Tia Powell

Allocation of Ventilators in a Public Health Disaster

BACKGROUND In a public health emergency, many more patients could require mechanical ventilators than can be accommodated. METHODS To plan for such a crisis, the New York State Department of Health and the New York State Task Force on Life and the Law convened a workgroup to develop ethical and clinical guidelines for ventilator triage. RESULTS The workgroup crafted an ethical framework including the following components: duty to care, duty to steward resources, duty to plan, distributive justice, and transparency. Incorporating the ethical framework, the clinical guidelines propose both withholding and withdrawing ventilators from patients with the highest probability of mortality to benefit patients with the highest likelihood of survival. Triage scores derive from the sepsis-related organ failure assessment system, which assigns points based on function in 6 basic medical domains. Triage may not be implemented by a facility without clear permission from public health authorities. CONCLUSIONS New York State released the draft guidelines for public comment, allowing for revision to reflect both community values and medical innovation. This ventilator triage system represents a radical shift from ordinary standards of care, and may serve as a model for allocating other scarce resources in disasters.

Definitive Care for the Critically Ill During a Disaster: A Framework for Allocation of Scarce Resources in Mass Critical Care: From a Task Force for Mass Critical Care Summit Meeting, January 26–27, 2007, Chicago, IL

BACKGROUND Anticipated circumstances during the next severe influenza pandemic highlight the insufficiency of staff and equipment to meet the needs of all critically ill victims. It is plausible that an entire country could face simultaneous limitations, resulting in severe shortages of critical care resources to the point where patients could no longer receive all of the care that would usually be required and expected. There may even be such resource shortfalls that some patients would not be able to access even the most basic of life-sustaining interventions. Rationing of critical care in this circumstance would be difficult, yet may be unavoidable. Without planning, the provision of care would assuredly be chaotic, inequitable, and unfair. The Task Force for Mass Critical Care Working Group met in Chicago in January 2007 to proactively suggest guidance for allocating scarce critical care resources. TASK FORCE SUGGESTIONS In order to allocate critical care resources when systems are overwhelmed, the Task Force for Mass Critical Care Working Group suggests the following: (1) an equitable triage process utilizing the Sequential Organ Failure Assessment scoring system; (2) the concept of triage by a senior clinician(s) without direct clinical obligation, and a support system to implement and manage the triage process; (3) legal and ethical constructs underpinning the allocation of scarce resources; and (4) a mechanism for rapid revision of the triage process as further disaster experiences, research, planning, and modeling come to light.

Definitive care for the critically III during a disaster: A framework for allocation of scarce resources in mass critical care

BACKGROUND Anticipated circumstances during the next severe influenza pandemic highlight the insufficiency of staff and equipment to meet the needs of all critically ill victims. It is plausible that an entire country could face simultaneous limitations, resulting in severe shortages of critical care resources to the point where patients could no longer receive all of the care that would usually be required and expected. There may even be such resource shortfalls that some patients would not be able to access even the most basic of life-sustaining interventions. Rationing of critical care in this circumstance would be difficult, yet may be unavoidable. Without planning, the provision of care would assuredly be chaotic, inequitable, and unfair. The Task Force for Mass Critical Care Working Group met in Chicago in January 2007 to proactively suggest guidance for allocating scarce critical care resources. TASK FORCE SUGGESTIONS In order to allocate critical care resources when systems are overwhelmed, the Task Force for Mass Critical Care Working Group suggests the following: (1) an equitable triage process utilizing the Sequential Organ Failure Assessment scoring system; (2) the concept of triage by a senior clinician(s) without direct clinical obligation, and a support system to implement and manage the triage process; (3) legal and ethical constructs underpinning the allocation of scarce resources; and (4) a mechanism for rapid revision of the triage process as further disaster experiences, research, planning, and modeling come to light.

Workgroup on expanded criteria organs for liver transplantation

Organ transplantation has progressed, in a relatively brief period of medical history, from an experimental to a standard treatment for end-stage organ failure. The replacement of a diseased heart, liver, or kidney with a functional transplant has become the preferred approach to restoring the well-being of a patient. However, while the number of patients who are medically suitable to undergo organ transplantation has markedly risen, the supply of deceased organ donors has remained insufficient to provide for the increasing demand. Thus, organ procurement and transplant professionals have considered other ways of addressing this organ shortage, such as the transplantation of organs from living donors or from deceased donors whose medical characteristics are not ideal. The ideal deceased donor of an organ has been identified as a donor younger than 40 years of age who has no characteristics that may predispose his or her organs to graft failure after transplantation. Currently, ideal deceased liver donors provide approximately one-third of all livers transplanted in the United States. All other deceased liver donors present a continuum of increased risk of graft failure compared with the ideal donor. The expanded criteria donor (ECD) designation is meant to describe a deceased donor with substantially increased risk of graft failure compared with the ideal donor. The following deceased donor characteristics have been associated with increased risk of graft failure and have been used to describe the ECD:

Ethical issues in pediatric emergency mass critical care

Introduction: As a result of recent events, including natural disasters and pandemics, mass critical care planning has become a priority. In general, planning involves limiting the scope of disasters, increasing the supply of medical resources, and allocating scarce resources. Entities at varying levels have articulated ethical frameworks to inform policy development. In spite of this increased focus, children have received limited attention. Children require special attention because of their unique vulnerabilities and needs. Methods: In May 2008, the Task Force for Mass Critical Care published guidance on provision of mass critical care to adults. Acknowledging that the critical care needs of children during disasters were unaddressed by this effort, a 17-member Steering Committee, assembled by the Oak Ridge Institute for Science and Education with guidance from members of the American Academy of Pediatrics, convened in April 2009 to determine priority topic areas for pediatric emergency mass critical care recommendations. Steering Committee members established subgroups by topic area and performed literature reviews of MEDLINE and Ovid databases. Draft documents were subsequently developed and revised based on the feedback from the Task Force. The Pediatric Emergency Mass Critical Care Task Force, composed of 36 experts from diverse public health, medical, and disaster response fields, convened in Atlanta, GA, on March 29–30, 2010. This document reflects expert input from the Task Force in addition to the most current medical literature. Task Force Recommendations: The Ethics Subcommittee recommends that surge planning seek to provide resources for children in proportion to their percentage of the population or preferably, if data are available, the percentage of those affected by the disaster. Generally, scarce resources should be allocated on the basis of need, benefit, and the conservation of resources. Estimates of need, benefit, and resource utilization may be more subjective or objective. While the Subcommittee favors more objective methods, pediatrics lacks a simple, validated scoring system to predict benefit or resource utilization. The Subcommittee hesitantly recommends relying on expert opinion while pediatric triage tools are developed. If resources remain inadequate, they should then be allocated based on queuing or lottery. Choosing between these methods is based on ethical, psychological, and practical considerations upon which the Subcommittee could not reach consensus. The Subcommittee unanimously believes the proposal to favor individuals between 15 and 40 yrs of age is inappropriate. Other age-based criteria and criteria based on social role remain controversial. The Subcommittee recommends continued work to engage all stakeholders, especially the public, in deliberation about these issues.

Face Transplant: Real and Imagined Ethical Challenges:

Ethical lapses associated with the first facial transplant included breaches of confidentiality, bending of research rules, and film deals. However, discussions of the risk-benefit ratio for face transplantation are often deficient in that they ignore the needs, experience, and decision-making capability of potential recipients.

Refusing Life‐Sustaining Treatment After Catastrophic Injury: Ethical Implications

n theory, a competent patient may refuse any and all treatments, even those that sustain life. The problem I with this theory, confidently and frequently asserted, is that the circumstances of real patients may so confound us with their complexity as to shake our confident assumptions to their core. For instance, it is not the case that one may always and easily know which patients are competent. Indeed, evaluation of decision-making capacity is notoriously difficult. Not only may reasonable and experienced evaluators, say a judge and a psychiatrist, disagree, but also a person’s capacity may change from hour to hour and may extend to some decisions yet not to others. And yet it is on this subtle art of capacity evaluation that life and death decisions often turn, especially when patients decline life-sustaining treatment. An evaluation of capacity may consider the impact of serious medical or psychiatric illness, as well as the patient’s life circumstances. A number of authors have addressed decision-making capacity in the setting of depression, fatal illness, and end-of-life treatment decisions.’ Less commonly, these factors have been examined in the context of competent patients with chronic disability, rather than terminal illness2 In the world of rehabilitation medicine and disability, which is so strikingly different from acute medicine in other ways, assumptions about decision-making capacity may also differ. These different assumptions may lead to a crisis when chronically disabled (but not dying) patients refuse life-sustaining treatments. This crisis, in turn, forces a reexamination of the concept of decisional capacity in the rehabilitation context. In particular, the impact of catastrophic trauma on decisional capacity is judged dif-

Consultation-liaison psychiatry and clinical ethics: Representative cases

The skills of the consultation-liaison psychiatrist are enormously valuable in the emerging field of clinical ethics consultation. Expertise in evaluating decision-making capacity is crucial, as is the larger issue of addressing the role that emotional factors play in making life or death decisions. Three cases are reviewed that illustrate the way in which the psychiatric perspective enhances the process of clinical ethics consultation.

Philosophy, Ethics, and Humanities in Medicine: Expanding the open-access conversation on health care

Natural philosophy once spanned the fields of philosophy, science, and medicine. Scientific disciplines and medical specialties have rapidly achieved independence, and the availability of the internet and open-access publishing promises a further expansion of knowledge. Nevertheless, a consideration of the grounding concepts and ethical principles that underlie health care remains paramount. It is timely, therefore, to contribute to the global conversation on health care with an open-access journal that focuses on addressing the conceptual basis of medicine and related disciplines, considering the ethical aspects of clinical practice, and exploring its intersection with the humanities (including history of medicine).

Extubating Mrs. K: psychological aspects of surrogate decision making.

Mrs. K is a thirty-one-year-old Russian-speaking mother of two, who was brought in by ambulance after attempting suicide by jumping in front of train. Probable depression x months. Stressor: lost custody battle over older child. Current status: deep coma, ventilator-dependent, and prognosis grim. Next of kin is estranged husband; he demands participation in medical decision making. Legal proxy is patients boyfriend; forcibly removed from the intensive care unit (ICU) for agitated behavior and alcohol intoxication.