Structural Inequities, Fair Opportunity, and the Allocation of Scarce ICU Resources.

The September-October 2021 issue of the Hastings Center Report highlights the important topic of allocating scarce critical care resources during the Covid-19 pandemic. The article by Alex Rajczi and colleagues urges that policy-makers use public reasoning, not private reasoning, when developing triage policies. We completely agree. We show how the allocation framework we developed as private scholars, the "Pittsburgh framework," has been supported by public reasoning. The article by MaryKatherine Gaurke and colleagues criticizes rationing based on maximizing life-years saved and mistakenly claims that our framework recommended this approach. We explain that our framework never contained such a criterion but instead included a more limited consideration of near-term prognosis. In December 2020, in response to emerging data and important criticisms, we modified our framework to further strengthen equity. We are committed to improving allocation guidelines during crisis standards of care through reflective discussions and debates.

Establishing a Distribution Network for COVID-19 Monoclonal Antibody Therapy Across a Large Health System During a Global Pandemic.

Emergency authorized coronavirus disease 2019 (COVID-19)-neutralizing monoclonal antibodies can aid outpatients with mild to moderate COVID-19 infection. Many report barriers to adequate distribution and uptake. We present our model for distribution in a large health system as well as early lessons learned.

US Ventilator Allocation and Patient Triage Policies in Anticipation of the COVID-19 Surge.

Before the predicted March 2020 surge of COVID-19, US healthcare organizations were charged with developing resource allocation policies. We assessed policy preparedness and substantive triage criteria within existing policies using a cross-sectional survey distributed to public health personnel and healthcare providers between March 23 and April 23, 2020. Personnel and providers from 68 organizations from 34 US states responded. While half of the organizations did not yet have formal allocation policies, all but 4 were in the process of developing policies. Using manual abstraction and natural language processing, we summarize the origins and features of the policies. Most policies included objective triage criteria, specified inapplicable criteria, separated triage and clinical decision making, detailed reassessment plans, offered an appeals process, and addressed palliative care. All but 1 policy referenced a sequential organ failure assessment score as a triage criterion, and 10 policies categorically excluded patients. Six policies were almost identical, tracing their origins to influenza planning. This sample of policies reflects organizational strategies of exemplar-based policy development and the use of objective criteria in triage decisions, either before or instead of clinical judgment, to support ethical distribution of resources. Future guidance is warranted on how to adapt policies across disease type, choose objective criteria, and specify processes that rely on clinical judgments.

Mitigating Inequities and Saving Lives with ICU Triage during the COVID-19 Pandemic.

The burdens of the coronavirus disease (COVID-19) pandemic have fallen disproportionately on disadvantaged groups, including the poor and Black, Latinx, and Indigenous communities. There is substantial concern that the use of existing ICU triage protocols to allocate scarce ventilators and critical care resources-most of which are designed to save as many lives as possible-may compound these inequities. As governments and health systems revisit their triage guidelines in the context of impending resource shortages, scholars have advocated a range of alternative allocation strategies, including the use of a random lottery to give all patients in need an equal chance of ICU treatment. However, both the save-the-most-lives approach and random allocation are seriously flawed. In this Perspective, we argue that ICU triage policies should simultaneously promote population health outcomes and mitigate health inequities. These ethical goals are sometimes in conflict, which will require balancing the goals of maximizing the number of lives saved and distributing health benefits equitably across society. We recommend three strategies to mitigate health inequities during ICU triage: introducing a correction factor into patients' triage scores to reduce the impact of baseline structural inequities; giving heightened priority to individuals in essential, high-risk occupations; and rejecting use of longer-term life expectancy and categorical exclusions as allocation criteria. We present a practical triage framework that incorporates these strategies and attends to the twin public health goals of promoting population health and social justice.

Eliminating Categorical Exclusion Criteria in Crisis Standards of Care Frameworks

During public health crises including the COVID-19 pandemic, resource scarcity and contagion risks may require health systems to shift-to some degree-from a usual clinical ethic, focused on the well-being of individual patients, to a public health ethic, focused on population health. Many triage policies exist that fall under the legal protections afforded by "crisis standards of care," but they have key differences. We critically appraise one of the most fundamental differences among policies, namely the use of criteria to categorically exclude certain patients from eligibility for otherwise standard medical services. We examine these categorical exclusion criteria from ethical, legal, disability, and implementation perspectives. Focusing our analysis on the most common type of exclusion criteria, which are disease-specific, we conclude that optimal policies for critical care resource allocation and the use of cardiopulmonary resuscitation (CPR) should not use categorical exclusions. We argue that the avoidance of categorical exclusions is often practically feasible, consistent with public health norms, and mitigates discrimination against persons with disabilities.

Should Pediatric Patients Be Prioritized When Rationing Life-Saving Treatments During COVID-19 Pandemic.

Coronavirus disease 2019 can lead to respiratory failure. Some patients require extracorporeal membrane oxygenation support. During the current pandemic, health care resources in some cities have been overwhelmed, and doctors have faced complex decisions about resource allocation. We present a case in which a pediatric hospital caring for both children and adults seeks to establish guidelines for the use of extracorporeal membrane oxygenation if there are not enough resources to treat every patient. Experts in critical care, end-of-life care, bioethics, and health policy discuss if age should guide rationing decisions.