Addressing Shortcomings in Contingency Standards of Care

Photo by Adhy Savala on Unsplash ABSTRACT During a crisis, when healthcare capacity becomes overwhelmed and cannot meet regular standards of patient care, crisis care are invoked to distribute scarce hospital space, staff, supplies. When transitioning between conventional standards, hospitals may have manage resources under scarcity constraints in an intermediate phase defined as the contingency phase. While much attention has been paid ethics standard protocols, measures were more widely implemented, though little exists within literature or clearly explicated care. This paper addresses three ethical issues with current response COVID-19: lack formalization, risks using short-term solutions for prolonged shortages, danger exacerbating health disparities through hospital-level resource allocation. To mitigate these issues, I offer recommendations reimagining allocation during INTRODUCTION situations where shortages do not immediately threaten delivery, phase, known “contingency” phase.[1] less covers Many states systems dictate absent event triggering standards. Crisis used reflect priorities relevant times shortage other emergencies. These include saving most lives, stewardship resources, justice relating equitable distribution.[2] delineate specialized protocols triage decision-making bodies at institutional state levels. require formal activation level, absence clear triggers governmental willingness use them, adopt informal strategies form measures. The is two simultaneous goals: prevent stall crisis-level managing limited providing that functionally equivalent usual care.[3] In words, allocate no significant consequences patients. However, this unrealistic expectation: meeting patient’s medical needs allocating basis instead indications can be odds, creating tension. stemming from tension: risk l. Lack Formalization One shortcoming they fail same level procedural detail clarity early COVID-19 surges Italy France demonstrated pitfalls bedside guidance. acute critical forced doctors countries make decisions bedside, which often resulted de facto age-based well experiences moral distress shame among providers.[4] France, guidelines statistics never released public, raising concerns over role transparency implementing causing public question trustworthiness provider triage.[5] Though many US implemented case large-scale event, vary widely. A 2020 review 31 found only 18 contained strong “ethical grounding,” 28 “evidence-based clinical processes operations,” 21 included “ongoing community engagement, education, communication,” 16 had “clear indicators, triggers, lines responsibility.”[6] need standardization, transparency, recognized. remain unresolved policy legislative efforts period before (or after) apply. recent study observed team members high-fidelity simulation highlighted challenges making frontline decisions.[7] simulation, participants nudged priority status up down depending what subjectively identified morally factors. Through reported difficulty separating implicit biases about characteristics their judgment. regional contingency-level there few safeguards against biased, ad hoc, non-transparent rationing. Without formalized standardized guidance, providers left susceptible individual patterns unintended discrimination. An example susceptibility seen allow patients who longer benefit ICU continue occupying beds. based first-come-first-served (FCFS) approach bed FCFS default intake, led access pandemic. Media reports “plenty space” being unwilling accept overwhelmed, lower-income illustrate advantages those could show first particular hospital: privileged, well-funded inaccessible low-income communities.[8] blind several factors, including likelihood survival discharge, reciprocity (i.e. prioritizing workers), varying degrees healthcare. Therefore, it inappropriately privileges proximity social connections enabling greater initial care.[9] excessive mortality would result mitigated system-wide potential resources. provide liability coverage reallocate beds away periods scarcity. shifts model, but if well-defined, established, providers. system guide process transition method period, gets operate basis, even approaching levels Additionally, will fall unsustainably transfer center workers, leading frontlines already strained. Lessons responses improve future responses. There multiple ways achieving equity allocation, ranging state-level changes. State-wide policies interventions facilitate resource-sharing relieve some burdens face period. For example, moving lower once sufficiently recovered challenge doctors, call find open situations, move unknowingly reinforce arrive keep beds, while later wait one disadvantaged having them. centers, facilitated departments, present alternative balancing distribution equitably efficiently than physicians do, following hospitalization.[10] centers aid tertiary also identifying assisting transferring out safely downgraded simplest solution encourage creation guidance level. hospitals, help navigate difficult conversations time-sensitive decisions, like useful tool transparent, principled, ethically justified real-time hoc ll. Unsuited Prolonged Resource Shortages Secondly, neither nor currently designed respond strains system. Since start pandemic, staffing began projected persist.[11] both assume eventually return standard, deferred elective surgeries preserve emergency life-saving procedures. Massachusetts, instance, issued order required defer 50 percent all non-essential non-urgent (elective) surgeries. demonstrates measure shortages.[12] deferral procedures adverse long-term consequences. Medical conditions typically addressed surgery, such joint replacement osteoarthritis patients, worsen delayed. numbers emergencies, complex surgical later, increased reliance pain medications, recovery times.[13] understanding complications health, existing strategies, surgeries, unsuitable shortages. threat safety take place risking implementation temporary use. Although planning documents identify indicators activating operations,[14] always action. New York did implement pandemic despite hardest-hit cities US.[15] Other states, California, Texas, Florida, activate leaving ultimately very similar identical protocols.[16] Due hesitance prevailed protocols. If set forth objective unfair supplies jeopardize ability necessary critically ill failures inappropriate place. With duration limited. activated state-wide outside hospital-specific limitations, generally into Leaving seem beneficial defining blurs line appropriate decision makers delayed failure them all. important automatic responses.[17] Automatic validated metrics remaining available inform must should transparent validated, updated time evolving data. confusion, inconsistent guidelines, inequitable hands distressed needed. Defining begin limit length protect application sustainably ameliorate. lll. Potential Exacerbate Health Disparities Inconsistencies door unequal different communities location needs. concern because unclear whether goal outcomes balanced patient-centered care.[18] meant definition assumes wrongly suggest) any strategy avoid impact outcomes. functional equivalence attainable, research achieve groups disproportionately affected harmful strategies. inability difference practice merely distinction visible, immediate sacrifices well-being crises less-obvious, decrements due protracted alterations. Two common cause disparate attainability equivalence. First, restricting room visits degree worrying late 2021 2022, Massachusetts faced widespread restricted needs.[19] reasonable staff department severe doubtful restriction soon-to-be emergencies filtered until worsen, resulting overflowing urgent clinics presenting ERs forms sicknesses on. Given empirical evidence demonstrating ER treatment admission disadvantage Black Hispanic exacerbate further limiting needed care.[20] Second, altered ratios, stretch number shortage, another concerning yet measure. Staffing viewed similarly space equipment, alterations operations significantly quality outwardly appear equivalent.[21] ratios qualified nurses associated poor higher inpatient mortality[22] rates in-hospital cardiac arrest patients.[23] examples highlight amplify disparities, particularly adopted frame. Lowered racial ethnic minorities.[24] scoring developed prioritize treatments actively gives rise discrimination disabled patients.[25] Not practice, varied sometimes hospital, across geographic regions.[26] departments without standardization advance ensure outcomes, likely burden primarily minorities. alone insufficient. factors details patients’ charts produce determine priority, criteria admissions transfers consistent. Thus, ongoing monitoring disparity accompany spots corrected. Bioethics long preoccupied micro-allocation confronting structural inequities underlie broader traditional dilemma certain overlooks questions how allocated, place, (and not) built, previous created bias fairness, bioethicists pay aspects determinants preventative measuring addressing Area Deprivation Index (ADI). ADI quantifies effects race, class, socioeconomic background region prioritization resources.[27] It shown promise regions targeted diabetes management electronic records.[28] tools proactively deciding Moreover, population data, organizations forecast allowing adoption might otherwise amplified decisions. CONCLUSION Meeting scarcity, after apply, rather inherently unjustifiable necessity requires consider equity, overall aim best achieved measures, consensus demand consideration. Because have, inadequate. Public parallel anticipate - [1] Altevogt, B. M., Stroud, C., Hanson, S. L., Hanfling, D., & Gostin, L. O. 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