Nadine Shehata MD, MSc University of Toronto, St. Michael’s Hospital, Canadian Blood Services
Dec 23, 2015
Nadine Shehata MD, MScUniversity of Toronto, St. Michael’s Hospital, Canadian Blood Services
The Need for Guidance with Resource Allocation
The Need for an Ethical Framework
The Need for an Ethical Framework
The Need for Guidance for Resource Allocation
National Plan for the Management of Shortages of Labile Blood Components
National Plan for the Management of Shortages of Labile Blood Components
RBC Inventory
Level
CBS Days On Hand
CBS # Units on Hand
Green Phase >3 days > 8,900 units
Amber Phase 2 – 3 days 6,000 to 8,899
Red Phase < 2 days < 5,999
National Plan for the Management of Shortages of Labile Blood Components
This phase includes a range of inventory levels ranging from an ideal inventory to shortages that occur periodically.
The national blood inventory is not sufficient to continue with routine transfusion practices.
The blood inventory levels are insufficient to ensure that patients with non-elective indications for transfusion will receive the required transfusion.
The Bleeding Patient who Requires Massive Blood Transfusion?
Who Shall Receive the Blood during a Critical Shortage?
55 year old male ex-smoker with multiple
trauma
Neonate undergoing urgent cardiac
transplantation
75 year old politician with multiple
medical problems responsible for
reforming health care with a ruptured
aortic aneurysm
Objectives
To understand the conflict between ethical
decisions and resource allocation
To describe the ethical principles of making
decisions about resource allocation
To describe potential methods of incorporating
ethical decisions into resource allocation
decisions
Ethics
Ethical Principles Are to Guide Decisions
Four Precepts for Respect
1. Autonomy 2. Beneficence
3. Nonmaleficence 4. JusticeDistributive justice
Shortages Create Conflicts in Ethical Principles Personal autonomy Beneficence
The duty of society is to preserve those values that contribute to the common good of society
Nonmaleficence The importance of protecting the most
vulnerable from exploitation by those with power and influence
Justice The ethical obligations of third parties i.e.,
health professions
A Guide to Making Ethical Decisions
1. Rational
2. Redeeming
3. Respectful
Weil MH et al. Crit Care Med 1988 Jun; 16(6): 636-41.
Four Categories of Ethical Values for Resource Allocation
1. Treating people equally
2. Favoring the worst-off: prioritarianism
3. Maximizing total benefits: utilitarianism
4. Promoting and rewarding social usefulness
Persad G et al. Lancet 2009 Jan 31; 373(9661): 423-31.
1. Treating People EquallyFirst Come First ServeLottery
Persad G et al. Lancet 2009 Jan 31; 373(9661): 423-31.
2. Favoring The Worst-Off: Prioritarianism
Sickest First Youngest First
Persad G et al. Lancet 2009 Jan 31; 373(9661): 423-31.
3. Maximizing Total Benefits: Utilitarianism
Prognosis or Life-Years Saved
Save the Most Lives
Persad G et al. Lancet 2009 Jan 31; 373(9661): 423-31.
4. Promoting and Rewarding Social Usefulness
Instrumental Value
Reciprocity
Persad G et al. Lancet 2009 Jan 31; 373(9661): 423-31.
Ethical Principles to Guide Resource Allocation for Bleeding Patients 55 year old male ex-
smoker with multiple trauma
Neonate undergoing urgent cardiac transplantation
75 year old politician, with multiple medical problems, responsible for reforming health care with a ruptured aortic aneurysm
1. Treating people equally
2. Favoring the worst-off
3. Maximizing total benefits
4. Promoting and rewarding social usefulness
The Combination of Ethical Principles Ethical principles can be combined
To allow for the incorporation of the intricacy of moral values
To allow for the justification of choices about inclusion, balancing and specification
Disadvantages Increases the overall complexity There may be disagreement about
which principles to include
Multi-principle Strategy for the Allocation of VentilatorsPrinciple Specificati
onPoint System
1 2 3
Save the most lives
Prognosis for short-term survival (SOFA score)
SOFA score <6
SOFA score6-9
SOFA score9-12
Save the most life- years
Prognosis for long-term survival (medical assessment of comorbid conditions)
No comorbidstates that limit long-
termsurvival
Minor comorbid
states, small impact on long-term survival
Major comorbid
states, substantialimpact on long-termsurvival
Life-cycle principle
Prioritize those with least chance to live through life’s stages (age)
12–40 y 41-60 y 61-74 y
White DB, Annals of Internal Medicine 2009 Jan 20; 150(2): 132-8
Multi-principle Strategy for the Allocation of Blood For Ruptured Aortic Aneurysm
Principle Specification
Point System
1 2 3
Save the most lives
Prognosis for short-term survival
Save the most life- years
Prognosis for long-term survival (medical assessment of comorbid conditions)
Life-cycle principle
Prioritize those with least chance to live through life’s stages (age)
Ethical Principles for Massively Bleeding Patients
Treating people equally
First come, first serve
Maximizing total benefits
Saving the most lives
Saving the most life years
The Goal of Any Multi-principle Strategy
To achieve the greatest good for the
greatest number of people
Summary and Conclusion
Scarce resources create a conflict of ethical decisions
There are several ethical principles that can be used to guide decisions about resource allocation during periods of critical blood shortages
An allocation system should make clear that all individuals are worth saving, and that no ethical principle to guide resource allocation is sufficient on its own
White DB et al. Annals of Internal Medicine 2009 Jan 20; 150(2): 132-8. Persad G et al. Lancet 2009 Jan 31; 373(9661): 423-31.
Summary and Conclusion
A multi-principle strategy has the
potential to decrease the conflict of
how to allocate resources
It is the responsibility of everyone to
discriminate wherever necessary to
ensure that our limited resources go
where they will do the most good
Summary and Conclusion
Prepare for the worse case
Have a triage criteria that is ethical,
defensible and fair to all
Maintain human dignity of all patients