1. Nadine Shehata MD, MSc University of Toronto, St. Michael’s Hospital, Canadian Blood Services

2. The Need for Guidance with Resource Allocation

3. The Need for an Ethical Framework

5. The Need for Guidance for Resource Allocation

6. National Plan for the Management of Shortages of Labile Blood Components

7. RBC Inventory Level CBS Days On Hand CBS # Units on Hand Green Phase>3 days> 8,900 units Amber Phase2 – 3 days6,000 to 8,899 Red Phase< 2 days< 5,999

8. National Plan for the Management of Shortages of Labile Blood Components This phase includes a range of inventory levels ranging from an ideal inventory to shortages that occur periodically. The national blood inventory is not sufficient to continue with routine transfusion practices. The blood inventory levels are insufficient to ensure that patients with non-elective indications for transfusion will receive the required transfusion.

9. The Bleeding Patient who Requires Massive Blood Transfusion?

10. Who Shall Receive the Blood during a Critical Shortage?  55 year old male ex-smoker with multiple trauma  Neonate undergoing urgent cardiac transplantation  75 year old politician with multiple medical problems responsible for reforming health care with a ruptured aortic aneurysm

11. Objectives  To understand the conflict between ethical decisions and resource allocation  To describe the ethical principles of making decisions about resource allocation  To describe potential methods of incorporating ethical decisions into resource allocation decisions

12. Ethics

13. Ethical Principles Are to Guide Decisions

14. Four Precepts for Respect 1. Autonomy2. Beneficence 3. Nonmaleficence4. Justice Distributive justice

15. Shortages Create Conflicts in Ethical Principles  Personal autonomy  Beneficence  The duty of society is to preserve those values that contribute to the common good of society  Nonmaleficence  The importance of protecting the most vulnerable from exploitation by those with power and influence  Justice  The ethical obligations of third parties i.e., health professions

16. A Guide to Making Ethical Decisions 1. Rational 2. Redeeming 3. Respectful  Weil MH et al. Crit Care Med 1988 Jun; 16(6): 636-41. Weil MH

17. Four Categories of Ethical Values for Resource Allocation 1. Treating people equally 2. Favoring the worst-off: prioritarianism 3. Maximizing total benefits: utilitarianism 4. Promoting and rewarding social usefulness Persad G et al. Lancet 2009 Jan 31; 373(9661): 423-31.

18. 1. Treating People Equally First Come First Serve Lottery Persad G et al. Lancet 2009 Jan 31; 373(9661): 423-31.

19. 2. Favoring The Worst-Off: Prioritarianism Sickest FirstYoungest First Persad G et al. Lancet 2009 Jan 31; 373(9661): 423-31.

20. 3. Maximizing Total Benefits: Utilitarianism Prognosis or Life-Years Saved Save the Most Lives Persad G et al. Lancet 2009 Jan 31; 373(9661): 423-31.

21. 4. Promoting and Rewarding Social Usefulness Instrumental ValueReciprocity Persad G et al. Lancet 2009 Jan 31; 373(9661): 423-31.

22. Ethical Principles to Guide Resource Allocation for Bleeding Patients  55 year old male ex- smoker with multiple trauma  Neonate undergoing urgent cardiac transplantation  75 year old politician, with multiple medical problems, responsible for reforming health care with a ruptured aortic aneurysm 1. Treating people equally 2. Favoring the worst- off 3. Maximizing total benefits 4. Promoting and rewarding social usefulness

23. The Combination of Ethical Principles  Ethical principles can be combined  To allow for the incorporation of the intricacy of moral values  To allow for the justification of choices about inclusion, balancing and specification  Disadvantages  Increases the overall complexity  There may be disagreement about which principles to include

24. Multi-principle Strategy for the Allocation of Ventilators PrincipleSpecificationPoint System 123 Save the most lives Prognosis for short-term survival (SOFA score) SOFA score <6SOFA score 6-9 SOFA score 9-12 Save the most life- years Prognosis for long-term survival (medical assessment of comorbid conditions) No comorbid states that limit long-term survival Minor comorbid states, small impact on long- term survival Major comorbid states, substantial impact on long- term survival Life-cycle principle Prioritize those with least chance to live through life’s stages (age) 12–40 y41-60 y61-74 y White DBWhite DB, Annals of Internal Medicine 2009 Jan 20; 150(2): 132-8

25. Multi-principle Strategy for the Allocation of Blood For Ruptured Aortic Aneurysm PrincipleSpecificationPoint System 123 Save the most lives Prognosis for short-term survival Save the most life- years Prognosis for long-term survival (medical assessment of comorbid conditions) Life-cycle principle Prioritize those with least chance to live through life’s stages (age)

26. Ethical Principles for Massively Bleeding Patients  Treating people equally  First come, first serve  Maximizing total benefits  Saving the most lives  Saving the most life years

27. The Goal of Any Multi-principle Strategy  To achieve the greatest good for the greatest number of people

28. Summary and Conclusion  Scarce resources create a conflict of ethical decisions  There are several ethical principles that can be used to guide decisions about resource allocation during periods of critical blood shortages  An allocation system should make clear that all individuals are worth saving, and that no ethical principle to guide resource allocation is sufficient on its own White DBWhite DB et al. Annals of Internal Medicine 2009 Jan 20; 150(2): 132-8. Persad G et al. Lancet 2009 Jan 31; 373(9661): 423-31.

29. Summary and Conclusion  A multi-principle strategy has the potential to decrease the conflict of how to allocate resources  It is the responsibility of everyone to discriminate wherever necessary to ensure that our limited resources go where they will do the most good

30. Summary and Conclusion  Prepare for the worse case  Have a triage criteria that is ethical, defensible and fair to all  Maintain human dignity of all patients