Ventilator Allocation and Mental Health Interventions in a Pandemic Flu Event

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Ventilator Allocation and Mental Health
Interventions in a Pandemic Flu Event

• Patricia Anders
• Director, Emergency Preparedness Training
• New York State Department of Health
• Office of Health Emergency Preparedness
• Confronting the Ethics of
• Pandemic Influenza Planning
• The 2008 Summit of the States

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Ventilator Shortage in a Pandemic

• Different estimates of severity based on CDC
  calculations
• Federal ventilator stockpile
• NYS ventilator stockpile
• Most severe epidemic
• Too few ventilators for patients
• Too few staff for more ventilators
• Rationing of ventilators needed

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Ventilator Allocation Guidance Document

• Written by the New York State Task Force on Life
  and Law
• Co-chaired by Tia Powell, M.D., and Gus Birkhead,
  M.D.
• Released in draft in March, 2007 for comment
• Available on NYSDOH website
• http//www.nyhealth.gov/diseases/communicable/infl
  uenza/pandemic/ventilators/
• Planning focus groups for community education,
  comment, and revision

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Rationing Ethical Implications

• Limits patient autonomy
• Limits physician autonomy
• Shifts doctors obligation from patient to group
• Radical threat to doctor- patient relationship

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Ethical Framework

• Duty to Care
• Duty to Steward Resources
• Duty to Plan
• Transparency
• Justice
• Key ethical concepts

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Duty to Care

• Physician must care for individual patient
• Autonomy not decisive factor
• Palliative Care

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Duty to Steward Resources

• Disaster Scarcity
• Survival for greatest number
• Allocation of resources
• First come, first served
• Most vulnerable
• Best balance of resource use and survival

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Duty to Plan

• Obligation to healthcare professionals and
  community
• Lack of planning creates vulnerability for
  front-line providers
• Flawed plan versus no plan
• Predictable emergency

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Justice

• Objective clinical criteria
• Applied broadly and evenly
• No differential access for special groups

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Transparency

• Public Communication
• Disaster care different
• Patient preference does not determine withdrawal
  or withholding of care
• Objective criteria guide patients and
  professionals

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Recommendations

• Pre-triage Requirements
• Patient categories
• Facilities
• Clinical algorithm
• Triage decision-makers
• Palliative care
• Appeals process
• Communications

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Pre-triage Requirements

• Obligation to plan
• Reduce vent need
• Elective surgery
• Increase vent supply
• Stockpile
• Collaborative arrangements
• Use of OR, transport, additional vents
• Alter staffing

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Patient Categories

• All patients in acute care facilities will be
  equally subject to triage guidelines
• Not flu only
• Disease category or role in the community not a
  factor
• Health care workers, first responders not given
  special priority

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Facilities

• Stepwise permission to initiate pre-triage steps,
  then adopt triage algorithm to allocate
  ventilators
• Regional differences in severity, but statewide
  consistency will prevent inequities
• Chronic care facilities will maintain different
  standards from acute care facilities

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Clinical EvaluationObjective, clear, easily
measured criteriaRule-in severe respiratory
compromiseRule-out end-stage illness

• Exclusion Criteria for Ventilator Access
• Cardiac arrest unwitnessed arrest, recurrent
  arrest, arrest unresponsive to standard measures
  Trauma-related arrest
• Metastatic malignancy with poor prognosis
• Severe burn body surface area gt40, severe
  inhalation injury
• End-stage organ failure
• Cardiac NY Heart Association class III or IV
• Pulmonary severe chronic lung disease with
  FEV1 lt 25
• Hepatic MELD score gt 20
• Renal dialysis dependent
• Neurologic severe, irreversible neurologic
  event/condition with high expected mortality
• Adapted from OHPIP guidelines
• Forced Expiratory Volume in 1 second, a
  measure of lung function
• Model of End-stage Liver Disease

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Measuring Clinical Status

• Sepsis-related Organ Failure Assessment (SOFA)
  criteria
• Non-proprietary
• Simple, reproducible
• Evidentiary basis for estimating mortality
• Points added based on objective measures of
  function in six key organs and systems lungs,
  liver, brain, kidneys, blood clotting, and blood
  pressure

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SOFA ScoringRange from 0 -240 is the best
possible score 24 is the worst Milestone
Scores7
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Time Trials

• Initial Assessment
• 48 hour Assessment
• 120 hour Assessment
• Patients may lose access to ventilators and other
  critical care resources if their SOFA score
  increases.
• Patients may lose access if SOFA scores fail to
  improve within the allocated period.

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Triage Decision-Making

• Based on
• Time trials
• Objective clinical criteria
• Primary clinicians will care for patients
• Will not determine ventilator allocation
• Role sequestration for decision-makers
• Supervising physician will take responsibility
  for triage decisions

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Palliative Care

• Triage, not abandonment
• Policies for end-of-life care
• Continue non-ventilator treatments
• Provide comfort to patients, including those
  ventilator ineligible

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Appeals Process

• Real-time or retrospective
• Review process needed to assure consistency and
  justice
• System to appeal triage decisions
• Multiple person review
• Daily retrospective review of all triage
  decisions
• Assure that standards are consistent
• Opportunity to correct guidelines or
  implementation

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Communication

• Government and clinicians need to provide
• Clear, accurate, consistent communication about
  guidelines
• Date gathering and public comment can help
  improve the triage system

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Project with Hospice and Palliative Care
Association of NYS

• Curriculum Planning Template for Healthcare
  Providers - Provide a focused resource for
  palliative care and hospice providers serving
  ventilator-ineligible patients in an acute care
  setting
• Decision will be made to withdraw or withhold
  ventilator support prior to referral to these
  providers
• Web-based curriculum

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Curriculum Planning Template for Healthcare
Providers

• Objectives
• Offer support and an explanation of palliative
  and/or hospice care management options
• Identify pandemic influenza symptoms, both
  psychological and physical
• Identify effective non-pharmacological symptom
  management for ventilator-ineligible patients
• Educate patients and families regarding infection
  control strategies

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Curriculum for Non-Providers in In-Patient
Settings

• Provide an educational resource for non-providers
  supporting ventilator-ineligible patients in
  acute care settings
• Exigencies of a pandemic influenza event will
  mean that health care providers will not always
  be available, even in an in-patient setting
• Web-based curriculum

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Curriculum for Non-Providers in In-Patient
Settings

• Objectives
• Access basic information about pandemic influenza
• Identify physical and emotional symptoms of
  affected patients
• Identify supportive interventions which
  non-health care providers can offer
• Educate patients and families about infection
  control strategies

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Sources

• Ontario Health Plan for an Influenza Pandemic
  (OHPIP) Working Group on Adult Critical Care
  Admission, Discharge, and Triage Criteria,
  Critical Care During a Pandemic, April 2006.
  Available at http//www.health.gov.on.ca/english/p
  roviders/program/emu/pan_flu/flusurge.html.
• Ferreira Fl, Bota DP, Bross A, Melot C, Vincent
  JL. Serial evaluation of the SOFA score to
  predict outcome in critically ill patients. JAMA
  2001 286(14) 1754-1758.
• J. L. Hick, D. T. OLaughlin, Concept of
  Operations for Triage of Mechanical Ventilation
  in an Epidemic, Academic Emergency Medicine,
  20063(2)223-229.
• University of Toronto Joint Centre for Bioethics
  Pandemic Influenza Working Group, Stand on Guard
  for Thee Ethical considerations in preparedness
  planning for pandemic influenza, November 2005.

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QUESTIONS?
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Pat Anders(518) 474-2893pea02_at_health.state.ny.us