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Allocation of Resources

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Different practical responses. Don't ask, don't tell. Tell, but don't ask. Tell, and ask ... require further critical care nursing interventions for four (4) ... – PowerPoint PPT presentation

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Title: Allocation of Resources


1
  • Allocation of Resources
  • Philip Boyle, Ph.D.
  • VP, 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
Importance of resource allocation?
  • Expresses the moral character of organization

4
Under what circumstances is it permissible to
allocate, perhaps deny healthcare services?
  1. What kind of health care services will exist?
  2. Who will get them and on what basis?
  3. Who will deliver them?
  4. How will the burdens of financing be distributed?
  5. How shall the power control of these services
    be distributed?

5
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?

6
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

7
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?

8
Done everywhere--micro
  • Triage
  • Admission transfer
  • Futility
  • Purchasing
  • Practice parameters
  • Formulary
  • Staffing patterns
  • Equipment

9
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?
  • Neediest/worst-off
  • Age natural life span
  • Lottery only if all things are equal
  • Those who can afford it
  • Alternatives
  • Forfeiture
  • Gate keeping

10
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

11
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?

12
  • An otherwise healthy 78-year-old man came to the
    emergency department with a pain in his throat
    and difficulty swallowing. He was found to have a
    turkey bone lodged in his throat. When the
    emergency room physician attempted to remove the
    bone, the patients esophagus ruptured. A surgeon
    attempted several repairs, starting with a
    thoracotomy. The patient developed an acute
    infection and was treated with numerous
    antibiotics, but became septic. He experienced
    acute liver and kidney failure and respiratory
    failure and required mechanical ventilation and
    hemodialysis. The patient was restless,
    grimacing, and neurologically unresponsive. The
    staff believed he should be transferred out of
    the ICU because he was moribund.

13
  • The issue of appropriate ICU management was
    raised because staff were aware that for rupture
    of the esophagus the literature reflects nearly a
    100 mortality rate. The patients surgeon has
    had good-but unpublished-results with patients of
    this sort he regularly defends his potion with
    other consultants who maintain the patient is
    likely to expire early on during the course of
    treatment.

14
  • 1. Vital signs are assessed as stable for the
    individual patient as agreed upon by the
    attending physician and nurse caring for the
    patient four (4) hours prior to transfer.
  • 2. Neurological status is assessed to be either
    the patient's normal preadmission level or at a
    level of stability that does not require further
    critical care nursing interventions for four (4)
    hours prior to transfer.
  • 3. Respiratory status is assessed to be such that
    the patient is able to maintain adequate
    ventilation and oxygenation without mechanical
    assistance four (4) hours prior to transfer.
  • 4. Cardiovascular status is assessed to be such
    that the patient's tissue perfusion is adequate.
  • 5. Cardiovascular status is assessed to be such
    that all life-threatening dysrhythmias have
    resolved to the point where certain IV cardiac
    medications which are given only in critical care
    units are no longer necessary to control the
    dysrhythmia or regulate vascular tone four (4)
    hours prior to transfer.
  • 6. Fluid and electrolyte status is assessed to be
    within reasonable limits for the individual
    patient four (4) hours prior to transfer.
  • 7. Any patient may be discharged from the
    critical care unit who is determined to be
    moribund in the assessment of the attending
    physician and for whom no extraordinary medical
    measures will be used to prolong life or prevent
    death.

15
Case
  • 21 day length of stay
  • Policy To define assessment criteria (that
    constitute safe parameters) for transfer or
    discharge of patients from a critical care unit.
  • Any patient may be discharged from the critical
    care unit who is determined to be moribund in the
    assessment of the attending physician and for
    whom no extraordinary medical measures will be
    used to prolong life or prevent death.

16
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?

17
Resource allocation
  • Formal analysis
  • 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 broad agreement that treatment is not
    beneficial or effective?

18
Possible moral criteria 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?

19
Resource allocation
  • Informal analysis
  • Is the policy evenly applied or are there
    variable interpretations?
  • How does the mechanism work?
  • Was there a previous informal mechanism?
  • Who devised when is it used?
  • What is the purpose of the mechanism
  • What are the goals of the mechanism?
  • Whose goals?
  • Does it meet the goal?

20
  • 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

21
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

22
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

23
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

24
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

25
  • 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

26
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

27
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

28
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?

29
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?

30
  • 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

31
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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