By Stephen Wood
The provision of scarce resources such as intensive care unit (ICU) beds, antivirals, and ventilators during this pandemic has been an ongoing topic of discussion. Repeatedly, states and hospital systems have considered implementing crisis standards of care, which establish triage protocols for scarce resources.
Though crisis standards of care are meant to provide an ethics-based approach to the complex process of allocating scarce health care resources, in reality, they fall short.
Even the best laid plans cannot guarantee an equitable division of health care resources. Geography and demography have always played a role in health care access and health-associated outcomes. The triage of resources and, even more so, top personnel is not an easy task. And most problematic is the ethical dilemma of who does and who does not receive critical, life-saving interventions.
Many of these plans dictate that patients should not receive care if it would be harmful, if not futile. This, however, is fairly complicated, as there is no concrete definition of what defines futile care. Further complicating this is that the utility or futility of an intervention can vary by the given clinical situation. Providers can be reluctant to suggest that care is futile, and the process of making difficult clinical decisions is often multifactorial, involving advance directives, family wishes, and other available data.
Clinicians need better guidelines when faced with these difficult decisions. Here I propose one path forward: including contraindications to interventions within clinical standards of care.
Contraindications are scenarios in which certain interventions are not recommended. For example, if a patient is allergic to the antibiotic penicillin, the drug would be contraindicated in their care. For COVID-19 related interventions, this could be based on the potential for harm, and/or lack of efficacy in a given clinical scenario.
Writing contraindications into standards of care would be a monumental shift to a more evidence-based framework that optimizes allocation of resources based on probable patient outcomes.
One example is the use of hemodialysis. In the setting of COVID-19, the development of acute kidney injury (AKI) is common in patients requiring mechanical ventilation. The mortality rate for those patients that develop severe kidney injury requiring dialysis is 90%. For those patients who do not receive hemodialysis, the mortality rate 91%. Given that there is no difference in clinical outcome, providers may wonder, is hemodialysis likely to be futile in this setting? If so, should it be offered to every patient who needs it when there is good data that it will only prolong an inevitable outcome?
One could argue that in the example of AKI and hemodialysis, 10 – 20% of those people will survive. How do we know who will and won’t benefit from this intervention and how can we take that chance as health care providers? There is no easy answer to this question. What we do know is that there can be real harm to patients and families when they receive prolonged care that ultimately results in poor outcomes. There is also the under-addressed yet significant issue of moral injury to health care providers when they feel that the care they are giving is both futile and harmful.
Scoring tools to determine futility dehumanize these decisions, and relying solely on either providers or families to make these decisions is fraught with problems. A standardized approach to when certain scarce resources will and will not be offered, in the form of written contraindications to standards of care, would be a big step in the right direction. These contraindications should be crafted by multi-disciplinary associations, including physicians, nursing, palliative care, legal experts and ethicists, rooted in evidence, and designed to advance equity. This approach could rely on data from the best available meta-analyses, disease-specific scoring tools, and expert opinion. Similar to a list of contraindications for a medication, contraindications to certain interventions could offer a practical approach that alleviates the moral conundrum that often accompanies difficult health resource allocation decisions.
This pandemic can serve as an opportunity to re-evaluate our health care delivery system as it pertains to valuable and limited resources.
Allocation of resources is already complicated in our health care system. In one study, close to upwards of 11% of ICU patients reviewed by researchers were receiving futile care. These are resources that come at a significant cost, approximately 2.6 million dollars annually. More so, there is the cost of harm to patients and families, as well as the moral injury that many health care providers endure providing care that they consider futile if not harmful.
We cannot expect health care providers to accept an “all or nothing” approach to providing resource-rich care without more concrete guidelines that are evidence-based and equitable. This is too great a moral burden; better guidance is required. Evidence-based contraindications help to relieve that struggle by better identifying who will and who will not benefit from interventions that include mechanical ventilation, hemodialysis, and extracorporeal membrane oxygenation.
This model of integrating contraindications to potentially scarce interventions into standards of care will help providers in their daily practice and prevent patients and their loved ones from the suffering associated with the administration of futile or potentially harmful treatments.