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| Journal of the New Zealand Medical Association,
13-October-2006, Vol 119 No 1243
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Criteria for prioritising access to healthcare
resources in New Zealand during an influenza pandemic or at other times of
overwhelming demand
Michael Ardagh
The emergence of a novel avian influenza virus (influenza A
H5N1) has given impetus to planning for another influenza pandemic.
Ethical issues arising during planning for, and responding
to, a pandemic include: a possible need to restrict personal freedoms
(quarantining and border control); the extent of the ‘duty of care’
of healthcare workers who are putting themselves at risk of infection in the
course of their duties; and the distribution of overwhelmed healthcare resources
(which are likely to be depleted due to illness among the healthcare workforce).
Overwhelming of healthcare resources may also occur at other
times of increased demand, such as after a natural or man-made disaster. This
paper is concerned with prioritising access to healthcare resources at times of
overwhelming demand, with a particular focus on an influenza pandemic.
Some useful publications about the incorporation of ethical
values in pandemic planning (e.g. Stand on guard for thee. Ethical issues in
preparedness planning for pandemic influenza. University of Toronto,
20051) have been published. Other publications
give decision-making guidance during a pandemic such as The Siracusa
Principles2 (which give guidance on the
restriction of individual freedoms), and the work of Lo and
Katz3 (which gives several general guiding
principles about a variety of ethical issues during a pandemic).
Hick and colleagues,4 and
Koenig and colleagues5 in an accompanying
editorial, introduced discussion of the distribution of mechanical ventilators
in an epidemic of respiratory disease. However, pragmatic guidance is limited
and is variably relevant to the clinician ‘on the ground’, making
decisions about real patients during a pandemic. In particular, there is a
paucity of useful, succinct advice for clinicians who must prioritise access to
overwhelmed resources such as emergency department cubicles, hospital beds,
intensive care beds, and antimicrobial drugs, among others.
This paper will present a list of criteria, in the form of
eight questions, to aid the clinician in prioritisation of patients for access
to resources during a pandemic, or at other times of overwhelming demand. It is
intended as a practical guide for clinicians and to be used to aid the
application of overarching ethical values and processes for pandemic
planning.1
Although the focus of this paper is the context of an
influenza pandemic, the criteria will have application to other situations where
there is overwhelming demand for limited healthcare resources.
Prioritisation criteriaEight questions are considered by clinicians who are
required to prioritise access to a resource for one or more competing patients.
Each question achieves relevance after answering the questions asked before.
After some of the questions, the decision regarding access to the resource may
be answered, otherwise the clinician proceeds to the next question.
A reference, or ‘wall
chart’ summary, is reproduced in Tables 1 and 2.
Table 1. Criteria for prioritising access to
resources during overwhelming demand
Table 2. Notes to assist the application of the
Priorisation Criteria
Question 1: Normal threshold
question—Does the patient meet the clinical criteria for access
to the resource during normal times (that is, when there is not overwhelming
demand for the resource)?
This question asks the clinician to consider if the resource
in question would be accessed by the patient even if the resource was plentiful.
The purpose of this question is to exclude those for whom the resource is not
clinically indicated, prior to questions of prioritisation of patients (for whom
the resource is clinically indicated) competing for the resource. For example, a
patient with chronic airways disease, with poor exercise tolerance, may not be
offered an Intensive Care Unit (ICU) bed for ventilation after an infective
exacerbation of their disease, because an assessment by the clinicians, in
consultation with the patient, is that ventilation would do the patient more
harm than good.
This question addresses an important determinant of access
to care and it is essential that it is not confused with the prioritisation
decisions which follow. Patients, or other observers, should not perceive that
access has been denied because of a rationing decision when access was, in fact,
denied on the basis of clinical determinants of what the resource had to offer
the patient. Knowledge that access to the resource would not have been offered
anyway, because it would not serve the best interests of the patient, should
allow a refocusing of energies away from the denied resource to better
alternatives.
If the patient does not meet the usual clinical criteria
then, as will usually be the case, the patient will not access the resource. If
the patient does meet the usual clinical criteria then the clinicians proceed to
question 2.
Question 2: Competition question—Are
there other patients who meet the normal clinical criteria (question 1), who are
competing for the same resource (which is currently insufficient to accommodate
all of the patients who are competing)?
This question confirms that there is insufficient resource
for those who have the clinical indications to access it. If there is available
resource, sufficient to accommodate the patient in question and without other
patients competing, then the patient accesses the resource. If there are too
many clinically appropriate patients for the resource to accommodate then the
clinicians proceed to question 3.
Question 3: Alternative options
question—Can any of the competing patients (including those who
are already using the resource) have alternative care which, although perhaps
not the first choice, will provide reasonably similar benefit to the patient and
not cause significant harm due to accessing the alternative rather than the
original choice?
This question asks the clinicians to consider other
interventions, for which there may be less competition, which may serve the
patient sufficiently well to be an alternative which will not disadvantage the
patient significantly. For example, a patient with a bacterial pneumonia
superinfection of influenza, who might normally be considered for intravenous
antibiotics in a hospital bed (and hospital beds are the limited resource in
question), may be able to be managed in a community setting with intravenous
antibiotics. Or, a patient with hypoxia from a viral pneumonitis, who is
competing for an ICU bed, may be able to be managed with non-invasive
ventilation in a high dependency unit.
If there is a suitable alternative then the appropriate
patient or patients should access the alternative care. For any remaining
patients, the clinicians go to question 4.
Question 4: Deferability question—Can
any of the competing patients have their access to the resource deferred to a
future time when demand is likely to be less, without coming to significant
harm?
Some patients may not need the resource immediately. For
example, much ‘elective’ surgery could be deferred so that hospital
and ICU beds are in less demand. Some ‘acute’ patients, for example
some with fractures which need open surgical fixation, could be managed with
more conservative means (a Plaster of Paris, for example) until competition for
hospital resources is reduced.
If access to the resource in question is deferred or if
other services are deferred (as might occur as a result of question 5, below),
then alternative care should be provided to mitigate symptoms (for example,
analgesia), or to manage the progression of the disease. Follow-up should be
arranged so that future access occurs, or expedited access might occur, if there
are changes to circumstances.
If access to the resource in question can be deferred,
without significant harm to the patient, then it should be. For any remaining
patients the clinicians should proceed to question 5.
Question 5: Expansion question—Can
the resource be expanded to accommodate greater access, perhaps by
redistribution of resources from services which are not experiencing
overwhelming demand, or from services which can be deferred without significant
harm to patients?
Resources from services which are less busy might be
redistributed. For example, outpatient staff, and those mostly providing
elective services, could be redeployed to augment ‘acute’ hospital
services, fully staff intensive care beds and possibly change the function of
some wards to provide a higher dependency (ICU step-down) function.
If this can be achieved then it should be. If there is no
such redistribution, of relevance to the patients in question, then the
clinicians should proceed to question 6.
Question 6: Mitigation question—After
consideration of questions 1 to 5, there are still more patients needing to
access the resource than the resource can accommodate. Are there any alternative
options for any of the competing patients, which will mitigate the harms of
missing out on the resource in question?
This question is not the same as question 3—the
Alternative options question. That question was looking for alternatives which
offer similar outcomes. Nor is it the same as question 4—the Deferability
question. In that question the patient will come to no significant harm as a
result of deferring access to the resource, although mitigation of symptoms and
progression of the disease remain appropriate. This question comes at a time
when it is conceded a patient (or patients) is going to be deprived of a
resource they would normally access, and that this is likely to result in harm
to them.
This question asks the clinician to explore options which
will mitigate any harm. For example, a patient who would normally access
in-hospital respiratory support cannot access it, but might be able to be given
domiciliary oxygen. Or, a patient who is denied surgery due to (postoperative)
ICU beds being used by victims of influenza, may have their pain managed with
intravenous analgesics.
The clinicians now proceed to question 7. However, the
relative benefits and harms of accessing or not accessing the resource will be
considered taking into account the potential to mitigate the harms of missing
out on the resource.
Question 7: Ranking question—After
consideration of questions 1 to 5, there are still more patients needing to
access the resource than the resource can accommodate. Of those competing for
the resource, (including those who are already using the resource)
‘rank’ them in order of perceived ‘net benefit’ of
accessing the resource—that is, the sum of the estimated benefit of access
to the resource and the harm of not accessing the resource. The ‘net
benefit’ should also take into account any mitigation of harm arising from
the options identified in question 6.
Can patients be ranked to clearly differentiate their net
benefit of accessing the resource?
Even in times with no extraordinary demands, those who seek
health care need prioritisation. Those with acute healthcare demands, who
present to hospitals in most countries of the Western world, will initially
undergo some form of triage.6 This triage puts
them in a queue for care mostly based on their need, or urgency, but also taking
into account when they first tried to access care.
In general, those who are least urgent will not miss out,
but they may have to wait. The philosophy of triage at this time is to allow
access to everyone but to allow quickest access to those with the most urgent
needs.
During a mass casualty incident (for example, an accident
involving mass public transport, a natural disaster, or a terrorist attack),
triage undergoes a change of emphasis. While urgency for care remains a key
determinant of the make up of the ‘queue’, explicit attention is
also paid to the patient’s ability to benefit.
The philosophy of triage takes on a utilitarian bent with a
catch phrase of disaster triage being ‘the greatest good for the greatest
number.’ A patient with severe head and other system injuries, who has
some, but small, chance of acceptable survival may be triaged to the front of
the queue under non-disaster conditions, but may be triaged to an alternative
and less urgent type of care in a disaster.
It appears, therefore, that the richer the resource,
relative to the demand, the more urgency, (or need), is a factor in
prioritisation of acute care. The poorer the resource relative to the demand,
the more ability to benefit influences prioritisation. However, discussions of
the relative merits, and contributions, of need and benefit in prioritisation
may seem academic to those who actually make triage decisions for acute care.
For example, acute chest pain is one of the most common presentations to
Emergency Departments (EDs).
Patients with whom the possibility of ischaemic cardiac
chest pain is entertained by the triaging clinician will be triaged so that they
are high in the queue. The reasons for a high triage ranking relate to the
benefit of urgent defibrillation in case of life-threatening cardiac
arrhythmias, and the benefit (decreased mortality and heart failure) associated
with urgent reperfusion (thrombolysis or angioplasty) for those for whom it is
indicated.
For the clinician, triaging patients presenting with acute
chest pain, and in acute patients in general, the distinction between need and
benefit is hard to make. Generally the more pressing the need (or urgency) for
care the more benefit (or avoidance of harm) will be a consequence of timely
care. Consequently, the term ‘benefit’ is used in these criteria to
encompass any relevant contributors of need or urgency.
Furthermore, ‘benefit’ may encompass
contributions less directly related to the patient. For example, a contributor
to the assessment of benefit might be that the patient has dependents who will
benefit from this person being restored to good health.
The patient might be a healthcare worker and it could be a
significant benefit to other patients to return this person to a depleted
workforce as soon as possible. In addition, it may be considered beneficial to
prioritise the care of healthcare workers who have caught the disease during
their work to reinforce the concept of reciprocity—that we will look after
those who put themselves at risk for us.1
In addition to the apparent fairness of the concept of
reciprocity, its explicit presence in planning and decision making will provide
healthcare workers with a greater degree of comfort in continuing to provide
care to infectious patients. Although they are taking on greater risk by doing
so, they know they will be looked after should they, themselves, become
unwell.
In the criteria, an assessment of ‘net benefit’
is made. This is the sum of the estimated benefit of access to the resource and
the harm of not accessing the resource. The ‘net benefit’ should
also take into account any mitigation of harm that can be achieved by
alternative interventions should the patient not access the resource in question
(question 6). Communication between clinicians, patients, and other relevant
parties will allow a patient-centred perception of ‘net benefit’ to
be brought to the deliberations.
Explicit, agreed criteria for measuring ‘net
benefit’ are impossible to construct given the variables of context, the
debated merits of different needs and benefits, and the difficulties of
quantifying them. Instead ‘ranking’ will be, most often, an
uncertain estimate based on the application of the education and experience of
clinicians, taking into account the many variables associated with the patients
in question and the resource they are seeking to access.
Ideally, senior clinicians should be involved in
‘ranking,’ and what opportunities exist for discussion with patients
and colleagues should be taken. An iterative interaction with the patients, to
maintain a transparency of process and to allow emerging relevant factors to
influence decisions, will contribute to trust in the process and fairness of the
outcome. Collaboration with colleagues so that agreement is reached, if
possible, will minimise the risk of bias due to the personal perceptions of
individual clinicians.
If patients can be ranked to clearly differentiate their net
benefit of accessing the resource, then those whose ‘net benefit’
ranks higher should access the resource before those whose ‘net
benefit’ ranks lower. If the patients cannot be ‘ranked’, then
the clinician should proceed to question 8.
Question 8: Final question—If the
competing patients cannot be differentiated in terms of ‘net
benefit,’ then fairness suggests they should access the resource according
to who sought access first. If they cannot be differentiated on a ‘first
come, first served’ basis, then access can be determined by a process of
equal and unbiased chance such as tossing a coin or use of a ballot.
If, after all of these considerations, there are competing
patients, (none of whom has a good alternative care option, none of whom can be
deferred, none of whom can have the harm of missing out mitigated any more, and
all of whom seem to be equally worthy [in terms of net benefit]), then access to
the limited resource should be on the basis of criteria which are fair,
explicit, and predetermined.
It is generally accepted that, all else being equal, those
who seek access first should get it. If there is still competition then access
should be on the basis of ‘equal chance’ such as might occur with a
toss of coin or a ballot.
Application of these criteria in a way which encourages respect for peopleCommunication is a key contributor to a respectful, trusting
relationship between carers, patients, and their families. During a pandemic,
ethical decision-making may be complicated by urgency to make decisions, (so
that time for deliberation is short), and possibly, impaired patient
decision-making capacity due to hypoxia or altered consciousness.
Prior public involvement in discussions about the criteria,
and explicit communication of these criteria before they need to be applied,
will ease their application during a pandemic. Similarly, real-time application
of the criteria will be made more palatable by transparency about how access to
a resource is achieved.
The views of individual patients seeking a resource should
be sought, particularly regarding net benefit of access, so that a
patient-centred perception of net benefit contributes to ranking, and to enhance
the sense of trust and empowerment consequent to being heard.
Knowledge of how a decision was made, and an understanding
that explicit and fair criteria were used, will contribute to trust of the
decision-makers and acceptance of the decisions.
An autonomous refusal of access, when it is offered, should
be respected. However, a request for access when the patient does not warrant
access according to the judicious application of these criteria, is insufficient
to gain access. Indeed, to allow access under these circumstances would be an
injustice to any patients who meet the criteria but are denied access as a
consequence of those who do not meet the criteria gaining access.
SummaryThis paper presents criteria for the
prioritisation of access to resources during overwhelming demand, such as during
a pandemic. The criteria are in the form of eight questions related to the
resource and the patients competing for it, and are intended to be sufficiently
comprehensive and sufficiently succinct to be useful to clinicians who might be
required to make such decisions.
Author information: Michael W Ardagh,
Professor of Emergency Medicine, Christchurch School of Medicine and Health
Sciences (and Emergency Department, Christchurch Hospital); Christchurch
Correspondence: Professor Michael Ardagh,
Emergency Department, Christchurch Hospital, Private Bag 4710, Christchurch.
Email: michael.ardagh@cdhb.govt.nz
References:
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