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Ethics/Resource Allocation - Ethics/Resource Allocation
IN SHORT: Ethics and standards of care may change in a crisis to emphasize community benefit, but there are specific frameworks to familiarize yourself with and follow. Unless specifically told you are entering contingency or crisis standards, assume normal standards of care apply. Centers should create triage experts to help with decision making.
AMA Journal of Ethics COVID19 Resource Center
NEJM on Fair Allocation of Scarce Medical Resources in the Time of Covid-19
JAMA Framework for Rationing Ventilators and Critical Care Beds During the COVID-19 Pandemic
SCCM Resource Availability for COVID19
- Standards of care may shift during emergency situations, with three prominent levels (IOM):
- Conventional: normal levels of staff, supplies; provide conventional care consistent with usual practices & standards
- Contingency: abnormal staffing, supplies but can be adapted to provide care functionally equivalent to usual patient care; typical standards of care predominantly apply
- Crisis: staffing, supplies, space cannot be adapted sufficiently to provide typical care due to a catastrophic disaster or emergency (including pandemic), work to provide best possible care to patients given the circumstances and resources available but activation constitutes a significant adjustment to standards of care with focus on community instead of simply individual patients
- Many US states are starting to come up with crisis standards of care (WA State here) and plans for triage; look up your regional standards and keep in touch with your hospital to ensure appropriate response to changing conditions
- Do not apply crisis standards of care until level reached and declared by authorities; many communities are currently in contingency but not crisis standards and applying crisis too early may needlessly sacrifice lives
- Many experts recommend creation of triage panels or officers separate from patient care to ensure any crisis decisions are objective and take pressure off of frontline providers (Emanuel et al, Truog et al, Anesi et al)
- Protections for caregivers participating in triage from criminal or civil suits are currently piecemeal and leave frontline workers at risk, reform is urgently needed (Cohen et al)
- Ethicists argue that providers should not be required to perform care in absence of adequate PPE, but also that they cannot abdicate the responsibility to care if PPE is available (Kramer et al)
