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The Ethics of Pandemic Influenza Planning and Response in Missouri

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Review the ethical implications of pandemic from a community health perspective. ... More importantly the community itself! Every community is unique. ... – PowerPoint PPT presentation

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Title: 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
  • gt10 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 patients life is more
    valuable than anothers?
  • 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 ones 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 pandemic influenza 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 Mass Casualty Events, Bioterrorism and
Other Public Health Emergencies 2006, 75
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
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