Jan 30, 2009 (CIDRAP News) Minnesota health groups today unveiled two preliminary guidance reports designed to help the state make and implement difficult decisions about allocating scare resources such as antivirals, respirators, ventilators, and vaccines during a severe influenza pandemic.
In accepting the groups' reports today at a press conference, Sanne Magnan, MD, PhD, commissioner of the Minnesota Department of Health (MDH), said the avian influenza virus was a hot topic in 2007 when the MDH hired the Minnesota Center for Health Care Ethics (MCHCE) and the University of Minnesota Center for Bioethics (UMCB) to study the issue and start writing guidance documents. Though bird flu news has waned in the public's consciousness, "the strain that triggered the concern is still making people ill in Asia and Africa," she said.
Magnan said the reports predict that in a pandemic as bad as the one in 1918, more than 30,000 Minnesotans will die. "And there will not be enough of anything we need to treat the ill," she added.
The preliminary reports clearly articulate the nonmedical criteria that will help public officials fairly distribute scarce pandemic resources, Magnan said, adding, "This does provide a roadmap for negotiating the difficult landscape, but doesn't tell us how to drive the car."
A vital next step is to gather public feedback to ensure that the final reports reflect the shared values of Minnesotans, she said, adding that transparency and trust may help community members understand the decisions health officials may someday have to make. Today MCHCE and UMCB launched a Web portal to gather public feedback on the draft documents.
Magnan told reporters that over the coming months the groups will also host town hall meetings in two Minnesota cities and convene six focus groups to review the recommendations.
J. Eline Garrett, JD, assistant director for health policy and public health at the MCHCE, said few states have conducted detailed pandemic planning and that even fewer have drafted ethical guidelines. Her collaborator, Debra DeBruin, PhD, associate director of the UMCB, said what sets Minnesota's process apart is a focus on how to carry out the ethical decisions in a pandemic setting. "We don't want to leave unanswered how the decisions can be practically implemented," she said.
Ethical rationing guidance
In the 75-page preliminary report on making ethical rationing decisions in a pandemic, the groups assumed, for example:
- A W-shaped mortality curve in which those aged 15 to 40 will join the very young and the elderly in having a high risk of death from influenza infection
- Enough antivirals to treat, with a standard regimen, 21% of the state's residents during the first wave of the pandemic
- The estimated supply of N95 respirators for protecting healthcare workers will last less than 3 weeks
- The pandemic vaccine will be available to only 6% of the state's residents over the first 12 weeks, and to about 24% over a year (assuming two 15-mcg doses)
- Acute care centers have about 1,200 ventilators, of which 85% are currently in use
The authors recommend that public officials consider a host of fairness characteristicssuch as high risk of death from the flu or good response to a particular treatmentbefore using random methods to ration scarce pandemic resources. They predict that one of their recommended characteristics, age-based rationing that favors the young, will be particularly controversial and should receive broad public consideration.
For most of the pandemic resources, the groups recommend a two-tier prioritization approach that addresses two groups: key workers in critical health and infrastructure jobs, and the general public. However, they recommend a one-tier system for prioritizing ventilators: the general public, including all types of workers.
At some point during a severe pandemic, public officials might be forced to allocate resources among people who have equal priority, the groups acknowledged. In those instances, they advise against using a first-come, first-served approach because it would probably heighten existing healthcare access inequity. "A more random technique, such as flipping a coin or a lottery, should be used instead," they wrote.
The groups advise public health officials to adjust the use of a range of resources and strategies to best protect as many Minnesotans as possible. For example, though elderly people may not be early candidates to receive vaccines, coordinated rationing of other measures, such as antivirals or N95 respirators, may provide an adequate degree of protection for the elderly
A roadmap for implementing rationing
In the accompanying 94-page report on implementing resource rationing decisions in a pandemic, the groups focuses on eight main issues:
- Equitable access to resources
- Eligibility for resources
- Emergency powers
- Standards of care
- Implementing rationing criteria
- Protecting the public
- Ethics consultation
- Palliative and hospice care
The groups recommend that the MDH gather an expert working group to discuss complex issues surrounding pandemic standards of care and liability issues. They recommend that any standard-of-care decisions give providers a degree of flexibility, based on their work settings, and avoid giving providers full immunity to liability. "There must be safeguards and protections for patients, as well," they wrote.
Two of the rationing criteria recommended in the first report, key workers and age, raised several issues when implementing the plan was considered. The authors point out that some volunteers will play such important roles that some should be prioritized as key workers. They also recommend that state officials and workplaces identify key workers in advance of a pandemic to ease their access to resources.
Although healthcare workers may run into difficulties accessing patient records to make rationing decisions during a pandemic, the group felt strongly that privacy protections should be enforced. "Patients' self-reports should be accepted as guiding rationing decisions where possible," they wrote.
If community engagement sessions show broad support for age-based rationing decisions, Minnesota officials should ensure that their actions comply with federal and state age discrimination laws, the authors advise.
To protect the public and build trust during a pandemic, the authors recommend that healthcare institutions create systems to routinely review their performance and provide a limited, streamlined process for real-time review of rationing decisions. "This process provides a safeguard for individuals or their families to question the procedural and substantive propriety of decisions at the time they are made," they wrote.
Discussions of rationing need to account for palliative and hospice care for patients who are terminally ill, the groups emphasize. They advise Minnesota officials to bring together a work group to plan for meeting the needs of dying patients by steps such as stockpiling palliative care resources, developing symptom-management algorithms, establishing caregiver educational programs for the community, and creating a process for ongoing community engagement.
Next steps
After the groups complete all of their community engagement activities, they will issue a summary of the public's comments and reaction, the MDH said in a press release today. The MDH said it will make that report public when it receives it by the end of the year.
The groups will then consider revising the preliminary reports and present the final version to state officials for implementation, the MDH said.
See also:
Jan 30 preliminary report on ethically rationing Minnesota health resources in a severe influenza pandemic
Public comment portal for pandemic ethics and implementation reports
Oct 31, 2006, CIDRAP News story "Pandemic vaccine rationing proposal favors the young"
