Protocols for rationing strategies & allocation systems

Introduction / overview

1. Non-abandonment: Healthcare providers have a duty to provide care. No person in need of medical care should ever be neglected or abandoned. Palliative care must be accessible for all patients with respiratory failure for whom life sustaining treatment such as mechanical ventilation will be withheld or withdrawn
   
2. Health systems have a duty to responsibly and equitably manage resources
   
3. Health systems have a duty to plan for these scenarios to avoid placing the burden on frontline healthcare workers
   
4. Rationing systems should ensure just and equitable allocation of resources
   
5. Protocols and decisions must be transparent

Procedures to consider for allocation systems

1. Utilise an officer or committee not involved in caring for the patient to guide decisions. This can help avoid individual health care workers from making tough decisions alone
   
2. A simple system might include:

• Assessing eligibility: Exclusion criteria for advanced care resources may include factors that will lead to near-term death regardless of intervention (e.g. cardiac arrest, irreversible septic shock and/or organ damage, severe traumatic brain injury)
• Standardise risk assessment: A replicable way for an officer or committee to use clinical data to assess mortality risk can help determine patients most likely to survive coronavirus infection. One example is the Sequential Organ Failure Assessment (SOFA) calculator
• Reassess at routine intervals: Decisions should be ongoing as clinical parameters change
• Transparency: The procedures should be easily accessible and understandable at an elementary school level and in all major languages in the institution’s catchment area
• Reciprocity and social usefulness during the pandemic: Providers of critical services, especially those who face disproportionate risk in helping others, should have a proportional return for their contributions such as priority in access to PPE, testing, treatment and psycho-social support. These might include doctors, nurses, midwives, housekeepers, sanitation workers, morgue workers, and emergency medical workers
• Vulnerable populations:
  • Patients who are vulnerable due to age, gender, sexual identity, race/ethnicity, disability, poverty, homelessness, social isolation, or any other form of discrimination may require more or more intense psycho-social services than others
  • Patients who are particularly vulnerable to infection due to chronic illness or disability, or to their living situation, may require enhanced protective measures

Sources & links:

• International Monetary Fund | A matter of life and death | Link
• AHRQ | Allocation of scarce resources during pandemics: strategies for policy makers | Link