chapter 3 ethical framework [enter facilitator’s name and contact information] developed by...
TRANSCRIPT
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Ch
apte
r 3
ETHICAL FRAMEWORK
[ENTER FACILITATOR’S NAME AND CONTACT INFORMATION]
Developed by Troutman Sanders LLPDeveloped for the Virginia Department of Health
Funded by Centers for Disease Control and Prevention
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2Ethical Framework
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3Ethical Framework
Toolkit Presentations Instructions for Use
Toolkit Presentations are intended to be a companion to the Hospital Implementation Guide and should not be used in isolation.
The Presentations are intended to serve as a starting point for the facilitator. The facilitator should thoroughly review the Presentation prior to use in Implementation Team, CRAG or Subcommittee meetings and customize the Presentation to meet the unique needs of the meeting participants.
Pay particular to attention to the information provided in brackets ([ ]), which must be completed by the facilitator prior to use.
Included in the “Notes” section of each slide are the following types of information:
• Slide Type, which indicates whether the slide is for information or discussion, serves as a placeholder, or is some combination thereof
• Planning Guide Section(s), which will direct the facilitator to the corresponding sections of the Planning Guide and Hospital Implementation Guide for further information
• Special Instructions, which provides directions for the facilitator to customize the slide for the intended audience
• Speaker’s Notes, which provides more detailed information to supplement the material on the slide
Refer to the Hospital Implementation Guide for further guidance and helpful hints on effectively completing the process described in the Planning Guide.
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4Ethical Framework
CRAG Members
[Enter names and departments of each CRAG member]
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5Ethical Framework
Add slides from Altered Standards Overview and/or Chapter 1 presentation, as needed, to re-introduce the CRAG to the concept of altered standards and critical resource shortage response planning, especially if new members are involved.
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6Ethical Framework
Introduction
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7Ethical Framework
Why Ethics?Decisions during a CRSE involve complex,
challenging ethical issues, including the allocation of scarce resources
An ethical framework will help ensure that the CRSRP and associated Protocols are developed in an ethical manner
Ideally, the application of an ethical framework will produce a CRSRP and Protocols that are accepted as ethically sound
While existing frameworks may be helpful, Planning Units should create their own framework which reflects their unique culture and values
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8Ethical Framework
Strong Foundation
Operational Infrastructure
Education & Communication
Building the CRSRP
Protocol
Protocol
Protocol
Protocol
Protocol
Protocol
Protocol
Protocol
Ad Hoc
Ethical Framework
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9Ethical Framework
Three Step Process
Step 1: Identify Ethical PrinciplesStep 1: Identify Ethical Principles
Step 2: Define the GoalStep 2: Define the Goal
Step 3: Determine Implementation SpecificationsStep 3: Determine Implementation Specifications
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10Ethical Framework
Step 1: Step 1: Identify Ethical PrinciplesIdentify Ethical Principles
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11Ethical Framework
Ethical Principles
Substantive Principles Individual Liberty Protection of the public from harm Proportionality Distributive justice and fairness Beneficence Non-maleficence Privacy Duty to provide care Reciprocity Respect for Autonomy Equity Trust Solidarity Stewardship
Procedural Principles Reasonable Open and Transparent Inclusive Responsive Accountable
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12Ethical Framework
Prioritization of Ethical Principles
Substantive Individual Liberty Protection of the public from harm Proportionality Distributive justice and fairness Beneficence Non-maleficence Privacy Duty to provide care Reciprocity Respect for autonomy Equity Trust Solidarity Stewardship
Procedural Reasonable Open and transparent Inclusive Responsive Accountable
High Medium Low
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13Ethical Framework
Ethical Principle Prioritization
High Priority Medium Priority Low Priority
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14Ethical Framework
BREAK
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15Ethical Framework
Step 2: Step 2: Define the GoalDefine the Goal
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16Ethical Framework
Protecting the functionality of societyProtecting societal and community infrastructurePreventing morbidity and mortalityGreatest good for the greatest numberGreatest good for the greatest number with “side
constraints”Greatest number of people benefitedGreatest number of lives savedGreatest number of life years savedGreatest number of quality life years saved
Potential Goals
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17Ethical Framework
“Protecting the Functionality of Society”
Modify practices and allocate resources to protect the societal infrastructure and prevent it from breaking down under the stress of the disaster
Prioritize for prophylaxis and treatment those people who are essential to preserving the functionality of society
Who is essential to protecting the functioning of society?• Health care providers?• Public Health Officials?• Legislators?• Police officers?• Truck drivers?• Janitors?• Sewage workers?
Will the answer depend on the disaster or the type of care that is being modified or allocated?
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18Ethical Framework
“Prevent Morbidity and Mortality”
Modify practices and allocate resources to prevent illness and death
Prioritize for prophylaxis and treatment those people who are most likely to become ill, make others ill, or die without the intervention
Will the prioritization change based on the disaster or the type of care that is being modified or allocated?
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19Ethical Framework
“Greatest Good for Greatest Number”
Widely used in critical resource shortage response planning literature
Not clear exactly what it means• Greatest number of lives saved?• Greatest number of life years saved?• Greatest number of quality life years saved?• Greatest number of people benefited?
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20Ethical Framework
“Greatest Good for Greatest Number with Side Constraints”
Greatest good for the greatest number + Respect for persons + Non-maleficence + Justice
Greatest good for the greatest number + Refraining from harming individuals and communities + Providing equal opportunity to access resources to those in priority groups + Employing the least restrictive interventions likely to be effective
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21Ethical Framework
Prophylaxis v. Treatment
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22Ethical Framework
Choose a Goal
Protecting the functionality of societyProtecting societal and community infrastructurePreventing morbidity and moralityGreatest good for the greatest numberGreatest good for the greatest number with “side
constraints”Greatest number of people benefitedGreatest number of lives savedGreatest number of life years savedGreatest number of quality life years saved
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23Ethical Framework
BREAK
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24Ethical Framework
Step 3: Step 3: Determine Implementation Determine Implementation
SpecificationsSpecifications
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25Ethical Framework
Withdrawal and Reallocation
Will providers be allowed to withdraw resources from one patient to give them to another patient?
If so, under what general circumstances?
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26Ethical Framework
How will you decide who gets the ventilator?
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27Ethical Framework
Minnesota’s Reallocation Criteria
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28Ethical Framework
Consider that…
If you are not willing to withdraw treatment, then you are essentially providing care on a first come, first served basis.
If you are willing to withdraw care, will this be construed as valuing one person’s life more than another’s life?
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29Ethical Framework
Withholding of Resources
Will providers be allowed to withhold a critical resource from one patient to conserve it for a future patient?
If so, under what general circumstances?
Is the answer different for durable v. consumable resources?
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30Ethical Framework
Consider that …
If you are not willing to withhold care, you will essentially be providing care on a first come, first served basis.
If you are willing to withhold care, you may have unused, available resources that are not being provided to a patient in need.
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31Ethical Framework
“Inclusion” and “Exclusion” Criteria
Many of the existing allocation algorithms include “inclusion” and “exclusion” criteria
Inclusion CriteriaThose patient
characteristics which indicate a need for the
Critical Resource
Exclusion CriteriaThose patient
characteristics that remove a patient from consideration
for the Critical Resource even when the inclusion
criteria are met
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32Ethical Framework
Example Exclusion CriteriaOntario Health Plan for Influenza Pandemic
Christian MD, et al. (Nov 2006) “Development of a Triage Protocol for Critical Care During an Influenza Pandemic.” CMAJ, 175(11): 1377-1381. Available online at: http://www.cmaj.ca/cgi/reprint/175/11/1377 (last visited March 9, 2009).
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33Ethical Framework
Example Exclusion CriteriaNew York Vent Allocation Guidance
Powell T, et al. (Mar 2008) “Allocation of Ventilators in a Public Health Disaster.” Disaster Medicine and Public Health Preparedness, 2(1): 20-26.
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34Ethical Framework
Example Exclusion CriteriaTask Force for Mass Critical Care
Working Group
Devereaux A, et al. (2008) “Definitive Care for the Critically Ill During a Disaster: A Framework for Allocation of Scarce Resources in Mass Critical Care.” Chest, 133: 51S-66S. Available online at: http://www.chestjournal.org/content/133/5_suppl/51S.full (last visited March 9, 2009).
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35Ethical Framework
Example Exclusion CriteriaUtah Pan Flu Hospital and ICU Triage
Utah Department of Health (Aug 2008) “Utah Pandemic Influenza Hospital and ICU Triage Guidelines.” http://www.uha-utah.org/Disaster%20Prep%20Materials/PANDEMIC%20FLU%20TRIAGE%2008-12-08.pdf (last visited March 9, 2009).
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36Ethical Framework
CA’s Exclusion Criteria Guidance
Acceptable Likelihood of survival Change in quality of life Duration of benefit Urgency of need Amount of resources
required
InappropriateAbility to paySocial worthPatient contribution to
diseasePast use of resources
California Department of Public Health. (2007). “California Department of Public Health Standards and Guidelines for Healthcare Surge During Emergencies, Volume I: Hospitals.” Available online at:http://bepreparedcalifornia.ca.gov/NR/rdonlyres/0DB13C5F-89DC-4B94-850B-EF12EA221FF3/0/volume1_hospital_FINAL.pdf (last visited September 25, 2009).
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37Ethical Framework
Inappropriate Exclusion Criteria
Ability to pay? Social worth? Race or ethnicity? Religion? Gender? Patient contribution to
disease? Past use of resources? Age? If so, what is the
cut-off?
Severe baseline cognitive impairment?
Known severe dementia? Metastatic malignant disease? End stage organ failure? Severe and irreversible
neurological event or condition?
Advanced and irreversible immunocompromise?
Advanced untreatable neuromuscular disease?
Known chromosomal or untreatable disorders fatal in first 2 years of life?
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38Ethical Framework
Questions?Questions?