Allocation of Resources Philip Boyle, Ph.D. Vice President, Mission & Ethics

1. Allocation of Resources Philip Boyle, Ph.D. Vice President, Mission & Ethics www.CHE.ORG/ETHICS

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3. Under what circumstances is it permissible to allocate, & perhaps deny healthcare services? • What kind of health care services will exist? • Who will get them and on what basis? • Who will deliver them? • How will the burdens of financing be distributed? • How shall the power & control of these services be distributed?

4. Related questions • Is perception of the need for limitations accurate? • Are denials necessary? Defensible? • Is there a just way to accomplish? • Where should allocation occur: bedside or nationally? • Are there procedural safeguards?

5. Ways to distribute healthcare • Macro (public policy) • Eliminate waste • Identify intelligent way to use resources • Public forum –Oregon • Government constraints: (invisible hand) • Public funds • Restrictions on private funds • Practice of professionals • Public criteria • Age • Caring versus curing? • Rationing? • Implicit or explicit?

6. Micro (at bedside) • First come, first serve • presupposes access to info • Status: based on society’s sympathies • Merit: past & future contribution • Quality of life / prognosis: discriminatory? • Age: natural life span • Lottery: only if all things are equal • Those who can afford it • Alternatives • Forfeiture • Gate keeping

7. Criteria for admission to LTC • First come, first serve: waiting lists • Neediest first: sickest worse prognosis • Rehabilitation: NH as transition • Merit: previous donor • Family ties: admitting spouse • Maintaining qualitative integrity of institution • Religion, ethnicity, affiliation with voluntary organization, PLU, quality of life & screamers • Social responsibility to community • Payment; eligibility for public funds or private pay

8. Resource allocation • Different names, same problem • Priority setting, rationing, futility judgments, medically necessary • Happening all over • Admission/discharge, formulary, capital purchase, staffing, mix of services

9. Resource allocation • Happenstance or intentional • Different goals • Cost containment, appropriate care • Different practical responses • Don’t ask, don’t tell • Tell, but don’t ask • Tell, and ask

10. Where does this question fit in clinical ethics? • When can or must a patient forgo treatment? When can or must an institution or society forego/deny treatment? • Who decides? • What basis can you withhold treatment? • Treatment is futile • Treatment is excessively burdensome with little benefit • Organizational ethics

11. Case of Rosemary • 80 year old • Assisted living • 3 vessel coronary artery disease • 90% stenosis of left main coronary • Cardiologist recommends medical management • Would it make a difference if: • 40 or 60 years old? • Living situation? • Method of payment

12. Allocation at beside • Pro • Always denied a treatment that does more harm than good; better to have MDs in control than outside influence • Clinicians are moral agents with professional integrity and judgment • Patients don’t have an unqualified right to request. • Helps the doctor-patient relationship • Must start somewhere; will occur with practice guidelines • Could cut the cost of any individual

13. Allocation at beside • Con • Applied inconsistently: which pts are chosen • Challenges the doc-pt relationship • Overrides PT autonomy • Peace dividend? Will the saved resources be transferred?

14. Is this policy or practice? • Are the definitions clear? • Are the reasons for why some therapies are withheld? • Is it clear about who should decide? • Are there checks and balances? • Is the resource allocation just applied only to the vulnerable dying or to all instances? • Is there broad agreement that treatment is not beneficial or effective?

15. Flu Pandemic • One of the side effects of SARS was that people scheduled for important treatments, such as cancer surgery, had their care postponed. A number of hospital beds, staff and equipment were redirected to the public health emergency. These kinds of decisions will be even more prevalent during a flu pandemic.

16. Flu Pandemic Determine relative chance of survival Staff first? Societal worth- example given- if only 5 people can run the water treatment plant, are they more valuable to the community than others? Groups identified- women, children? First come, first served Provide education sheet for care at home- chest PT Abbreviate care?- 2 days of antibiotics and best wishes

17. Recommendations • Governments and the health care sector should publicize a clear rationale for giving priority access to health care services, including antivirals and vaccines, to particular groups, such as front line health workers and those in emergency services. The decision makers should initiate and facilitate constructive public discussion about these choices. • Governments and the health care sector should engage stakeholders (including staff, the public, and other partners) in determining what criteria should be used to make resource allocation decisions (e.g., access to ventilators during the crisis, and access to health services for other illnesses), should ensure that clear rationales for allocation decisions are publicly accessible and should provide a justification for any deviation from the pre-determined criteria. • Governments and the health care sector should ensure that there are formal mechanisms in place for stakeholders to bring forward new information, to appeal or raise concerns about particular allocation decisions, and to resolve disputes.

18. Macro allocation • Oregon • Method • Research & expert testimony on effectiveness of treatment • A formula that considered cost and benefit • Public values: 47 community meetings; 12 public hearings; 1000 telephone survey • Commissioners’ judgment of what is most important to Oregonians

19. Oregon • Listed 709 conditions/treatments • Developed 17 categories • Essential 1-9 • Very Important 10-13 • Valuable to certain individuals 14-17 • Acute v. non-acute • Fatal v. non-fatal • Effectiveness of outcomes

20. Oregon • Every person entitled to services necessary for diagnosis • 1.Acute fatal: treatment prevents death and allows for full recovery • Appendectomy, whooping cough • 2. Maternity care: most newborn disorders • 3.Acute fatal: prevents death but not full recovery • Non-surgical treatment of stroke, burns, TBI • 4. Preventive care for children: • Immunizations

21. 5. Chronic fatal: improves life span and quality of life • Asthma, drug treatment for HIV • 6. Reproductive services • Infertility services, birth control • 7. Comfort care • Pain management • 8. Preventive dental care: exams, cleaning • 9. Effective preventive care for adults

22. Very important • 10. Acute non-fatal: return to health • 11. Chronic nonfatal: treatment improves the quality of life • Hip replacement • 12. Acute non-fatal: treatment but no return to baseline • Dislocated elbow • 14. Chronic non-fatal : repetitive treatment improves quality of life

23. Valuable to certain individuals • 14. Acute non-fatal: treatment speeds recovery • Viral sore throat • 15. Infertility services • 16. Less effective preventive care • Routine screening for those not at risk • 17. Fatal or non-fatal where treatment causes minimal or no improvement in quality of life • Aggressive end-stage care

24. Allocating Resources • Which resources should be managed? • Who should make the decision? • Formal & informal mechanisms? • Is informal still used? • Are they applied evenly? • What was the goal of the mechanism? • Whose goals are they? • Does the Goal meet intended end? • Is goal defensible? Goal meet inted end?

25. Measurement employed • Medical or social? • What unit is measured? Single intervention or episode? • Effectiveness: effective for what, how long, who judges? • Severity of illness • Costs: which should count? Length? • Social measurements?

26. Due process • notice, in this case information why and what alternatives exist • means of meaningful appeal • consistency in judgment and action • Correction of bias judgments • transparency to the public and all those who will affected by the choices • checks & balances

27. Conclusion • Denied services only when shortage, exhaust all options • Applied uniformly • Open process free of bias • Clear who decides • Appeals process