1. Jon Stanger, MD, MDiv, MHS Ethics Chair Contra Costa Regional Medical Center Allocation of Medical Resources in the Lifeboat

3. The Clinician’s “Hippocratic” Ethic A 48 year-old man with a recent diagnosis of incurable cancer has a prognosis of less than 6 months to live. He presents to the emergency department with pneumonia and respiratory failure. The emergency physician places the patient on a ventilator, starts antibiotics, and admits him to the ICU. The attending physician in the unit advises the family that the ventilator support should be discontinued because it is medically futile and an inappropriate use of scarce resources. The family objects.

4.  Unrestricted Advocacy  Restricted Advocacy  Justly Restricted (or Proportional) Advocacy After Jecker et al.

5. A previously healthy 34 year-old, single mother of three is in the ICU with sepsis and multi-organ failure. She is on CRRT and has a roughly 20% chance of survival to discharge. A 67 year-old homeless man sustained multiple injuries from an assault. He has developed renal failure and requires CRRT. With treatment, he has a 60% chance of survival to discharge.There is only one CRRT unit available. Neither patient is stable for transfer.

6. Defining the “Good” Allocation Guidelines GUIDELINETRIAGE CRITERIA Beauchamp & Childress Constituency  Medical Utility (need + likelihood of success)  Queuing or Lottery NYS Workgroup + OHPIP Exclusion Criteria (cardiac arrest, metastatic cancer, sever burn, end stage organ failure, severe neuro condition)  SOFA Score Task Force for Mass Critical Care Exclusion Criteria (as above + > 85 years old + severe baseline cognitive impairment)  SOFA Score White et al (UCSF) Lives Saved (SOFA) + Life-Years Saved (comorbid conditions) + Life Cycle Principle

7. You have been asked to participate in the process of formulating a county- wide medical “disaster plan” for a pandemic that far exceeds available medical resources. North County is home to a well-to-do population. South County is a largely poor, minority population. There are 5 private hospitals in North County (total 50 ICU beds). South County has one public hospital (10 ICU beds), serving an equivalent population. A total of 120 ventilators will be available to the county. How should the ventilators be distributed amongst the hospitals?

8.  True emergency.  Alternatives exhausted.  Anticipate. Avoid. Plan.  Priorities and criteria reflect values.  Open public process determines rationing system.  Identify constituency.  Identify rationing criteria.  Avoid “social worth” criteria – unless “instrumental”.  Address social justice issues.  Identify and involve vulnerable groups.  Identify and address special needs.  Triage by team without direct care.  Clinician advocates for patient within constraints of plan.  Retrospective review. After Pellegrino, Beauchamp & Childress, The Bellagio Group, Jecker.

9. “There will be no additional rules. Use your good judgment in all situations.” - Nordstrum Employee Handbook

12. 1.33 year-old housewife with 3 young children and low family income. 2.27 year-old single, businessman with no children; church leader and active volunteer in community; recently named “Citizen of the Year” in his town. 3.34 year-old single mother of 2; waitress on welfare. 4.43 year-old single woman; musician, composer, and conductor of the metropolitan symphony. 5.37 year-old husband and father of 4 young children; serving 10- year sentence for robbery. You Must Choose One

13. SOFA Scoring to Predict Outcome