Debra L. Beck and Eugene Braunwald, MD

As COVID-19, the disease caused by the novel coronavirus SARS-CoV-2, continues to spread across numerous countries and territories, it is expected that demand for health care will create the need to ration medical equipment and interventions. An international team of medical ethicists and experts in medicolegal issues, emergency medicine, and public health provided recommendations on how to approach resource allocation during the COVID-19 pandemic.

Emanuel et al wrote that even using conservative estimates of infection, the numbers of individuals requiring hospital care and ICU care in the United States will go well beyond available capacity. There is already unmet need for N-95 masks and ventilators.

The authors suggested four fundamental value around which they base recommendations for allocation of scarce resources: maximizing benefits, treating people equally, promoting and rewarding instrumental value, and giving priority to the worst off.

Based on these values, the authors 6 specific recommendations to guide allocation of scarce resources:

1. Maximizing benefits in the most important value and reflects the importance of responsible stewardship of resources. Put simply, patients who are more likely or recovery should be prioritized over those less likely to recover. Save the most lives and save the most life-years. This could include, said the authors, withdrawing care (removing a patients from a ventilator or ICU bed) to provide care to others in need. Patients should be made aware of this possibility at admission and, although it will be extremely psychologically traumatic for clinicians, “many guidelines” agree that this decision “is not an act of killing and does not require the patient’s consent.”
2. Prioritizing front-line health care workers. HCWs should be the first to receive testing, personal protection equipment (PPE), ICU beds, ventilators, therapeutics, and vaccines. Even if an infected HCW will not be able to return to work, they should still receive priority care, if only to boost morale and discourage absenteeism.
3. Avoid allocation according to the idea of first-come, first-served. For individuals with similar needs and prognoses, random allocation can be used and may help avoid crowding or violence. Using a first-come, first-served will unfairly penalize “people who happen to get sick later on, perhaps because of their strict adherence to recommended public health measures…” said the authors.
4. Prioritization guidelines should differ by intervention and respond to changing evidence. For example, current evidence indicates that vaccines, when they are available, should be given first to HCWs and first responders, but then to the elderly, as opposed to children and younger individuals, given the higher risk of death seen with increasing age. Conversely, ventilators are life-saving rather than preventive and therefore priority may be given to younger patients over older patients. Reserving some test kits for epidemiologic modeling should be considered.
5. Individuals who consent to participate in clinical research to prove the safety and effectiveness of therapeutics and vaccines should receive some priority for interventions. This will reward their participation and encourage others to participate. “Research participation, however, should only be used as a tiebreaker among patients with similar prognoses,” wrote Emanuel et al.
6. Fair allocation requires prioritizing the idea of maximizing benefit across all patients who need resources. This means, that non-COVID-19 patients should be considered when, for example, determining which patients will be given an ICU bed or ventilator support. The authors provide an example of this: if a frontline HCW goes into anaphylactic shock and requires a ventilator, he/she should receive priority over a COVID-19 patients who is not an HCW.

Summary

Fair and consistent allocation procedures should be designed considering the principles and recommendations discussed. This should preferably be done before scarcity occurs to ensure public trust in fairness and reduce the burden on front-line HCWs who may have to make allocation decisions in an improvised fashion. To help physicians navigate these challenges, Emanuel et al suggest hospitals employ triage officers (physicians in roles outside direct patients care) who can apply the guidelines thereby relieving front-line physicians of this burden.

Comments

In a Perspective article published alongside the Emanuel et al article, Truog and colleagues strongly support the use of triage personnel or committees to remove this burden from front-line clinicians. “Though some people may denounce triage committees as ‘death panels,’ in fact they would be just the opposite—their goal would be to save the most lives possible in a time of unprecedented crisis.” Withdrawal of ventilator support should not be required of physicians, nurses, or respiratory therapists who are caring for the patient, but rather they should be supported by a team willing to serve in this role that has skills and expertise in palliative care and emotional support of patients and families.

References

• https://www.ncbi.nlm.nih.gov/pubmed/32202722
• https://www.ncbi.nlm.nih.gov/pubmed/32202721

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