Fair allocation of scarce medical resources in the time of Covid-19
Selected in The New England Journal of Medicine by D. Milasinovic
This article attempts at providing some practical guidance for resource allocation in difficult clinical scenarios where the patient needs outstrip the existing medical supplies.
References
Authors
Emanuel EJ, Persad G, Upshur R, Thome B, Parker M, Glickman A, Zhang C, Boyle C, Smith M, Phillips JP.
Reference
N Engl J Med. 2020 Mar 23 [Epub ahead of print]
Published
March 2020
Link
Read the abstractReviewer
My Comment
Article recommended by Jean Marco:
"COVID-19 can place extraordinary and sustained demands on public health and health systems and on providers of essential community services. Such demands will create the need to ration medical equipment and interventions. This article could help your team to take in a teamwork approach, difficult decision for particular patients according to your critical reflection on your local experience and local constraints."
We invite you to critically react and express your point of view on this difficult topic.
As COVID-19 increasingly sets the tone of medical profession and dominates our health care systems, we all may be confronted with decision-making processes that go well beyond our previous experiences.
The recent article by Emanuel et al. (1) attempts at providing some practical guidance for resource allocation in difficult clinical scenarios where the patient needs outstrip the existing medical supplies.
COVID-19 pandemic: the imminent threat of resource scarcity
On March 11th 2020, World Health Organization (WHO) declared COVID-19 to be a pandemic. The current situation was then characterized with the following words: “We have never before seen a pandemic sparked by a coronavirus. This is the first pandemic caused by a coronavirus. And we have never before seen a pandemic that can be controlled, at the same time.” (2)
Under these premises resource scarcity across different health care systems can easily be imagined. According to a recent model developed for the United States, if 5% of the population is infected by SARS-CoV-2 (which is a conservative estimate) over 3 months, there would be a need for 960,000 ICU beds. The currently estimated capacity, counting in the number of ventilators and available staff, would be to care for approximately 100 000 ICU patients per day (1). From these data it is clear that an acute shortage of life-saving resources is a possibility that cannot be excluded.
The ethics of maximizing benefit
Considering the possibility that medical staff will be facing the dilemma of how to perform fair allocation of available resources, the authors recur to 4 basic ethical principles (maximizing benefits, treating people equally, prioritizing the worst off and those who actively contribute to the well being of others), in order to formulate specific recommendations for practicing clinicians. The described 4 principles, as well as from them derived 6 specific recommendations, seem to all be grounded in the utilitarian principle of maximizing benefits to most people, mainly in terms of patient years gained. More specifically, the authors advocate 1) achieving maximum benefit by offering intensive treatment to patients with severe symptoms but enough potential to recover (e.g. younger patients, without major comorbidities), 2) prioritizing front-line health care workers and others directly involved in the health care industry, 3) random allocation in cases of similar prognosis, rather than the first-come first-serve approach, 4) adapting allocation strategies to evolving new scientific evidence (e.g. prognosis assessment in the light of new medication protocols), 5) granting priority to clinical research participants and 6) not allowing COVID-19 to overshadow other life-threatening diseases for which sufficient resources need to be allocated as well.
What can be done to alleviate resource shortage?
Given the above-described numbers for the US (and the situation may not be more optimistic for most European countries and the rest of the world), the strategy of “flattening the curve” by adhering to social distancing has been widely advised.
Social distancing
Social distancing means avoiding close contact with others. For most medical personnel it means working in small teams in shifts to prevent en masse disease spread among health care workers. This also means that the very basis of medical education, i.e. its starting point – daily local case discussion among institutional peers, is disturbed. This is of acute importance in times of a pandemic, where only the continuous flow of information can ensure real-time updates for front-line health care workers making difficult decisions (often in ethically challenging settings, as made specific in the Recommendation 5 in the article by Emanuel et al. (1)). For this reason, it is paramount to keep open and regularly updated reliable educational platforms and professional channels of communication, which make possible a broad exchange of experience among peers.
Flattening the curve
The principle of reducing a sudden surge in the incidence of COVID-19 has been broadly recognized as “flattening the curve”. The purpose seems to be to allow health care systems to absorb the COVID-19 patients, while at the same time maintaining an uninterrupted care of patients with other life-threatening diseases, including acute coronary syndromes and other cardiovascular diseases.
The flip side of this strategy is that it could potentially last for a protracted period of time, at least until the purported disappearance of the virus in the summer, or, if this does not happen, until the cure and/or vaccine is found, or at the very last until the herd immunity is achieved.
Even though actively testing and isolating may speed up this process, the implications of a prolonged battle with COVID-19 are significant for our community of cardiologists. As specified in the Recommendation 6 in the article by Emanuel et al., non-COVID-19 patients need to also be taken into account when pondering how to allocate available health care resources (1).
Interventional cardiovascular medicine in times of COVID-19
American College of Cardiology (ACC) Interventional Council and SCAI Cardiology community have recently issued a joint statement on patient selection, resource allocation and personal protection in the cath lab (3). The overarching principle is to reduce the case volume and/or the hospitalization length, as well as to provide optimal personal protection for the cath lab staff. To this end, deferral of PCI in stable ischemic heart disease or PFO closure could be considered. For patients with ACS, rapid nucleic acid tests to detect the presence of SARS-CoV-2 could be performed, if available, prior to sending a patient to the cath lab. Fibrinolytic therapy in selected STEMI patients and conservative therapy in patients with NSTEMI and a likely type 2 MI could be considered.
As this has already been highlighted, fair resource allocation (1) mandates that care for non-COVID-19 patients with life-threatening diseases should also be taken into account when allocating health care resources. As an example of how this ethical decision-making is necessary informed by scientific data, it may perhaps be relevant to remember, when making decisions about patients with suspected stable ischemic heart disease, that significant left main stenosis was found in 8.7% of the screened population in the ISCHEMIA trial, and that these patients were ultimately excluded from the study.
Ethics, science and individual responsibility
In times of COVID-19 pandemic the entire community of cardiovascular specialists is facing difficult decisions on a day to day basis that are inherently linked to the question of resource allocation. Although individualized decision-making is inevitable, clinical algorithms incorporating both updated scientific information and ethical considerations may ease the pressure on individual clinicians and provide some guidance in difficult situations where, at times, diverging interests of a multitude of patients are at play.
COVID-19 and interventional cardiology
References
1. Emanuel EJ et al. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. N Engl J Med 2020 Mar 23[Online ahead of print]
2. WHO Director-General's opening remarks at the media briefing on COVID-19 - 11 March 2020 https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020
3. Welt FGP et al. Catheterization Laboratory Considerations During the Coronavirus (COVID-19) Pandemic: From ACC's Interventional Council and SCAI. J Am Coll Cardiol 2020 Mar 16[Online ahead of print]
No comments yet!