The Ethics of Pandemic Influenza Planning and Response in Missouri

1. The Ethics of Pandemic Influenza Planning and Response in Missouri Lea Brandt, OTD, MA, OTR/L MHPC OTA Program Director Clinical Assistant Professor School of Health Professions Faculty, MU Center for Health Ethics

2. Objectives • Review the ethical implications of pandemic from a community health perspective. • Provide foundation for discussion regarding community-based response efforts.

3. Potential Problem • In the event of a pandemic current health care resources will be overwhelmed. • More importantly the community itself! • Every community is unique. • Current ethics-based criteria for allocation of resources does not apply in situations of pandemic.

4. Preparing for Pandemic Influenza

5. Barriers to Provision of Care • Ventilator shortages. • Decreased Capacity • ED overcrowding reported by 91% of ED directors • Decrease of inpatient bed capacity by 4.4% nationwide. • Shortage of trained and qualified healthcare professionals • Lack of “surge capacity” • >10 day LOS for ICU patients with acute respiratory syndrome • Public Response

6. Whose life is more valuable?

7. Decision Maker?

8. Healthcare Organizations and Public Health Agencies must plan for the fair distribution of resources • Rationale: Must ensure that there is a process in place at their healthcare organization for the fair distribution of resources. • Includes both the educational opportunities for clinicians to be informed of the guidelines for ethical decision-making • A process for making ethical decisions accomplished through a vehicle such as an “Ethics Committee” with clinical input that meets to review criteria for admission, discharges, procedures, allocation of scarce resources.

9. Organizations and Communities must be non-competitive • Rationale: To achieve “the greater good for the community” leaders must set aside competitive goals and do what is best for the community. Leaders must ensure that there are agreements in place for the sharing of supplies, equipment and personnel and also for the triaging and acceptance of patients, based on what is best for the patients and the community.

10. Ethical Discussion • We need a regional plan. • Should facilities be able to abstain from participation? • Does the plan need to be consistent between facilities? • Who should decide which patients receive mechanical ventilation? • Who can decide whether on patient’s life is more valuable than another’s? • Who should develop the criteria?

11. Disaster Ethics is a set of principles and values that direct: • Duties • Obligations • Parameters • Disaster Ethics is the study of what ought to be done in a disaster situation. • Post Katrina, we need to reset our expectations. We need to realize that, in a disaster, things will not always go well; people will die; some people may not get treatment

12. Choosing an ethics model • Traditional focus on patient autonomy was deemed ineffective for resource poor environments • Utilitarian or “distributive justice” model is more effective for scarce resource allocation

13. Fundamental Ethical Values • Fairness • Respect • Solidarity • Limiting Harm

14. Fairness: Healthcare resources are allocated fairly with a special concern for the most vulnerable With limited resources: • The fair distribution of resources is governed not by what is best for the individual, but rather by the principle of “the greater good of the community” • Decisions will be made that result in certain people getting these resources and others not getting these resources • Not every need will be able to be addressed in a disaster.

15. Respect • *Each person must know that they will always be cared for and will be treated with dignity. • A person is, by nature, worthy of esteem and respect • They should be assured that they will be provided with dignified comfort care With limited resources: • some persons will receive treatment • some will receive limited treatment • some will receive palliative treatment

16. Solidarity • Each individual must consider the needs of others • Each person makes a commitment not only to family and loved ones but also to the community With Limited resources: • Each person has an obligation to care for the other • Each person must consider the greater good of the community rather than one’s own self-interest.

17. Nonmaleficence: Limiting Harm Do No Harm With limited resources: • Healthcare professionals may not be able to meet the needs of all patients • Healthcare professionals will do as much good as possible for each patient, which means “limiting harm done to patients” because of the lack of necessary resources. Example, with hospitals filled with patients, patients, who would normally be hospitalized, may need to be cared for at home. In this case, there will be public messages available to help family members take care of sick persons at home.

18. Procedural Values • Reasonableness • Transparency/ Openness • Inclusiveness • Responsiveness • Responsibility

19. Reasonableness • Reasonableness is the quality of being believable and acceptable by the average person With Limited Resources: • Treatment decisions are to be based on science, evidence, practice, experience and principles and be guided by the values that are identified in this document • Both healthcare workers and the public should at least understand that science, evidence, practice, experience and principles are being used for addressing healthcare decisions in a disaster

20. Transparency/Openness: • The process of discussing the guidelines in this document and how these guidelines will be applied in a disaster is open to public discussion and scrutiny • This period of discussion is an opportunity for both healthcare workers and the public to provide their recommendations about editing the guidelines and to have their recommendations recognized and acted upon.

21. Inclusiveness • Health Ethics Considerations: Planning for and Responding to Pandemic Influenza in Missouri • Community Engagement

22. Responsiveness • There are to be opportunities to revisit and revise guidelines as new information emerges, especially throughout the actual crisis • There are to be mechanisms to address comments, recommendations, disputes and complaints

23. Duty to Care The “duty to care” is a duty incumbent upon healthcare professionals. However, all healthcare workers provide essential functions and all contribute to patient care. Thus, this “duty” is incumbent upon all healthcare workers. Especially in high-risk incidents, all healthcare workers along with other critical infrastructure workers will be faced with conflicting obligations.

24. Duty to Care This same “duty” applies to everyone, because, in a disaster, when there are limited resources, each person has an obligation to care for others, knowing that with limited resources, all must all think of the greater good rather than think only of themselves.

25. Moving Forward • Identify and acknowledge health system limitations at a regional level. • Identify if there are current related policies developed by community hospitals and public health agencies and if there are conflicts between policies of the organizations. • Identify potential champions in communities that are willing to assist in standardizing criteria. • Organize focus groups including community leaders and representatives from local health related organizations. • Ultimately develop a contingency plan to address such a situation in advance.

26. Moving Forward • Provide guidelines for individual physicians with regard to withdrawal, which will improve consistency and decrease need for defense of position. • Implemented on a regional not institutional basis • Include liability protections for providers and institutions • Special attention should be paid to vulnerable populations and representatives affiliated with these groups should be involved in decision-making. • Restrictions should apply equally to those infected and those hospitalized for other reasons.

27. Altered Standards of Care???? • The term "altered standards" has not been definitively defined, but generally is assumed to mean a shift to providing care and allocating scarce equipment, supplies, and personnel in a way that saves the largest number of lives in contrast to the traditional focus on saving individuals

28. References 2008, Corneliuson, E. Ethical Decisions in a Mass Casualty or Biological Incident. Region 7 Wisconsin Hospital Emergency Preparedness Program Presentation. 2006, State Expert Panel, Inpatient/Outpatient Surge Capacity: HRSA Wisconsin Hospital Preparedness Program 2005, Upshur, R.; Faith, K.; Gibson, J.; Thompson, A.; Tracy, C.; Wilson, K.; Singer ,P. Stand on Guard For Thee, Ethical considerations in preparedness planning for pandemicinfluenza; A report of the University of Toronto Joint Centre of Bioethics Pandemic Influenza Working Group 2005, Agency for Healthcare Research and Quality and the Office of the Assistant Secretary for Public Health Emergency Preparedness, U.S. Department of Health and Human Services, Altered Standards of Care in MassCasualty Events, Bioterrorism and Other Public Health Emergencies 2006, 7:5 Ruderman, C.; Tracy, S.; Bensimon,C.; Bernstein,M.; Hawryluck,L.; Zlotnik, R; Shaul2, 5 and Ross EG ; Upshur,S.; Upshur,R.; On pandemics and the duty to care: whose duty? who cares? Published: 20 April BMC Medical Ethics 2007, Roberts, M.; Hodge, J.; Gabreil, E.: Hick, J.; Cantrill, S.; Wilkinson, A.; Matzo, M.; Mass Medical Care with Scarce Resources Published: February Agency for Healthcare Research and Quality