Ventilator Allocation Protocols: Sophisticated Bioethics for an Unworkable Strategy

Time-Limited Trials for Patients With Critical Illness: A Review of the Literature

TOPIC IMPORTANCE

Since the 1990s, time-limited trials have been described as an approach to navigate uncertain benefits and limits of life-sustaining therapies in patients with critical illness. In this review, we aim to synthesize the evidence on time-limited trials in critical care, establish what is known, and highlight important knowledge gaps.

REVIEW FINDINGS

We identified 18 empirical studies and 15 ethical analyses about time-limited trials in patients with critical illness. Observational studies suggest time-limited trials are part of current practice in ICUs in the United States, but their use varies according to unit and physician factors. Some ICU physicians are familiar with, endorse, and have participated in time-limited trials, and some older adults appear to favor time-limited trial strategies over indefinite life-sustaining therapy or care immediately focused on comfort. When time-limited trials are used, they are often implemented incompletely and challenged by systematic barriers (eg, continually rotating ICU staff). Predictive modeling studies support prevailing clinical wisdom that prognostic uncertainty decreases over time in the ICU for some patients. One study prospectively comparing usual ICU care with an intervention designed to support time-limited trials yielded promising preliminary results. Ethical analyses describe time-limited trials as a pragmatic approach within the longstanding discussion about withholding and withdrawing life-sustaining therapies.

SUMMARY

Time-limited trials are endorsed by physicians, align with the priorities of some older adults, and are part of current practice. Substantial efforts are needed to test their impact on patient-centered outcomes, improve their implementation, and maximize their potential benefit.

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

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.

Rationing, Responsibility, and Vaccination during COVID-19: A Conceptual Map

Throughout the COVID-19 pandemic, shortages of scarce healthcare resources consistently presented significant moral and practical challenges. While the importance of vaccines as a key pharmaceutical intervention to stem pandemic scarcity was widely publicized, a sizable proportion of the population chose not to vaccinate. In response, some have defended the use of vaccination status as a criterion for the allocation of scarce medical resources. In this paper, we critically interpret this burgeoning literature, and describe a framework for thinking about vaccine-sensitive resource allocation using the values of responsibility, reciprocity, and justice. Although our aim here is not to defend a single view of vaccine-sensitive resource allocation, we believe that attending critically with the diversity of arguments in favor (and against) vaccine-sensitivity reveals a number of questions that a vaccine-sensitive approach to allocation should answer in future pandemics.

The Ethics of Implementing Emergency Resource Allocation Protocols

AbstractWe explore the various ethical challenges that arise during the practical implementation of an emergency resource allocation protocol. We argue that to implement an allocation plan in a crisis, a hospital system must complete five tasks: (1) formulate a set of general principles for allocation, (2) apply those principles to the disease at hand to create a concrete protocol, (3) collect the data required to apply the protocol, (4) construct a system to implement triage decisions with those data, and (5) create a system for managing the consequences of implementing the protocol, including the effects on those who must carry out the plan, the medical staff, and the general public. Here we illustrate the complexities of each task and provide tentative solutions, by describing the experiences of the Coronavirus Ethics Response Group, an interdisciplinary team formed to address the ethical issues in pandemic resource planning at the University of Rochester Medical Center. While the plan was never put into operation, the process of preparing for emergency implementation exposed ethical issues that require attention.

Coronavirus disease 2019 aftermath: psychological trauma in ICU healthcare workers

PURPOSE OF REVIEW

We aim to describe the extent of psychological trauma and moral distress in healthcare workers (HCW) working in the intensive care unit (ICU) during the coronavirus disease 2019 (COVID-19) pandemic. Specifically, we review reports on prevalence of mental health symptoms, highlight vulnerable populations and summarize modifiable risk factors associated with mental health symptoms in ICU HCW.

RECENT FINDINGS

The pandemic has resulted in a multitude of closely intertwined professional and personal challenges for ICU HCW. High rates of posttraumatic stress disorder (14-47%), burnout (45-85%), anxiety (31-60%), and depression (16-65%) have been reported, and these mental health symptoms are often interrelated. Most studies suggest that nurses and female HCW are at highest risk for developing mental health symptoms. The main personal concerns associated with reporting mental health symptoms among ICU HCW were worries about transmitting COVID-19 to their families, worries about their own health, witnessing colleagues contract the disease, and experiencing stigma from their communities. Major modifiable work-related risk factors were experiencing poor communication from supervisors, perceived lack of support from administrative leadership, and concerns about insufficient access to personal protective equipment, inability to rest, witnessing hasty end-of-life decisions, and restriction of family visitation policies.

SUMMARY

The COVID-19 pandemic has severely impacted ICU HCW worldwide. The psychological trauma, manifesting as posttraumatic stress disorder, burnout, anxiety, and depression, is substantial and concerning. Urgent action by lawmakers and healthcare administrators is required to protect ICU HCW and sustain a healthy workforce.

Who gets the ventilator? A multicentre survey of intensivists' opinions of triage during the first wave of the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic has caused a shortage of intensive care resources. Intensivists' opinion of triage and ventilator allocation during the COVID-19 pandemic is not well described.

METHODS

This was a survey concerning patient numbers, bed capacity, triage guidelines, and three virtual cases involving ventilator allocations. Physicians from 400 ICUs in a research network were invited to participate. Preferences were assessed with a five-point Likert scale. Additionally, age, gender, work experience, geography, and religion were recorded.

RESULTS

Of 437 responders 31% were female. The mean age was 44.4 (SD 11.1) with a mean ICU experience of 13.7 (SD 10.5) years. Respondents were mostly European (88%). Sixty-six percent had triage guidelines available. Younger patients and caretakers of children were favoured for ventilator allocation although this was less clear if this involved withdrawal of the ventilator from another patient. Decisions did not differ with ICU experience, gender, religion, or guideline availability. Consultation of colleagues or an ethical committee decreased with age and male gender.

CONCLUSION

Intensivists appeared to prioritise younger patients for ventilator allocation. The tendency to consult colleagues about triage decreased with age and male gender. Many found such tasks to be not purely medical and that authorities should assume responsibility for triage during resource scarcity.

Ethics of Extracorporeal Membrane Oxygenation under Conventional and Crisis Standards of Care

Extracorporeal membrane oxygenation (ECMO) is a form of life support for cardiac and/or pulmonary failure with unique ethical challenges compared to other forms of life support. Ethical challenges with ECMO exist when conventional standards of care apply, and are exacerbated during periods of absolute ECMO scarcity when "crisis standards of care" are instituted. When conventional standards of care apply, we propose that it is ethically permissible to withhold placing patients on ECMO for reasons of technical futility or when patients have terminal, short-term prognoses that are untreatable by ECMO. Under crisis standards of care, it is ethically permissible to broaden exclusionary criteria to also withhold ECMO from patients who have a low likelihood of recovery, to maximize the overall number of lives saved. Unilateral withdrawal of ECMO against a patient's preferences is unethical under conventional standards of care, but is ethical under crisis standards of care to increase access to ECMO to others in society. ECMO should only be rationed when true scarcity exists, and allocation protocols should be transparent to the public. When rationing must occur under crisis standards of care, it is imperative that oversight bodies assess for inequities in the allocation of ECMO and make frequent changes to improve any inequities.