Ethical Issues in Pandemic Influenza Planning

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Ethical Issues in Pandemic Influenza Planning

• Four Hot Topics
• July 16, 2008

Margaret M. Gaffney, M.D. Indiana University
Center for Bioethics Indiana University School of
Medicine
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Four Hot Topics

• Vaccine Allocation and Anti-virals
• Healthcare Workforce Management
• Triage
• Altered Standards of Care

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Goals of this phase of project

• Review and update the technical advisory
  documents (TAD) of each Expert Panels
• Apply ethical points to consider
• Assess feasibility of recommendations case
  studies
• Record and transmit concerns to the ISDH
• Recommendations are to the ISDH, and concern
  (primarily) healthcare delivery

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Ethical Points to Consider

• Consistency with mission of ISDH and other health
  care organizations
• Transparency
• Public accountability
• Responsiveness
• Proportionally
• Reciprocity
• Uniformity of implementation

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Expert Panel Members

• Healthcare and legal professionals
• Business and community leaders
• Public safety and service leaders
• Teachers, students and other community members
• Media

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RecommendationsVaccines and Anti-Virals

• Adopt a rank-order prioritization scheme
• (U.S. Department of HHS, CDHS, or merge)
• Adopt anti-viral allocation strategy emphasizing
  treatment rather than prophylaxis
• Educate all stakeholders about criteria for
  allocation and prioritization

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Expert Panels Responses

• Some recommended a triage scoring tool for
  anti-viral distribution
• Great need to really educate all stakeholders on
  ranking and prioritization
• General anxiety about securing supplies
• At least one expert disagreed with emphasis on
  treatment

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Ethical points Vaccines and Anti-Virals

• Transparency of prioritization plan
• Public accountability in policy making and
  review
• Responsiveness to public and professional input
• Reciprocity for those at increased risk
• Uniformity of implementation state wide

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Recommendations Healthcare Workforce Management

• Identify and designate critically necessary
  personnel, clinical and non-clinical
• Expect healthcare facilities to have adequate
  equipment and supplies for critical personnel
• High expectations, low consequences
• Develop fair policies of reimbursement,
  incentives and sanctions

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Expert Panels Responses

• Clear and explicit communication is vital to all
  employees and professionals
• Identify who will educate and communicate with
  providers when, how, and where
• Possibly link professional licensure to pandemic
  influenza training
• Need uniform incentives for employees to come to
  work, and fair reimbursement
• Special problems if employees float
• Convene a group to address issue
• Statewide or institution specific guidelines

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Ethical points Healthcare Workforce

• Missions of healthcare professionals and ISDH
• Transparency - regarding protocol decisions
• Public accountability HC workers inform
  policies, more likely to adhere to them
• Responsiveness - bi-directional communications
• Proportionality critical personnel balance risk
  and professional duties

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• As sicknesse is the greatest misery,
• So the greatest misery of sicknesse is solitude.
• Even the physician dares scarse come.
• John Donne

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Recommendations Triage

• Adopt a protocol that employs strictly
  physiologic criteria and rejects age and social
  role (SOFA)
• Encourage acute care facilities to use same
  criteria for admission and treatment
• Advise acute care facilities to develop
  procedures to conduct daily retrospective review
  of all triage and amend protocols if necessary
  (in real time)

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Expert Panels Responses

• Special physiologic criteria needed for pediatric
  patients
• Strongly urged that age be considered in triage
  (cited tradition and HC worker resistance)
• Urged the development of multi level triage
  criteria to use as a tiebreaker
• Urged institutional as well as statewide review
  and appeal

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Ethical points Triage

• Transparency public education critical
• Accountability objective criteria for triage
• Responsiveness appeals process and review
• Proportionality increasingly severe measures as
  pandemic worsens
• Reciprocity denial of aggressive therapy,
  provision of other care
• Uniform implementation objective criteria on
  physiologic data

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Recommendations Altered Standards Of Care

• Develop a protocol for implementing altered
  standards at some specific point and include
  legal protections
• Select potential alternate sites for care
  fairly
• Develop database of healthcare workers, including
  potential healthcare workers
• Encourage development of programs to educate
  healthcare workers on pandemic influenza and
  their related duties
• Help develop minimal standards for modifying
  documentation

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Expert Panels Responses

• Reality of legal liabilities and protections
• (addressed separately in next session)
• Need altered documentation standards for daily
  patient review as well as admissions, discharge
  or disposition of patients

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Ethical points Altered Standards

• Transparency public and healthcare workers need
  extensive information on all aspects of altered
  care (burial rituals, funerals, etc.)
• Responsiveness treating alternate care sites as
  partners, with respect
• Proportionality alternate sites, care
  procedures, staffing and documentation are used
  only if/when necessary
• Reciprocity caring for healthcare workers and
  providing insurance or compensation to selected
  alternate care sites

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Conclusions

• Broad input, vigorous debate
• Many points of consensus
• Several points of deep division
• Critical unknowns virus, efficacy of
  anti-virals, lag time until effective vaccine,
  public and professional response to pandemic
• Reassurance and gratitude

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The dogmas of the quiet past are inadequate to
the stormy present. The occasion is piled high
with difficulty and we must rise to the
occasion. As our case is new, so must we think
anew, and act anew. Abraham Lincoln