The Ethics of Creating a ResourceAllocation Strategy During theCOVID-19 PandemicNaomi Laventhal, MD, MA, FAAP,a Ratna Basak, MD, FRCPCH (UK), FAAP,b Mary Lynn Dell, MD, DMin,c

Douglas Diekema, MD, MPH, FAAP,d Nanette Elster, JD, MPH,e Gina Geis, MD, MS, FAAP,f Mark Mercurio, MD, MA, FAAP,g

Douglas Opel, MD, MPH, FAAP,d David Shalowitz, MD, MSHP,h Mindy Statter, MD, MBE, FACS, FAAP,i Robert Macauley, MD, FAAPj

abstractThe coronavirus disease 2019 pandemic has affected nearly every aspect ofmedicine and raises numerous moral dilemmas for clinicians. Foremost ofthese quandaries is how to delineate and implement crisis standards of careand, specifically, how to consider how health care resources should bedistributed in times of shortage. We review basic principles of disasterplanning and resource stewardship with ethical relevance for this and futurepublic health crises, explore the role of illness severity scoring systems andtheir limitations and potential contribution to health disparities, and considerthe role for exceptionally resource-intensive interventions. We also reviewthe philosophical and practical underpinnings of crisis standards of care anddescribe historical approaches to scarce resource allocation to offer analysisand guidance for pediatric clinicians. Particular attention is given to theimpact on children of this endeavor. Although few children have requiredhospitalization for symptomatic infection, children nonetheless have thepotential to be profoundly affected by the strain on the health care systemimposed by the pandemic and should be considered prospectively in resourceallocation frameworks.

The coronavirus disease 2019 (COVID-19), previously named 2019 novelcoronavirus and abbreviated 2019-nCoV,1 pandemic raises weighty andurgent ethical questions affecting allpatients and the clinicians who carefor them. As bioethicists, we hope toprovide support to our colleagueswho care for children during thischallenging pandemic. In particular, wewill focus on the ethical issues relatedto resource allocation in times ofshortage and offer analysis andguidance informed by new andhistorical literature.

During the COVID-19 pandemic,guidelines affecting the clinical care ofadult and pediatric populations mayoverlap significantly. Likewise, many of

the ethical principles relevant toresource allocation strategies and theirimplementation will be similar.However, ethical care of pediatricpatients during a pandemic requiresspecial consideration and is the focus ofthis report. Some important ethicalconsiderations that primarily affectadult populations are not discussed indetail. We recognize that childrenreceive health care not only frompediatricians but also from a diversegroup of nonpediatrician physician andnonphysician clinicians. Accordingly,we will refer to our intended audienceas pediatric clinicians. Although thisarticle was written with specificattention to the immediate needs ofclinicians during the COVID-19

aDepartment of Pediatrics, Medical School, University ofMichigan, Ann Arbor, Michigan; bBrookdale UniversityHospital Medical Center, Brooklyn, New York; cDepartmentsof Psychiatry and Pediatrics, College of Medicine, The OhioState University, Columbus, Ohio; dDepartment of Pediatrics,School of Medicine, University of Washington, Seattle,Washington; eNeiswanger Institute for Bioethics andHealthcare Leadership, Stritch School of Medicine, LoyolaUniversity Chicago, Chicago, Illinois; fBernard and MillieDuker Children’s Hospital, Albany Medical College, Albany,New York; gDepartment of Pediatrics, School of Medicine,Yale University, New Haven, Connecticut; hDepartment ofObstetrics and Gynecology, School of Medicine, Wake ForestUniversity, Winston-Salem, North Carolina; iDpartment ofSurgery, Albert Einstein College of Medicine, Bronx, NewYork; and jDepartment of Pediatrics, Oregon Health andScience University, Portland, Oregon

The guidelines/recommendations in this article arenot American Academy of Pediatrics policy, andpublication herein does not imply endorsement.

Drs Laventhal, Basak, Dell, Diekema, Geis, Macauley,Mercurio, Opel, Shalowitz, and Statter and Mrs Elsterparticipated in the planning, literature review, andwriting of this manuscript and critically reviewedthe manuscript for important intellectual content;and all authors approved the final manuscript assubmitted and agree to be accountable for allaspects of the work.

Drs Laventhal, Basak, Geis, Opel, Statter, andMacauley are members of the American Academy ofPediatrics (AAP) Committee on Bioethics, to whichDrs Dell, Diekema, and Shalowitz are liaisons and MsElster is a consultant. Drs Mercurio and Laventhalare members of the Executive Committee of the AAPSection on Bioethics.

DOI: https://doi.org/10.1542/peds.2020-1243

Accepted for publication Apr 28, 2020

To cite: Laventhal N, Basak R, Dell ML, et al. TheEthics of Creating a Resource Allocation StrategyDuring the COVID-19 Pandemic. Pediatrics. 2020;146(1):e20201243

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pandemic, it is largely informed byprevious work on scarceresource allocation and crisismedicine; many of the guidingprinciples offered here areapplicable to other pandemics andhealth crises.

COVID-19 AND THE SHIFT IN THEORIENTATION OF CLINICAL ETHICS

Amid a pandemic, real-timedashboards are needed to accuratelyreport the number of cases anddeaths because these change by theminute. As of April 22, 2020, nearly2.6 million cases are confirmedworldwide and nearly 178 000deaths.2 In the United States, thereare just .825000 cases, and nearly45 000 patients have died,2 with moststates still experiencing anexponential increase in cases anddeaths. Because of limited testing,reliable data are not yet available onthe number of children withconfirmed COVID-19 infection, butchildren appear to be lesssusceptible to severe infection, anddeaths have been rare.3,4 Severity ofillness and case fatality have beenlinked to advanced age andpreexisting comorbidities, but severeillness and death have occurred inyounger, previously healthyadults.3,5–7

Social and clinical efforts to limit theprevalence and morbidity of COVID-19 include social distancing andhygiene campaigns as well as therestriction of nonessential health careencounters. Surgeries and otherprocedures judged to be nonurgentare being deferred, and patients maynot be permitted to have visitors tosupport them through their medicalcare. These changes, among others,represent a fundamental shift inpriority from maximizing theoutcomes of individual patients tooptimizing the welfare of thecommunity. Unfortunately, thedemands of the COVID-19 pandemichave already exceeded our ability toprovide sufficient numbers of

diagnostic tests and adequatepersonal protective equipment (PPE)and may still exceed the ability ofsome places to provide enoughventilators, ICU beds, and health careprofessionals required to support theneeds of patients. Participation inovert health care rationing is,therefore, likely for the first time inthe lives of many clinicians.Consequently, institutions and clinicalpractices nationwide have needed todevelop protocols to determine fair,systematic, and evidence-basedmethods for deciding who willreceive health care resources ifdemand for these resources exceedsavailable supply. This shift reflects anabrupt and urgent transition froma usual standard of care, in whicha respect for patient autonomy isprioritized and benefit to each patientis maximized, to public health crisisstandards of care, in which thecommon good is prioritized andbenefit to the community ismaximized.

IMPLEMENTATION OF CRISISSTANDARDS OF CARE AND TRIAGEACROSS INSTITUTIONS

Crisis standards of care areimplemented when health caresystems are so overwhelmed bya pervasive or catastrophic publichealth event that providing thenormal, or standard, level of care topatients is impossible. In anticipationof that demand for care exceedingavailable resources, contingencyplanning is essential beforeimplementation of crisis standards ofcare. Hospitals and local disasterplanning committees shouldproactively explore andimplement mechanisms to increasetheir ability to provide appropriatecare to all patients throughmodifications in 3 essential areas:space, staff, and supplies. Keystrategies to accomplish this includemodular expansion of acute andcritical care capacity in hospitals,preestablished tiered staffing models,

transfer of patients to otherfacilities, shared ventilator andequipment protocols, andconserving, adapting, or substitutingsupplies.8

Local, state, and regional consensuson crisis procedures and standards ofcare is desirable because it facilitatescoordination of care across systemsand conservation of needed resourcesin a way that is consistent andstandardized. Several states do havepublicly available triage guidelines9;in Michigan, for example, they serveas general guidance,10 and inWashington State, the call foruniformity in the triage process ismore prescriptive.11 Once it becomesnecessary to implement crisisstandards of care, ideally thesestandards are adoptedsimultaneously across hospitalswithin a region or state. Simultaneousadoption of crisis standards of carefacilitates the equitable distributionof available resources acrossinstitutions and health systems. Thegeneral principle should be that nohospital in a region or state shouldenter crisis standards of careuntil all hospitals in the region orstate have reached that point. Ideally,transfers of patients from hospitals atcapacity to those with capacity shouldoccur until no capacity exists in thearea. This requires a regional orstatewide effort to monitor theavailability of beds and scarceresources across the region and assistin the movement of patients orresources.

In the United States, mechanisms andapproaches for distribution ofresources in times of shortage vary bystate. Washington State offers onepromising model. The NorthwestHealthcare Response Network, incollaboration with theWashington State Department ofHealth, has implementeda Disaster Clinical AdvisoryCommittee to develop clinicallyfocused tools and planning fora disaster- or pandemic-related

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surge. This working group servesa monitoring and coordinationfunction across the state duringa surge response.11 There has alsobeen significant variation in the plansfor resource conservation anddistribution among different clinicsand hospital systems. As a resource,organizational guidelines have beenpublished in real time to adviseclinical and organizationalpractice, informed by theexperiences with COVID-19 in Asiaand Europe. Institutions, however, aresubject to different challengesregarding the medical supplychain and variable state publichealth responses, such as schoolclosures and shelter-in-placeordinances.

Crisis standards of care may requirethat some scarce resources can onlybe made available to some patients,requiring triage. Triagejudgments are best made by a triageteam composed of a triage officer,who leads the team, and other healthcare providers. The application of anyallocation protocol requires carefulattention to the potential for biasbased factors not relevant to survivalor need. The best way to minimizeimplicit bias is to develop a process inwhich a triage team is blinded to allbut prognostic factors that speak tolikelihood of benefit and degreeof need.

While the triage assessment occurs,first responders and bedsideclinicians should perform theimmediate stabilization of any patientneeding critical care. Importantly, thetriage team’s decision-making shouldoccur independent of the primaryclinician caring for the individualpatient. Although the clinician whohas established a relationship withthe patient might be the best personto inform the patient or family of thetriage team’s decision, a member ofthe triage team ideally should beavailable to communicate how thedecision was made.

RESOURCE STEWARDSHIP ANDCONSTRAINTS TO USUAL CLINICAL CARE

Referral medical centers that providehighly specialized care, treat thepatients who are sickest and the mostcomplex, and serve the needs of largegeographic catchment areas will faceunique ethical challenges. Theseissues are particularly salient forchildren because their specificneeds are less likely to be met incommunity hospitals given theconcentration of pediatricspecialists in academic centers.Moreover, children who requirespecialized treatment of otherconditions have needs that are notexpected to diminish in frequencybecause of the pandemic. Forinstance, infants will continue to beborn prematurely or with congenitalanomalies requiring prompttreatment. Children will still requirecare for complex chronic medicalillnesses, such as cystic fibrosis, sicklecell disease, cancer, and traumaticinjuries.

As institutions and state governmentsdeprioritize elective procedures andnonurgent medical care, distributedisposable and durable equipment,allocate hospital beds, and deployhealth professionals to care for adultswho are sick, they should remainmindful of the usual needs of theregions they serve and recognizethat there will be patients who aresick who do not have COVID-19 andneed specialized care. These decisionsmay cause conflict betweeninstitutions’ duty to care for patientsand their responsibility to stewardresources. Institutions may be forcedto revisit their commitment toprovide some services if thenecessary resources are toodebilitating for an already strainedhealth care system or are simply notavailable. NICU and PICU beds,extracorporeal membraneoxygenation (ECMO) circuits,continuous renal replacementmachines, blood products, andadvanced ventilators all may need to

be redistributed for the purpose ofpreserving the most lives.

Children should not be excluded fromadvanced care therapies withoutcareful consideration of their uniqueneeds and vulnerabilities. Goodcontingency planning can helpmitigate the effects of resourceallocation and redistribution. Inaddition, illness severityscores should enable concurrentevaluation of patients with andwithout COVID-19 and supportintegrated, rather than siloed,resource allocation.12

GENERAL CONSIDERATIONS FOR THEALLOCATION OF SCARCE RESOURCES

Historically, several models for scarceresource allocation have beendeveloped and iteratively debated.The response to the COVID-19pandemic is largely informed by thephilosophical underpinnings ofdifferent resource allocationframeworks. We review thefundamental ethical principles ofscarce resource allocation andinterpret them in the context of theCOVID-19 pandemic. We alsoacknowledge that final institutionalpolicies will likely vary on the basis ofthe type and availability of theresource being allocated, institutionalfactors, and the local trajectory ofCOVID-19 cases.

There is broad agreement thatframeworks for allocating scarceresources should be focused onproviding the greatest benefit to thegreatest number of individuals whilethe fewest resources are used. A fairsystem of allocation must betransparent and applied consistently.It is important to be mindful thatsocially vulnerable populations aremost likely to suffer the greatestimpact during public healthemergencies13,14 and to consider howmedical criteria incorporated intotriage algorithms may perpetuateinequities. Unfortunately, real-timeobservation of racial and ethnic

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disparities in COVID-19 cases anddeaths15,16 have served as a soberingreminder that seemingly objectivehealth care decisions and illnessseverity scoring systems mayperpetuate inequities by overlookingsocial determinants of health.17,18 Asthe magnitude of racial and ethnicdisparities in COVID-19 outcomesbecomes apparent,19,20 the potentialfor illness severity scores to amplify,rather than mitigate, healthdisparities for historicallydisadvantaged groups (which areoften more burdened by the verycomorbidities that impart lessfavorable scores, such ashypertension and chronic kidneydisease) has appropriately motivatedcloser scrutiny of triage algorithms.21

All patients should be treatedrespectfully; race, ethnicity, disability,gender, sex, religion, citizenship,social status and power,socioeconomic status, ability to pay,past use of resources, and otherdemographic factors should not beused in allocation decisions.

Although protocols may varydepending on the resource, scarcity,and setting, several criteria should beconsidered in theirdevelopment.12,22–28 Preferably,multiple criteria will be integratedinto an allocation protocol because nosingle element incorporates everyapplicable moral consideration.29

Allocations frameworks withparticular relevance include(summarized in Table 1) thefollowing:

Likelihood of benefit: Likelihood ofbenefit should be optimized in anyallocation framework. Ideally,survival prognosis assessmentsshould be as objective as possibleby using existing, validatedmeasures. Whether survival tohospital discharge or long-termsurvival (or both) should be usedas the measure of benefit regardingintensive care intervention, such asventilators (and the requisite ICUbeds and clinician support) and

blood products, is debatable.Although it might be argued thatlong-term survival ultimately maylead to a more objective benefit (interms of optimizing life-yearssaved), a long-term survivalframework carries the risk ofdiscriminating against personswith shorter life spans because ofunderlying disease, disability, orage. In the setting of COVID-19,benefit for patients has beenlargely defined as short-termsurvival, at least regardingallocation of treatment modalitiesand hospital beds. However, thispandemic has also brought to lightaspects of societal and publichealth benefits (other thansurvival) that need to beconsidered in the allocation ofscarce resources and that servepurposes other than the benefit ofindividual patients. For example,PPE stewardship and strategicdiagnostic testing serve benefitssuch as maintaining a healthyworkforce and limiting furthertransmission of infection.

Greatest need: Among patients withsimilar likelihood of benefit, thosewith the greatest need (defined asmost likely to suffer harm withoutthe resource) should get firstpriority. For example, when 2patients are both likely to benefitfrom ventilator support, the patientat greater risk of imminentrespiratory failure should beprioritized.

Amount of resource required:Arguably, if 2 people carry a similarprognosis, the 1 requiring thefewest resources should beprioritized. Because of thedifficulty in predicting how muchof a resource might be required bya patient (eg, how long someonemight remain on a ventilator), mostframeworks have not included thiscriterion. However, in somecircumstances, prioritizing patientswho have a generally predictableshort-term need for a scarce

resource (eg, need for ventilationas a consequence of respiratorysyncytial virus bronchiolitis) maybe appropriate. Additionally, thisframework might advantagechildren regarding rationedmedications that are dose-reducedfor pediatric use.

Persons performing vital functions:Arguably, the community benefitswhen persons performing vitalfunctions during a disaster areprioritized regarding PPE, vaccines,and treatment.12,27 These rolesusually include health care workersand first responders, although thegroup may be expanded, dependingon the community’s needs, toinclude those working in grocerystores, food and mail delivery, andessential government services, forexample. The argument for suchprioritization includes therecognition that those individualsare essential to continue caring forothers in the community during thecrisis. In addition, prioritizing carefor those individuals providessome degree of reciprocity forputting themselves in harm’s wayto assist others during the crisis.Furthermore, prioritization is anincentive for health care personnelto continue working even when thework is, or feels, unsafe. Thesecompelling arguments areparticularly powerful when theresource being allocated willprevent occupational harm (PPE,vaccines) or prevent rapid returnof a provider who is infected toservice. In many triage algorithms,those who perform vital functionsare prioritized only as a way ofmaking decisions between peoplewith a similar likelihood ofsurvival.

Random allocation: When all else isequal, randomization should beused to make decisions aboutordering for priority. Randommethods are generally consideredto be fairer than prioritization ofthose who were first to arrive

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because the latter tends to benefitthose with knowledge andresources to seek early assistancefrom health care institutions, whichmay contribute to inequities inaccess and outcome.

With attention to these frameworks,there are a few guiding principleswhen creating new resourceallocation guidelines for COVID-19.First, short-term survival (survival todischarge) is a reasonable criterionby which to prioritize resourceallocation. Second, first come, firstserved should not be used todetermine who gets a scarce resourcefor patients with similar prognosesbecause this unfairly benefits patientswho have better access to health careinstitutions. Third, prioritization ofpersons performing vital functions asa discriminator between patients ofequivalent priority scores in a triagealgorithm is justifiable.

SPECIAL CONSIDERATIONS FOR THEALLOCATION OF SCARCE RESOURCES INPEDIATRIC POPULATIONS

The unique characteristics of childrenraise additional challenges that mustbe considered when balancing theneeds of pediatric and adultpopulations. Many triage protocolsare designed for adult patients forwhom standardized clinical scoringmethods are commonly used.30–33

Although the vast majority of patientswith COVID-19 who are critically illare adults, children may be placedinto competition with adult patientsfor scarce resources either becausethey have severe infection or becauseof other conditions requiringresource-intensive interventions. Inaddition, the surge in adult patientsmay overflow into emergencydepartments, inpatient wards, andICUs normally designated for infantsand children.

Historically, age and life stage havebeen frequently invoked in resource

allocation ethics.12,22,34,35 It has beenargued that some priority should be

given to those in earlier life stages.The basis for this prioritization

criterion is a “fair innings” argumentthat suggests that with all otherthings being equal (such as prognosis

and need), those who have notexperienced as many life stages as

others should have the opportunity todo so.36,37 This would prioritizechildren over adults and youngeradults over older adults, at leastwithin similar prognostic categories.Prioritization of younger patients canalso be supported by the utilitarianargument that younger patients canderive more benefit from a life-savingintervention by amortizing the returnon that investment over more futureyears. Again, purely applied, thisapproach prioritizes not only children

TABLE 1 Summary of Resource Allocation Frameworks With Specific COVID-19–Related Considerations

Overview Limitations and Pitfalls Special COVID-19 Considerations

Likelihood ofbenefit

Generally determined by survivalestimates; allocate resources tothose likeliest to survive

Debate about whether short-term survival or long-term survival is the better metric; long-termsurvival introduces potential for age- and/ordisability-related bias

PPE conservation and reduction of risk oftransmission to health care works could alsobe considered as benefits

Benefit can also be defined in terms of othermetrics of population health

Empirical data to inform COVID-19 survivalestimates largely lacking

Greatest need Allocate resources to those withmost urgent or acute need

Difficult to determine objectively in real time In resource allocation algorithms, it is likelyassumed that alternative treatments havealready been considered for patients who areless ill

May disproportionally allocate to patients withhighest likelihood of mortality

Amount ofresourcerequired

Consider the absolute number ofpatients who can be helped andmaximize opportunities to helpmore patients

For wt-based resources (eg, many pharmacologictreatments), may be biased toward younger,smaller patients unfairly

Could be considered regarding anticipatedduration of mechanical ventilation andrequires consideration of differencesbetween COVID-19 illness and other reasonsfor respiratory failure

Personsperformingvital functions

Considers health care workers andother first responders for priorityin resource allocation

May not consider other essential workers whoassume risk of infection in other settings

Potential multiplier effect to promote populationhealth, but providers sick enough to requiresuch resources may be less likely to return toworkforce quickly

Potential to amplify existing societal inequities Potential incentive for vital workforce retentionPotential threat to public trust in health care

systemRandomallocation

Maximize fairness by forgoing allvalue or temporal triageweighting; distinct from firstcome, first served

Difficult to operationalize if patients do not presentsimultaneously

Sequential (rather than simultaneous)presentation for care presents practicaldifficultiesRisks investment of resources on patients unlikely

to derive tangible benefit when used as the onlymethod of resource allocation; notrecommended as a first-line method of resourceallocation

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over adults but also infants over olderchildren.

In recognition of increased mortalityrates for older patients with COVID-19 (6.4% in patients.60 years of agecompared with 0.32% in those,60 years of age38), some countrieshave instituted age limits forintubation for COVID-19–relatedrespiratory failure.39 This, however,has prompted accusations of ageism.Regional guidelines in the UnitedStates that include even suchnonspecific considerations as “loss ofreserves in energy, physical ability,cognition and general health”11 haveprompted lawsuits40 appealing tofederal health regulations thatprohibit discrimination on the basisof age or disability.41 The unreliableassociation between chronologicaland functional age has also raisedconcerns about arbitrary age cutoffs.Contrarily, community focus groupshave endorsed consideration of age ifnot as a primary determinant forallocation then as a discriminatorbetween patients of equivalentpriority scores.32 With recognition ofthe need for standardization andtransparency in prioritizationprotocols, the degree of priority givento children should be made explicit,with an ethical justification provided.In principle, some prioritization ofchildren over adults in situations ofequivalent illness severity is morallyjustifiable on the basis of utility byamortizing investment in medicalresources over more life-years and byvirtue of the fair innings argument.However, COVID-19 alreadydisproportionately affects those whoare older, mortality rates risesubstantially with age, and olderindividuals are more likely to sufferfrom comorbidities that impactlikelihood of survival and illnessseverity scores. With a disease thatalready strongly favors younger agegroups on the basis of likelihood ofsurvival, further prioritizing youngerage groups may be difficult to justify.Therefore, for COVID-19–specific

resource allocation, we do notrecommend explicit age-basedprioritization; rather children, likemembers of the vital workforce, couldbe considered as an alternative torandom allocation in rare situationsof true clinical impasse.

A FRAMEWORK FOR BALANCINGOBLIGATIONS TOWARD CHILDREN ANDADULTS

An ideal measure for estimatingsurvival likelihood across the agespectrum would be both objectiveand reliably accurate. The SequentialOrgan Failure System (SOFA) foradults42 and the Pediatric LogisticOrgan Dysfunction (PELOD) andPediatric Logistic Organ Dysfunction2 (PELOD 2) scoring systems forchildren,43,44 for instance, usephysical findings and laboratorydata to determine the short-termprognosis of patients32 and appearfrequently in institutional and statetriage guidelines. Several otherquantitative metrics have beendeveloped to assist in makingdecisions about prognosis, includingan age-adapted SOFA score,45 thePediatric Risk of Mortality III score46

for older children, and multipleiterations of the Score of NeonatalAcute Physiology and the Clinical RiskIndex for Babies score for neonates.47

Many cite the parameters, ease ofcalculation, and robustness of thesescoring systems as evidence of theirvalidity.48 Whether any neonatal orpediatric illness severity score willprove to be a valid measure ofprognosis in the setting of COVID-19remains unclear; no availablepediatric illness severity scoringsystem is validated in a public healthcrisis or as a triage tool.25,33

Furthermore, the PELOD and PELOD2 have not been validated in the NICUpopulation, a group commonlyomitted from published frameworks.Although these measures remain thebest available scoring systems forprognosis, their shortcomingshighlight the need for an updated

large-scale triage protocol developedfrom quantitative analyses of patientoutcomes. Because numbers ofchildren with severe COVID-19 illnessare small and because, thus far, triagealgorithms for ventilator allocationhave not been activated, whethersome children with chronic illnessand/or disability will be unfairlydisadvantaged by existing prognosticscoring systems remains unknown49;however, such concerns arereasonable, and careful attention todisability bias remains essential toresource allocation protocols forchildren as for adults.

Identifying a single, simpleframework to allocate ventilators andother medical resources acrosspopulations of children and adults iscomplicated by heterogeneity in theorganization of children’s hospitalsand management of resources. Forexample, a framework fora freestanding children’s hospital toshare its resources with an affiliatedadult hospital will differ greatly fromthat adopted by a children’s hospitalwithin a hospital with potentially lessrestrictive boundaries betweenpediatric and adult patients.Management of ventilator fleets alsomay vary greatly. Some NICUs usededicated neonatal ventilators, whichcannot be reallocated to adults;others use ventilators that functionacross the age spectrum and are partof a common fleet. These factors havethe potential to alter how allocationprotocols get applied to infants andchildren during a respiratory illnesspandemic.

As discussed previously, infants andchildren arguably should receivepreference in situations of a tie inpriority scores on the basis of a fairinnings or life stages argument. Somemay reject the entire premise ofsubjecting children to triage protocolson the basis of a moral, rather thanethical, intuition to protect childrenover adults. Consider, however,a neonate or young child with a 10%chance of survival if given the needed

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resource. Should she be givenpreference over a 22-year-old womanwho, with that resource, would havea 90% chance of survival? This seemscounterintuitive, even to a pediatricclinician, and would also beinconsistent with the goal of savingthe most lives. A fair and feasiblemethod must be found to allocatescarce resources among all patientsacross the age spectrum.

Should the resource allocation systemexplicitly confer an advantage forchildren? For instance, if one givesthe same prioritization score toa child with a 60% to 70% chance ofsurvival as an adult with a 70% to80% chance, children are slightlyfavored. Giving the sameprioritization score to a child witha 20% chance as an adult with a 50%chance clearly favors children evenmore. However, it should berecognized that as systemsincreasingly favor patients witha lower likelihood of survival, theydeviate from the goal of saving themost lives (although perhaps notfrom saving the most life-years).Anyone creating guidelines should doso with that understanding as well asan understanding of the inherentlimitations of using differentprediction tools in the same protocol.

Neonates present yet anotherchallenge. Scoring newborns who arecritically ill is difficult because onetool is not applicable to all infants inthis population. The NationalInstitutes of Health ExtremelyPreterm Birth Outcomes Tool couldbe used for those between 22 and 25weeks’ gestation,50 but the likelihoodof survival for this age groupincreases over the first days andweeks of life, making the tool lesspredictive over time; in fact, the toolwas developed to inform obstetricand neonatal clinicians for prenatalcounseling and decision-making, notto serve as a postnatal decision tool.51

A number of neonatal illness severityscores, used primarily for clinicalresearch purposes, exist, and

consideration could be given to theseas a parallel to SOFA and PELOD andPELOD 2 scores; importantly, thesescores have not been found to be ofhigh clinical utility and are not usedin clinical practice.52 To scorenewborns beyond the first few days,one might need to rely on clinicaljudgment regarding likelihood ofsurvival using input fromsubspecialists and outcomes data fora given pathologic condition, but thisstrategy is prone to bias and providervariation. Comorbidities thatinfluence neonatal survival could beused to adjust a prediction tool score,as they do for adults in other tools.However, once a system relies onclinical assessment of the likelihoodof survival rather than specific clinicaland laboratory data, the additionaluse of comorbidities to adjust thescore carries the risk of doublecounting the effect of the comorbidityon the assigned score.

ALLOCATION OF ECMO DURINGCOVID-19

World Health Organization interimguidelines for the management ofCOVID-19–related acute respiratorydistress syndrome recommendadministering venovenous ECMO toeligible patients in specialized centerswith sufficient case volumes toensure clinical expertise. In general,ECMO can be a viable rescue strategyfor some patients,53 but the potentialbenefit and duration of ECMOsupport for patients with COVID-19will require systematic, prospectiveinvestigation.

In addition, ethical challenges willaffect decision-making when ECMOtherapy is offered in a pandemic. Inthe American Pediatric SurgicalAssociation guidelines for ECMOcandidacy for neonatal and pediatricpatients who are COVID-19–positive,as well as for controlled cardiac orrespiratory cannulation, standardECMO inclusion criteria are used.54

Extracorporeal cardiopulmonaryresuscitation (the implantation of

venoarterial ECMO in a patient aftersudden and unexpected pulselesscondition attributable to cessation ofcardiac mechanical activity)55 inpediatric patients who are COVID-19–positive is discouraged especiallyfor those with other comorbidities,septic shock, or evidence ofmultisystem organ failure.54 It hasbeen suggested that the immunologicstatus of patients should beincorporated when assessing ECMOcandidacy because, reportedly, duringECMO, interleukin 6 concentrationswere consistently elevated and wereinversely correlated with survival inadults and children.56 For patientsunder investigation for COVID-19 (ie,patients who are awaiting COVID-19test results or whose test results wereinconclusive), standard ECMOcandidacy guidelines apply forrespiratory, cardiac, andextracorporeal cardiopulmonaryresuscitation. ECMO cannulation forboth patients who are COVID-19–positive and patients underinvestigation requires carefulattention to correct donning of PPE.

ECMO is a finite resource thatrequires investment of specializedequipment, highly and specificallytrained health professionals, andlarge volumes of blood products. Useof ECMO during a pandemic,regardless of indication, thuswarrants additional considerationwhen hospital resources are strainedor limited.57 These considerationsmay also be applied to otherresource-intensive interventions forthe patients who are sickest, such ascontinuous renal replacementtherapy. We do not recommenduniform prohibition of ECMO orsimilar interventions during a publichealth crisis as a preemptive strategyto preserve resources. Consideringcannulation for ECMO for infants andchildren who stand to benefit from it(in terms of survival or preservationof function) is appropriate, butapplication of resource allocation

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policies by a triage officer may benecessary in times of scarcity.

CODE STATUS FOR CHILDREN WITHSEVERE COVID-19 INFECTION

Code status for adults with severeCOVID-19 infection has becomecontroversial in the United States,partly on the basis of the highmortality observed among thepatients who are sickest, the risk ofviral transmission duringresuscitation, and the use of PPE foran entire code team of providers.58,59

Transparent and consistentapproaches to code status forinpatients with COVID-19 infectionare an essential component ofinstitutional scarce resourceallocation guidelines. Some haveadvocated for unilateral do notattempt resuscitation (DNAR) ordersfor all patients admitted to hospitalswith COVID-19 infection (or at leastfor those who are severely ill).59 It isreasonable to consider prioritizingpediatric clinician safety and PPEstewardship when a high-riskintervention has a low likelihood ofsuccess. Any justification forunilateral code status decision-making should be made explicit inhospital policies, and medical futilityshould not be conflated with theunique circumstances of thispandemic. If appropriate PPE isavailable, neither risks to the codeteam nor desire to conserve PPE areadequate justification for unilateralDNAR without first consideringwhether resuscitation is likely to

successfully resuscitate the patient.However, well-established principlesand processes exist for considerationof cardiopulmonary resuscitation andother extraordinary measures at theend of life and are often codified inpolicies regarding nonbeneficialtreatment.60 Such policies can beapplied in the context of thispandemic but may requiremodifications on the basis of availableresources. Members of the code teamshould never be expected to forgoappropriate donning of PPE beforeinitiating the resuscitation. Familiesshould be informed that resuscitationefforts might be delayed for clinicalproviders to don appropriateprotective gear.

Although children seem less likely tobecome critically ill, consideration ofcode status for those who do alsorequires explicit justification. Theevidence that informs decisions foradult patients is likely not applicableto children, and children with COVID-19 might have a higher likelihood ofrecovery after a resuscitation effortthan adults with similar illnessseverity. Although DNAR status maybe appropriate for children withCOVID-19 who are critically ill withprogressive hypoxemia, we do notrecommend a preemptive strategy ofunilateral DNAR orders for allchildren with severe infection.

CONCLUSIONS

In this article, we have exploredseveral considerations in the

development of an allocation protocolfor distributing scarce resourcesduring COVID-19. In these protocols,how to allocate resources across theage spectrum must be considered,and multiple criteria should beintegrated to capture all medicallyand morally relevant values.Transparency and inclusivity indevelopment of allocation protocols iscritical to ensure that inequities arenot exacerbated or perpetuated. Theunique needs of children must beincluded in planning prospectively toprepare to meet their needs.

ACKNOWLEDGMENTS

The approach to assessment of thelikelihood of survival for newbornswas developed with assistance fromDrs Renee Barrett, Patrick Gallagher,and Steven Peterec.

ABBREVIATIONS

COVID-19: coronavirus disease2019

DNAR: do not attemptresuscitation

ECMO: extracorporeal membraneoxygenation

PELOD: Pediatric Logistic OrganDysfunction

PELOD 2: Pediatric Logistic OrganDysfunction 2

PPE: personal protectiveequipment

SOFA: Sequential Organ FailureSystem

Address correspondence to Naomi Laventhal, MD, MA, FAAP, 8-621 C.S. Mott Children’s Hospital, 1540 E Hospital Drive, SPC 4254, Ann Arbor, MI 48105.

E-mail: naomilav@med.umich.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2020 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: Dr Dell has publishing contracts with American Psychiatric Publishing and Oxford University Press; the other authors have indicated they

have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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