventilators has called for investigations on the fair allocation of mechanical ventilators. Objective To determine the priorities of the medical experts towards the fair allocation of ventilators during the COVID-19 pandemic. Methods This study was conducted from May 28 to Aug 20, 2020. The questionnaire was sent to 50 medical specialists as the Delphi panel. Participants were asked to rate each prioritising factor: “−1” for low priority, “+1” for high priority, and “Zero” for equal priority. Results Among 38 experts who responded to the email, the responses of 35 were analysed. 31 (88.6%) participants recommended that pregnant women be considered high priority in allocating ventilators, 27 (77.1%) mothers of children <5 years, 26 (74.3%) patients under 80-years, and 23 (65.7%) front-line-healthcare-workers. In contrast, 28 (80.0) participants recommended that patients who are terminally ill should be considered as a low priority, 27 (77.1%) patients with active-malignancy, 25 (71.4%) neurodegenerative diseases, and 16 (45.7%) patients aged >80. The panel did not reach a consensus regarding the role of patients' laboratory profiles, underlying diseases, or drug abuse in the prioritisation of ventilators. Conclusions The panel considered pregnant mothers, mothers of children under 5 years, age groups younger than 80, and front-line healthcare workers to have high priority in allocating mechanical ventilators.
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Butler CR, Webster LB, Sakata VL, Tonelli MR, Diekema DS, Gray MM. Functionality of Scarce Healthcare Resource Triage Teams During the COVID-19 Pandemic: A Multi-Institutional Simulation Study. Crit Care Explor 2022; 4:e0627. [PMID: 35083438 PMCID: PMC8785932 DOI: 10.1097/cce.0000000000000627] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Plans for allocating scarce healthcare resources during the COVID-19 pandemic commonly involve the activation of institutional triage teams. These teams would be responsible for selecting patients who are most likely to survive to be prioritized to receive scarce resources. However, there is little empirical support for this approach. DESIGN High-fidelity triage-team simulation study. SETTING Healthcare institutions in Washington state. SUBJECTS Triage teams, consisting of at least two senior clinicians and a bioethicist. INTERVENTIONS Participants reviewed a limited amount of deidentified information for a diverse sample of critically ill patients. Teams then assigned each patient to one of five prioritization categories defined by likelihood of survival to hospital discharge. The process was refined based on observation and participant feedback after which a second phase of simulations was conducted. MEASUREMENTS AND MAIN RESULTS Feasibility was assessed by the time required for teams to perform their task. Prognostic accuracy was assessed by comparing teams' prediction about likelihood of survival to hospital discharge with real-world discharge outcomes. Agreement between the teams on prognostic categorization was evaluated using kappa statistics. Eleven triage team simulations (eight in phase 1 and three in phase 2) were conducted from December 2020 to February 2021. Overall, teams reviewed a median of 23 patient cases in each session (interquartile range [IQR], 17-29) and spent a median of 102 seconds (IQR, 50-268) per case. The concordance between expected survival and real-world survival to discharge was 71% (IQR, 64-76%). The overall agreement between teams for placement of patients into prognostic categories was moderate (weighted kappa = 0.53). CONCLUSIONS These findings support the potential feasibility, accuracy, and effectiveness of institutional triage teams informed by a limited set of patient information items as part of a strategy for allocating scarce resources in healthcare emergencies. Additional work is needed to refine the process and adapt it to local contexts.
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Affiliation(s)
- Catherine R Butler
- Division of Nephrology, Department of Medicine, University of Washington, Seattle WA
- Veterans Affairs Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle WA
| | - Laura B Webster
- Virginia Mason Medical Center, Seattle, WA
- Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA
| | - Vicki L Sakata
- Northwest Healthcare Response Network, Seattle, WA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Mark R Tonelli
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Douglas S Diekema
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
- Trueman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle WA
| | - Megan M Gray
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
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Abbasi-Kangevari M, Arshi S, Hassanian-Moghaddam H, Kolahi AA. Public Opinion on Priorities Toward Fair Allocation of Ventilators During COVID-19 Pandemic: A Nationwide Survey. Front Public Health 2022; 9:753048. [PMID: 34970524 PMCID: PMC8712311 DOI: 10.3389/fpubh.2021.753048] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 11/23/2021] [Indexed: 01/08/2023] Open
Abstract
Background: The rapidly growing imbalance between supply and demand for ventilators during the COVID-19 pandemic has highlighted the principles for fair allocation of scarce resources. Failing to address public views and concerns on the subject could fuel distrust. The objective of this study was to determine the priorities of the Iranian public toward the fair allocation of ventilators during the COVID-19 pandemic. Methods: This anonymous community-based national study was conducted from May 28 to Aug 20, 2020, in Iran. Data were collected via the Google Forms platform, using an online self-administrative questionnaire. The questionnaire assessed participants' assigned prioritization scores for ventilators based on medical and non-medical criteria. To quantify participants' responses on prioritizing ventilator allocation among sub-groups of patients with COVID-19 who need mechanical ventilation scores ranging from -2, very low priority, to +2, very high priority were assigned to each response. Results: Responses of 2,043 participants, 1,189 women, and 1,012 men, were analyzed. The mean (SD) age was 31.1 (9.5), being 32.1 (9.3) among women, and 29.9 (9.6) among men. Among all participants, 274 (13.4%) were healthcare workers. The median of assigned priority score was zero (equal) for gender, age 41-80, nationality, religion, socioeconomic, high-profile governmental position, high-profile occupation, being celebrities, employment status, smoking status, drug abuse, end-stage status, and obesity. The median assigned priority score was +2 (very high priority) for pregnancy, and having <2 years old children. The median assigned priority score was +1 (high priority) for physicians and nurses of patients with COVID-19, patients with nobel research position, those aged <40 years, those with underlying disease, immunocompromise status, and malignancy. Age>80 was the only factor participants assigned -1 (low priority) to. Conclusions: Participants stated that socioeconomic factors, except for age>80, should not be involved in prioritizing mechanical ventilators at the time of resources scarcity. Front-line physicians and nurses of COVID-19 patients, pregnant mothers, mothers who had children under 2 years old were given high priority.
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Affiliation(s)
- Mohsen Abbasi-Kangevari
- Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shahnam Arshi
- Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Ali-Asghar Kolahi
- Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Basu S. Approaches to critical care resource allocation and triage during the COVID-19 pandemic: an examination from a developing world perspective. J Med Ethics Hist Med 2021; 14:5. [PMID: 34849214 PMCID: PMC8595072 DOI: 10.18502/jmehm.v14i5.5652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 02/13/2021] [Indexed: 12/16/2022] Open
Affiliation(s)
- Saurav Basu
- Senior Resident, Department of Community Medicine, Maulana Azad Medical College, New Delhi, India
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12
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Cardona M, Dobler CC, Koreshe E, Heyland DK, Nguyen RH, Sim JPY, Clark J, Psirides A. A catalogue of tools and variables from crisis and routine care to support decision-making about allocation of intensive care beds and ventilator treatment during pandemics: Scoping review. J Crit Care 2021; 66:33-43. [PMID: 34438132 DOI: 10.1016/j.jcrc.2021.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 07/15/2021] [Accepted: 08/06/2021] [Indexed: 01/16/2023]
Abstract
PURPOSE This scoping review sought to identify objective factors to assist clinicians and policy-makers in making consistent, objective and ethically sound decisions about resource allocation when healthcare rationing is inevitable. MATERIALS AND METHODS Review of guidelines and tools used in ICUs, hospital wards and emergency departments on how to best allocate intensive care beds and ventilators either during routine care or developed during previous epidemics, and association with patient outcomes during and after hospitalisation. RESULTS Eighty publications from 20 countries reporting accuracy or validity of prognostic tools/algorithms, or significant correlation between prognostic variables and clinical outcomes met our eligibility criteria: twelve pandemic guidelines/triage protocols/consensus statements, twenty-two pandemic algorithms, and 46 prognostic tools/variables from non-crisis situations. Prognostic indicators presented here can be combined to create locally-relevant triage algorithms for clinicians and policy makers deciding about allocation of ICU beds and ventilators during a pandemic. No consensus was found on the ethical issues to incorporate in the decision to admit or triage out of intensive care. CONCLUSIONS This review provides a unique reference intended as a discussion starter for clinicians and policy makers to consider formalising an objective a locally-relevant triage consensus document that enhances confidence in decision-making during healthcare rationing of critical care and ventilator resources.
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Affiliation(s)
- Magnolia Cardona
- Institute for Evidence-Based Healthcare, Bond University Gold Coast, Queensland, Australia; Gold Coast University Hospital Evidence-Based Practice Professorial Unit, Southport, Queensland, Australia.
| | - Claudia C Dobler
- Institute for Evidence-Based Healthcare, Bond University Gold Coast, Queensland, Australia; Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA; The University of New South Wales, South Western Sydney Clinical School, NSW, Australia
| | - Eyza Koreshe
- InsideOut Institute, Central Clinical School, The University of Sydney, NSW, Australia
| | - Daren K Heyland
- Department of Critical Care Medicine, Queens University, Kingston, Ontario, Canada
| | - Rebecca H Nguyen
- The University of New South Wales, South Western Sydney Clinical School, NSW, Australia
| | - Joan P Y Sim
- The University of New South Wales, South Western Sydney Clinical School, NSW, Australia
| | - Justin Clark
- Institute for Evidence-Based Healthcare, Bond University Gold Coast, Queensland, Australia
| | - Alex Psirides
- Intensive Care Unit, Wellington Regional Hospital, Wellington, New Zealand
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Is Prone Positioning Effective in Improving Hypoxemia for Nonventilated Patients With Covid-19? A Rapid Evidence Assessment. Cardiopulm Phys Ther J 2021. [DOI: 10.1097/cpt.0000000000000184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Cove ME, MacLaren G, Brodie D, Kellum JA. Optimising the timing of renal replacement therapy in acute kidney injury. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:184. [PMID: 34059096 PMCID: PMC8165519 DOI: 10.1186/s13054-021-03614-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 05/21/2021] [Indexed: 11/22/2022]
Abstract
The optimal timing of renal replacement therapy (RRT) in critically ill patients with acute kidney injury (AKI) has been much debated. Over the past five years several studies have provided new guidance for evidence-based decision-making. High-quality evidence now supports an approach of expectant management in critically ill patients with AKI, where RRT may be deferred up to 72 h unless a life-threatening indication develops. Nevertheless, physicians’ judgment still plays a central role in identifying appropriate patients for expectant management.
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Affiliation(s)
- Matthew E Cove
- Department of Medicine, National University Singapore, NUHS Tower Block, Level 10, 1E Kent Ridge Road, Singapore, 119228, Singapore.
| | - Graeme MacLaren
- Cardiothoracic ICU, National University Hospital, 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
| | - Daniel Brodie
- Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY, USA.,Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - John A Kellum
- Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh, 606 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15261, USA
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Zeneli A, Brandi G, Di Pasquale G, Orlandini D, De Carolis P, Bravi F, Pugliese F, Poluzzi E, Catena F, Giovanardi F, Valpiani G, Mantovani R, Magnanimi E, Iannone P. Identifying ethical values for guiding triage decisions during the COVID-19 pandemic: an Italian ethical committee perspective using Delphi methodology. BMJ Open 2021; 11:e043239. [PMID: 34006543 PMCID: PMC8130741 DOI: 10.1136/bmjopen-2020-043239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 02/04/2021] [Accepted: 03/10/2021] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES This study aimed to identify the guiding ethical principles that should be considered for critical resource allocation during pandemic emergency situations, and especially for the COVID-19 outbreak. The secondary objective was to define the priority to be assigned to each principle. SETTING The study was conducted from March to June 2020 within the context of an ethical committee (EC) in Northern Italy. PARTICIPANTS Eleven EC members and five additional external healthcare and bioethical professionals, forming a multidisciplinary panel, took part in the study. PRIMARY AND SECONDARY OUTCOME MEASURES The compilation of a list of ethical principles (maximum of 10 items) and their priority ranking and application within an emergency pandemic context was established as the expected outcome of this work. RESULTS A consensus on 10 guiding ethical principles was reached by the multidisciplinary panel. Transparency ranked first on the priority list as the most frequently voted principle, followed by the number of lives saved, life-years saved, respect for individuals' autonomy and equity. Other principles including life cycle, 'sickest first', reciprocity, instrumental value and lottery were also considered appropriate as potential tiebreakers. These principles were discussed and made consistent with the current Italian pandemic context by producing an explanatory document. CONCLUSIONS The identified principles could be used in preparedness plans to guide resource allocation during pandemic events. By combining their rank and relevance in relation to disease, health system organisations, social and economic settings, and critical resources at risk of scarcity, these principles could help to maximise the benefit of resource use for the community, thus reducing inequalities for individuals.
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Affiliation(s)
- Anita Zeneli
- Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRST IRCCS, Meldola, Italy
| | - Giovanni Brandi
- Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | | | | | | | | | | | | | - Fausto Catena
- Emergency and Trauma Surgery, Maggiore Hospital, Parma, Italy
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Public Preferences for Allocating Ventilators in an Intensive Care Unit: A Discrete Choice Experiment. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2021; 14:319-330. [PMID: 33660163 PMCID: PMC7929628 DOI: 10.1007/s40271-021-00498-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/05/2021] [Indexed: 12/14/2022]
Abstract
Background and Objective During the COVID-19 pandemic, resources in intensive care units (ICUs) have the potential to be inadequate to treat all those who might benefit. Therefore, it is paramount to identify the views of the community regarding how to allocate such resources. This study aims to quantify Australian community preferences for ventilation allocation. Methods A discrete choice experiment was designed and administrated to an adult Australian online panel. Each survey respondent answered 12 choice sets from a total design of 120. Each choice set placed the respondent in the role of hypothetical decision maker, prioritising care between two patients. Conditional logit, mixed logit regression and latent class analysis were used to analyse the data. Additionally, we asked a series of attitudinal questions about different methods of making such decisions in practice, focusing on who should be responsible. Results A total of 1050 community members completed the survey and responded to each choice. Dimensions considered most important were age, likely effectiveness, smoking status, whether the person has dependents, whether they are a healthcare worker, and whether they have a disability or not. Estimating marginal rates of substitution between patient characteristics and chance of survival if ventilated yielded values of up to 30 percentage points if the patient was 70 years old relative to being 30. However, respondents typically said they would prefer such decisions to be made by medical professionals. Conclusion This study demonstrated the preferences of the community to allocation of ventilators during the COVID-19 pandemic. The use of such information should be treated with some caution as the underlying reason for such preferences are unclear, and respondents themselves preferred the decision to be made by others. Supplementary Information The online version contains supplementary material available at 10.1007/s40271-021-00498-z.
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Simultaneous ventilation in the Covid-19 pandemic. A bench study. PLoS One 2021; 16:e0245578. [PMID: 33465155 PMCID: PMC7815120 DOI: 10.1371/journal.pone.0245578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 01/05/2021] [Indexed: 12/05/2022] Open
Abstract
COVID-19 pandemic sets the healthcare system to a shortage of ventilators. We aimed at assessing tidal volume (VT) delivery and air recirculation during expiration when one ventilator is divided into 2 test-lungs. The study was performed in a research laboratory in a medical ICU of a University hospital. An ICU (V500) and a lower-level ventilator (Elisée 350) were attached to two test-lungs (QuickLung) through a dedicated flow-splitter. A 50 mL/cmH2O Compliance (C) and 5 cmH2O/L/s Resistance (R) were set in both A and B test-lungs (A C50R5 / B C50R5, step1), A C50-R20 / B C20-R20 (step 2), A C20-R20 / B C10-R20 (step 3), and A C50-R20 / B C20-R5 (step 4). Each ventilator was set in volume and pressure control mode to deliver 800mL VT. We assessed VT from a pneumotachograph placed immediately before each lung, pendelluft air, and expiratory resistance (circuit and valve). Values are median (1st-3rd quartiles) and compared between ventilators by non-parametric tests. Between Elisée 350 and V500 in volume control VT in A/B test- lungs were 381/387 vs. 412/433 mL in step 1, 501/270 vs. 492/370 mL in step 2, 509/237 vs. 496/332 mL in step 3, and 496/281 vs. 480/329 mL in step 4. In pressure control the corresponding values were 373/336 vs. 430/414 mL, 416/185 vs. 322/234 mL, 193/108 vs. 176/ 92 mL and 422/201 vs. 481/329mL, respectively (P<0.001 between ventilators at each step for each volume). Pendelluft air volume ranged between 0.7 to 37.8 ml and negatively correlated with expiratory resistance in steps 2 and 3. The lower-level ventilator performed closely to the ICU ventilator. In the clinical setting, these findings suggest that, due to dependence of VT to C, pressure control should be preferred to maintain adequate VT at least in one patient when C and/or R changes abruptly and monitoring of VT should be done carefully. Increasing expiratory resistance should reduce pendelluft volume.
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