7.3 Crisis standards of care and resource allocation

Crisis standards of care are crucial during public health emergencies when resources are scarce. They provide a framework for allocating limited resources, aiming to maximize benefits for the population while minimizing harm and upholding ethical principles.

Implementing these standards involves balancing ethical principles like utility and equity. Challenges include potential exacerbation of health disparities, logistical constraints, and maintaining public trust. Fairness and transparency are key in developing and communicating allocation decisions.

Crisis Standards of Care: Role in Emergencies

Framework for Allocating Limited Resources

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• Crisis standards of care provide a framework for allocating limited resources during public health emergencies when demand exceeds available resources
• The goal of crisis standards of care is to maximize benefits to the population as a whole, while minimizing harm and adhering to ethical principles
• Crisis standards of care involve modifying usual healthcare operations and treatment decisions, such as prioritizing patients most likely to survive with treatment (ventilator allocation during COVID-19 pandemic)

Implementing Crisis Standards of Care

• Implementing crisis standards of care requires a formal declaration by state government and activation of emergency response plans
• Crisis standards of care guidelines should be developed in advance of emergencies through a transparent, inclusive process involving stakeholders (healthcare providers, public health officials, community leaders)
• Guidelines may include protocols for triage, resource allocation, and modifications to usual care delivery (alternate care sites, expanded scope of practice for healthcare workers)
• Activation of crisis standards of care may involve legal and regulatory changes to facilitate emergency response (liability protections, suspension of certain regulations)

Ethical Frameworks for Resource Allocation

Balancing Ethical Principles

• The ethical principle of utility seeks to maximize benefits and minimize harms for the greatest number of people
• The principle of equity requires fair distribution of resources and avoiding discrimination based on non-medical factors such as race, ethnicity, disability, or socioeconomic status
• Prioritizing those most likely to survive with treatment reflects the principle of maximizing benefits, while random selection upholds equality of opportunity (lottery system for allocating scarce medications)
• First-come, first-served approaches may exacerbate disparities, while prioritizing essential workers has been justified based on reciprocity and instrumental value (early vaccine access for healthcare workers and first responders)

Developing Allocation Frameworks

• Ethical frameworks balance multiple principles and values, acknowledging that no single principle is absolute and that difficult trade-offs are inevitable
• Frameworks should be developed through inclusive, transparent processes that engage diverse stakeholders and incorporate community values
• Allocation criteria should be based on objective medical factors such as likelihood of survival, urgency of need, and prospect of benefit (Sequential Organ Failure Assessment (SOFA) score for prioritizing critical care resources)
• Frameworks should include provisions for palliative care and emotional support for patients and families who do not receive scarce resources
• Allocation decisions should be made by multidisciplinary triage teams using clear, consistent criteria rather than left to individual clinician judgment

Challenges of Implementing Crisis Standards of Care

Exacerbating Disparities

• Preexisting disparities in health status, access to care, and social determinants of health may result in disproportionate impact on disadvantaged populations (higher COVID-19 mortality rates among racial and ethnic minorities)
• Bias and discrimination in healthcare delivery may be exacerbated under crisis conditions without clear, objective allocation criteria
• Individuals with disabilities, advanced age, or comorbidities may be disadvantaged by allocation frameworks emphasizing short-term survival (denying ventilator access based on pre-existing conditions)

Logistical and Resource Constraints

• Limited healthcare infrastructure and resources in rural and underserved areas may necessitate earlier implementation of crisis standards (hospital bed shortages in rural areas during COVID-19 surges)
• Inadequate supplies of personal protective equipment, medications, and medical devices may limit ability to provide care according to usual standards
• Staffing shortages due to illness, burnout, or other factors may necessitate modifications to usual care delivery models (team-based nursing, expanded scope of practice for non-physician providers)

Public Trust and Perceptions of Fairness

• Public distrust and perceptions of unfairness may undermine adherence to public health measures and erode social cohesion
• Inconsistent application of allocation criteria across jurisdictions or facilities may contribute to perceptions of inequity
• Lack of transparency or clear communication about allocation decisions may fuel rumors and misinformation (concerns about "death panels" during H1N1 pandemic)

Fairness and Transparency in Resource Allocation

Establishing Clear, Objective Criteria

• Establish clear, objective criteria for allocation decisions based on medical need, urgency, and prospect of benefit
• Utilize multidisciplinary triage teams to make allocation decisions, rather than relying on individual clinician judgment
• Develop clear exclusion criteria for conditions with poor prognosis even with maximal treatment (severe burns, end-stage organ failure)
• Include provisions for regular review and adjustment of allocation criteria based on evolving clinical evidence and circumstances

Engaging Stakeholders and Communicating Decisions

• Engage diverse community stakeholders in developing crisis standards guidelines to incorporate community values and promote trust (public forums, community advisory boards)
• Communicate allocation decisions and rationale clearly and compassionately to patients, families, and the public
• Provide clear guidance and support for healthcare workers implementing crisis standards of care
• Establish mechanisms for appeals and review of individual allocation decisions

Ensuring Legal and Ethical Accountability

• Ensure legal and ethical review of crisis standards policies and procedures to uphold constitutional rights and anti-discrimination laws
• Provide liability protections for healthcare workers and institutions acting in good faith under crisis standards of care
• Establish processes for monitoring and addressing unintended consequences or disparities in allocation decisions
• Conduct post-incident review and evaluation to identify areas for improvement in future crisis planning and response