The surge-upon-surge of COVID-19 cases in the United States has again focused attention on scarcity of lifesaving medical resources—hospital beds, ICU equipment, ventilators, oxygen, medications, and hospital staff. With nearly 124,000 people hospitalized—and more than 23,000 in ICU care—hospitals have reached and exceeded their capacity from California to Georgia to Texas to Tennessee.
What happens next in each of those states will differ. Guidelines for how to allocate health care resources—where they exist at all—vary widely by state. Fundamental questions about who gets treated and who does not are addressed in vastly different ways, sometimes from one hospital to the next. Some rely on a “first come first served” system. Others use “lottery” approaches. Some prioritize younger patients over older ones. Some, but not all, prioritize treatment for health care workers. In places without clear protocols, clinical staff become de facto allocators of lifesaving care, leading to moral distress.
Even some existing allocation policies have been found wanting during the pandemic. For instance, ventilator allocation guidelines from New York were based on a flu pandemic—but COVID-19 presents and responds to treatment differently than the flu, limiting applicability of the criteria used as the basis for these decisions. Clinicians and health systems also must strike a balance between patient-centered care in individual treatment decisions and addressing community-wide public health needs. Yet no systematic effort has been undertaken to align ethical and clinical principles for health care resource allocation.
In places without clear protocols, clinical staff become de facto allocators of lifesaving care, leading to moral distress.Share on Twitter
To improve decisionmaking, increase transparency, and reduce potentially harmful variation in guidelines from one facility to the next, we developed a Core Guidance Checklist. It is based on input from a panel of clinicians, health system leaders, patients and consumers, disability advocates, policymakers, legal scholars, bioethicists, and clinical researchers.
The checklist includes four major elements that any guidelines should include to enable clear and consistent decisionmaking, while also allowing for adjustment as knowledge and contexts change:
Statement of principles. A clear statement of the clinical and ethical principles that will guide allocation of scarce medical resources is the foundation. Beyond traditional medical ethics, guidelines should address achieving the most good at the population level and avoiding bias (racial, gender, disability, etc.) in decisions. They also should spell out what criteria will be used to determine a patient's prognosis.
Data review. Guidelines should specify how frequently data and new clinical findings will be reviewed. Information reviews should include a range of clinical and public perspectives, including consideration of regional rather than solely facility-level resources.
Evaluation and auditing. Guidelines should include criteria for measuring fidelity to the chosen policies and how the allocation is functioning in practice. These audits are crucial to identify unintended consequences, such as disproportionate negative impact on communities of color.
Flexibility. Guidelines should allow for local, context-sensitive adaptation and communication, including collaboration with relevant stakeholders on implementation.
Our decision guidance also includes a Responsibility Grid to illustrate how each affected group should contribute to creating a policy, its implementation, and its monitoring and adjustment. (See Figure 1.) It ensures that decisions are, in keeping with the Core Guidance Checklist, clear, consistent, current, collaborative, and context sensitive.
Figure 1: The Responsibility Grid
Health system clinicians
|Collaborate within and across health systems||-||SR||PR||I||SR|
|Review relevant information||SR||PR||C||C||C|
|Shape public communication and build trust||-||SR||I||C||PR|
|Monitor for unintended consequences||I||PR||C||C||SR|
|Evaluate results of policy||SR||PR||C||C||I|
Health system clinicians includes internists, hospitalists, specialists, respiratory and rehabilitation therapists, nurses, and other health professionals involved in providing primary prevention or care of patients with the condition. Public includes patients, family members, informal caregivers, advocates and members of disproportionately affected communities, and individuals who are at risk of infection.
The grid provides a roadmap for shared responsibility and accountability across the relevant groups. It also proactively accounts for those disproportionately affected by the public health crisis due to heightened exposure risk, clinical risk, and barriers to care access. In the COVID-19 pandemic, this includes the financially impoverished, older adults and others in congregate housing, and racial and ethnic minorities.
Allocation policies are a fusion of clinical and ethical considerations—but too few give explicit attention to affected communities.Share on Twitter
Allocation policies are a fusion of clinical and ethical considerations—but too few give explicit attention to affected communities. Without this representation, allocation decisions risk perpetuating patterns of health disparity and other unintended consequences.
As COVID-19 cases and hospitalizations surge to new highs in early 2021, states, health systems, and the public continue to need clarity on health care resource allocation policy. The Core Guidance Checklist provides clear and consistent criteria for structuring such decisions, particularly when resources are scarce and when clinical and ethical principles must be reconciled. By involving affected communities beyond clinicians and health systems, RAND's checklist offers a remedy for troubling variation in access to lifesaving care during the pandemic and can improve public trust in decisions.
- Piscitello GM, Kapania EM, Miller WD, et al. Variation in Ventilator Allocation Guidelines by U.S. State During the Coronavirus Disease 2019 Pandemic. A Systematic Review. JAMA Network Open. 2020;3(6):e2012606. DOI:10.1001/jamanetworkopen.2020.12606
- Emanuel EJ, Persad G, Upshur R, et al. Fair Allocation of Scarce Medical Resources in the Time of COVID-19. New England Journal of Medicine 2020; 382:2049-2055. DOI: 10.1056/NEJMsb2005114
- Rosenbaum L. Harnessing Our Humanity—How Washington's Health Care Workers Have Risen to the Pandemic Challenge. New England Journal of Medicine 2020; 382:2069-2071. DOI: 10.1056/NEJMp2007466.
- Zucker H, Adler K, Berens D. Ventilator Allocation Guidelines (PDF). 2015. New York State Department of Health Task Force on Life and the Law.
- Frank L, Concannon TW, Patel KV. RAND Report RR-A326: Health Care Resource Allocation Decisionmaking During a Pandemic. Santa Monica, CA: RAND Corporation, 2020.
- Blumenshine P, Reingold A, Egerter S et al. Pandemic influenza planning in the United States from a Health Disparities Perspective. Emerging Infectious Diseases 2008;14(5):709-715.
- Blanchard J, Haile-Mariam T, Powell NN et al. For us, COVID-19 is Personal. Academic Emergency Medicine. 2020 May 17;10.1111/acem.14016. DOI: 10.1111/acem.14016.Online ahead of print.
Lori Frank is a senior behavioral scientist at the nonprofit, nonpartisan RAND Corporation. She is also president of the International Society for Quality of Life Research and serves on the Board of the Personalized Medicine Coalition and the Alzheimer's Foundation of America Medical, Scientific, and Memory Screening Advisory Board. Thomas Concannon is a senior policy researcher at RAND, assistant professor of medicine at Tufts University School of Medicine, and director of Stakeholder and Community Engagement at Tufts Clinical and Translational Science Institute.
Commentary gives RAND researchers a platform to convey insights based on their professional expertise and often on their peer-reviewed research and analysis.