The Ethics of Implementing Emergency Resource Allocation Protocols

Dees, Richard H.; Herington, Jonathan; Chiafery, Marianne; Shand, Jessica C.; D’Angio, Carl T.; Ching, Chin-Lin; Shaw, Margie Hodges

doi:10.1086/723323

Cited by 2 publications

(1 citation statement)

References 21 publications

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“…(23) The criteria for re-allocation (and the timing of re-assessments) must therefore strike a balance between giving each individual a chance to recover and preventing “wastage” of ventilators on patients who will not recover. (24) In this respect, the criteria for reallocation may have significant effects on the survival of individual patients and the overall numbers of lives saved. Unfortunately, our existing dataset and simulation strategy cannot accommodate reallocation of ventilators, since it only includes SOFA scores collected at point of intubation, and thus envisages allocation until survival or natural expiration.…”

Section: Discussionmentioning

confidence: 99%

Investigating Ethical Tradeoffs in Crisis Standards of Care through Simulation of Ventilator Allocation Protocols

Herington,

Shand,

Holden-Wiltse

et al. 2024

Preprint

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Introduction: Arguments over the appropriate Crisis Standards of Care (CSC) for public health emergencies often assume that there is a tradeoff between saving the most lives, saving the most life-years, and preventing racial disparities. However, these assumptions have rarely been explored empirically. To quantitatively characterize possible ethical tradeoffs, we aimed to simulate the implementation of five proposed CSC protocols for rationing ventilators in the context of the COVID-19 pandemic. Methods: A Monte Carlo simulation was used to estimate the number of lives saved and life-years saved by implementing clinical acuity-, comorbidity- and age-based CSC protocols under different shortage conditions. This model was populated with patient data from 3707 adult admissions requiring ventilator support in a New York hospital system between April 2020 and May 2021. To estimate lives and life-years saved by each protocol, we determined survival to discharge and estimated remaining life expectancy for each admission. Results: The simulation demonstrated stronger performance for age- and comorbidity-sensitive protocols. For a capacity of 1 bed per 2 patients, ranking by age bands saves approximately 28.7 lives and 3408 life-years per thousand patients, while ranking by Sequential Organ Failure Assessment (SOFA) bands saved the fewest lives (13.2) and life-years (416). For all protocols, we observed a positive correlation between lives saved and life-years saved. For all protocols except lottery and the banded SOFA, significant disparities in lives saved and life-years saved were noted between White non-Hispanic, Black non-Hispanic, and Hispanic sub-populations. Conclusion: While there is significant variance in the number of lives saved and life-years saved, we did not find a tradeoff between saving the most lives and saving the most life-years. Moreover, concerns about racial discrimination in triage protocols require thinking carefully about the tradeoff between enforcing equality of survival rates and maximizing the lives saved in each sub-population.

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Section: Discussionmentioning

confidence: 99%

Investigating Ethical Tradeoffs in Crisis Standards of Care through Simulation of Ventilator Allocation Protocols

Herington,

Shand,

Holden-Wiltse

et al. 2024

Preprint

Self Cite

View full text Add to dashboard Cite

show abstract

Investigating ethical tradeoffs in crisis standards of care through simulation of ventilator allocation protocols

Herington,

Shand,

Holden-Wiltse

et al. 2024

PLoS ONE

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Introduction Arguments over the appropriate Crisis Standards of Care (CSC) for public health emergencies often assume that there is a tradeoff between saving the most lives, saving the most life-years, and preventing racial disparities. However, these assumptions have rarely been explored empirically. To quantitatively characterize possible ethical tradeoffs, we aimed to simulate the implementation of five proposed CSC protocols for rationing ventilators in the context of the COVID-19 pandemic. Methods A Monte Carlo simulation was used to estimate the number of lives saved and life-years saved by implementing clinical acuity-, comorbidity- and age-based CSC protocols under different shortage conditions. This model was populated with patient data from 3707 adult admissions requiring ventilator support in a New York hospital system between April 2020 and May 2021. To estimate lives and life-years saved by each protocol, we determined survival to discharge and estimated remaining life expectancy for each admission. Results The simulation demonstrated stronger performance for age-sensitive protocols. For a capacity of 1 bed per 2 patients, ranking by age bands saves approximately 29 lives and 3400 life-years per thousand patients. Proposed protocols from New York and Maryland which allocated without considering age saved the fewest lives (~13.2 and 8.5 lives) and life-years (~416 and 420 years). Unlike other protocols, the New York and Maryland algorithms did not generate significant disparities in lives saved and life-years saved between White non-Hispanic, Black non-Hispanic, and Hispanic sub-populations. For all protocols, we observed a positive correlation between lives saved and life-years saved, but also between lives saved overall and inequality in the number of lives saved in different race and ethnicity sub-populations. Conclusion While there is significant variance in the number of lives saved and life-years saved, we did not find a tradeoff between saving the most lives and saving the most life-years. Moreover, concerns about racial discrimination in triage protocols require thinking carefully about the tradeoff between enforcing equality of survival rates and maximizing the lives saved in each sub-population.

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The Ethics of Implementing Emergency Resource Allocation Protocols

Cited by 2 publications

References 21 publications

Investigating Ethical Tradeoffs in Crisis Standards of Care through Simulation of Ventilator Allocation Protocols

Investigating Ethical Tradeoffs in Crisis Standards of Care through Simulation of Ventilator Allocation Protocols

Investigating ethical tradeoffs in crisis standards of care through simulation of ventilator allocation protocols

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