Nadine Shehata MD, MSc University of Toronto, St. Michael’s Hospital, Canadian Blood Services

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


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


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


2. Favoring The Worst-Off: Prioritarianism

Sickest First Youngest First


3. Maximizing Total Benefits: Utilitarianism

Prognosis or Life-Years Saved

Save the Most Lives


4. Promoting and Rewarding Social Usefulness

Instrumental Value

Reciprocity


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.


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


Prepare for the worse case

Have a triage criteria that is ethical,

defensible and fair to all

Maintain human dignity of all patients

Documents

Nadine Shehata MD, MSc University of Toronto, St. Michael’s Hospital, Canadian Blood Services