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Allocation of Resources

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Lottery: only if all things are equal. Those who can afford it ... Rehabilitation: NH as transition. Merit: previous donor. Family ties: admitting spouse ... – PowerPoint PPT presentation

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Title: Allocation of Resources


1
  • Allocation of Resources
  • Philip Boyle, Ph.D.
  • Vice President, Mission Ethics
  • www.CHE.ORG/ETHICS

2
Etiquette
  • Press 6 to mute
  • Press 6 to unmute
  • Keep your phone on mute unless you are dialoging
    with the presenter
  • Never place phone on hold
  • If you do not want to be called on please check
    the red mood button on the lower left of screen

3
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?

4
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?

5
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?

6
  • 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

7
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

8
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

9
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

10
  • 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

11
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

12
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

13
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?

14
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?

15
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.

16
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

17
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.

18
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

19
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

20
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

21
  • 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

22
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

23
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

24
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?

25
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?

26
  • 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

27
Conclusion
  • Denied services only when shortage, exhaust all
    options
  • Applied uniformly
  • Open process free of bias
  • Clear who decides
  • Appeals process
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