Rational and Just Distribution of Healthcare Resources Martin McKneally and Josh Mayich Department...

Rational and Just Distribution of Healthcare Resources

Martin McKneally and Josh MayichDepartment of Surgery and Joint Centre for Bioethics

University of Toronto

Principles of SurgeryNovember 6, 2012

Plan of Talk

Cases: ICU bed, transplant, emergency,

uninsured patient, others

Rationing resources

Allocating resources

Setting priorities

Fair procedures

Coping strategies

ICU Case: 63 y.o. Mr. E is brought to the emergency room with severe but potentially reversible brain injury after an MVA.

You consider going through the charts of each patient in the intensive care unit in the hope of finding one whose need for intensive care is less than that of Mr. E.

You also consider sending Mr. E to the floor, but know that this will overtax the capabilities of the floor staff, who are not prepared to manage the patient’s elevated intracranial pressure and seizures. Because of recent hospital closures in the region, no other facility is available to share responsibility for the care of patients with neurosurgical problems of this magnitude.

Rationing

Is rationing wrong? Unjust?

Unethical?

Indefensible politically?

Systematic distribution of goods to specific individuals in conditions of scarcity

Rationing

rations on the raft

Rationing

The reasoned and justifiable distribution of goods to specific individuals in conditions of scarcity.

When all beneficial health care cannot be provided to all who might want it, implicit or explicit rationing occurs.

“Though devoted to the medical ethic of ‘rendering to each patient a full measure of service and devotion’, physicians who have many patients have traditionally rationed their services…”

Mark Siegler

University of Chicago

No beds again – can he solve the rationing problem alone?

Resource Allocation

Macro-Allocation

Highways, Education, Healthcare

Meso-Allocation

Hospital care

cancer, trauma, cardiac, neuro, etc.

Home care

Micro-Allocation

Who gets the bed

Systematic distribution of resources to programs

Determining Just Distribution by Setting Priorities

To each an equal share

To each according to effort

To each according to need

To each according to contribution

To each according to merit

To each according to free-market exchange procedures and rules

Priority Setting

Current politically correct term for rationing / resource allocation

Rational allocation of resources based on the priorities set by appropriate decision makers

Suggested Priority List for Decisions about ICU Care

1. Reasonable chance in ICU - would die

outside ICU

2. High risk of life-threatening

complications, need rapid response

3. Lower priorityComatose with a poor expected outcomeCare is unlikely to result in a good

outcomeLow risk for life-threatening complications

Transplant Case: Chris D, a 21 y.o. programmer with CF, is a candidate for retransplantation. Chronic rejection and fungal infections are destroying the double lung transplant he received 15 months ago. He has intermittently required ventilation during flareups of infection or rejection. The presence of infection and the risks associated with repeat transplants predict a survival rate of 65% at one month, and 38% at 24 months.

Mrs. J, a 42 y.o. schoolteacher and mother of 3, is a candidate for double lung transplantation because of rapidly progressing pulmonary hypertension associated with hemoptysis and hypoxemia. She is unable to manage at home because of decompensated right heart failure unresponsive to maximal therapy. As a first time candidate free of infection, her predicted survival at one month is 82%, and 62% at 2 years.

Dr. K has ONE donor for these two patients. He knows that the best result can be achieved by transplanting both lungs of the donor into one of his patients.

Fair Procedures for Decision Making

Reasonable Transparent

Appealable Enforceable Norm Daniels,Boston

UNOS Headlines

“Multiple-Organ Allocation Policy approved for public comment”

“Public Comment sought on pediatric renal allocation”

“Blood Type O Liver Allocation sent for public comment”

“Heart Allocation for Domino Transplants approved for public comment”

Ortho case: You are a busy foot & ankle surgeon with a two year waiting list – a patient cancels…

Pt 1 has subtalar arthritis following a calcaneus fracture. He is a smoker. He has been unable to find work since his arthritis advanced clinically 3 years ago (which is how long he has been waiting for the OR).

Pt 2 is a very pleasant, affluent 69 year old retiree from a financial investment company. He is very disabled by his ankle arthritis. He has been waiting 1.5 years.

Strategies to Cope with the ‘Shortage’ of Resources

Use the tests & treatments that work

Choose the least costly ones

Minimize marginally beneficial ones

Use the natural queue

modify by need/benefit

Rank current patients ahead of imagined future patients

Strategies…

Address shortages at the level of the institution/government

Support conservation of health resources

Avoid gaming, but keep modifying the system

Avoid frightening vulnerable patients

‘Emergency’ case: As the elective schedule winds down, Mr. M, the third patient listed for an elective cancer resection, is cancelled because of insufficient time to complete the operation within the day shift.

What is the fair thing to do:Put him on the emergency schedule?For tonight? This weekend?Displace tomorrow’s first elective patient? Send him home and readmit?

Uninsured case: Mrs. C, a Guyanese woman with complications from cancer, was refused complex elective surgical treatment at an Ontario hospital.

The resource allocation decision, had to be made after she had been admitted and a caregiver-patient relationship established. Caregivers and administrators struggled with the moral anguish of choosing between protecting limited resources for Canadian patients and their desire to provide care for a hospitalized visitor in need of complex and expensive care.

You are making these decisions now

You will make more and larger decisionsYou are the future

Coping strategies to eliminate or reduce

rationing include: 1. Choose interventions known to be beneficial on the basis of

evidence of effectiveness.

2. Minimize the use of marginally beneficial tests, such as the diagnostic zebra-hunt.

3. Minimize the use of marginally beneficial interventions, such as the latest generations of antimicrobials for common infections.

4. Seek the least costly tests or treatments that will accomplish the diagnostic or therapeutic goal.

5. Use the natural queue, treating patients in order of appearance unless morally relevant considerations of need and benefit require modification of this approach.

6. Rank patients with whom you have an established patient-doctor relationship ahead of unknown or future patients.

7. Support rather than oppose reasonable efforts to conserve health care resources.

8. Avoid manipulation of the rules of the health care system to give unfair advantage to your particular patients.

9. Resolve conflicting claims for scarce resources justly, on the basis of morally relevant criteria of need and benefit.

10. Employ fair and publicly defensible procedures for resolution of conflicting or competing claims.

11. Seek resolution of unacceptable shortages at the level of hospital management (meso allocation) or through political action at the level government (macro allocation).

12. Inform your patients of the impact of cost constraints on care in a humanistic way, as a matter of respect for all concerned.

13. Embittered blaming of administrative or governmental systems during discussions with the patient at the point of treatment should be avoided.

14. Develop guidelines for individualization in the face of uncertainty in order to promote a reasonable balance between individual choice and systemic cost control.

SummaryKeep Mr. E in ERTransplant Mrs. JMove Mr. M to the next available

morning slotDischarge Mrs. CRation/Allocate justly

benefit and need

Use Fair Procedures reasonable transparent appealable

Share the problem

Acknowledgements

Paintings by Robert Pope and Joe Wilder

Deborah McKneally, The Ravine Research and Education Centre

martin.mckneally@utoronto.ca