Allocation of Resources

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

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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?

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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?

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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?

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• Micro (at bedside)
• First come, first serve
• presupposes access to info
• Status based on societys 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

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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

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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

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Resource allocation

• Happenstance or intentional
• Different goals
• Cost containment, appropriate care
• Different practical responses
• Dont ask, dont tell
• Tell, but dont ask
• Tell, and ask

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• 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

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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

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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 dont 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

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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?

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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?

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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.

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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

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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.

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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

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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

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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

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• 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

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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

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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

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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?

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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?

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• 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

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Conclusion

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