Available now online:

A Model Hospital Policy for Allocating Scarce Critical Care Resources

To assist hospitals and health systems to implement a fair and transparent approach to allocating scarce critical care resources during the COVID-19 pandemic, we have created a model hospital policy that hospitals can download and adapt for their needs. Click here for a PDF version and here for an editable MS Word version.

In March 2020, in response to the intensifying COVID-19 pandemic, Dr. Douglas White consolidated a decade-long research and community engagement effort into a model hospital policy that is designed to be practical and clear for clinicians. Dr. White and Dr. Halpern (from the University of Pennsylvania) are undertaking extensive efforts to disseminate the policy nationally and internationally.

What are the important features of the model hospital policy?

1. A major strength of the allocation framework described in the policy is that it does not exclude large groups of community members and patients from access to critical care, which many other allocation strategies do.

2. It allows priority to go to those patients most likely to benefit.

3. The framework is grounded in widely-endorsed ethical principles and has been vetted with ethicists and community members.

4. The model policy was intentionally designed to be feasible to deploy in the chaotic and time-pressured circumstances of a pandemic or disaster.

How did we develop the model policy?

The model hospital policy arose out a decade-long effort involving ethicists, diverse community members' and patients’ groups, and disaster medicine experts. This process began in 2009 when Dr. White and colleagues published the original allocation framework in the Annals of Internal Medicine.

Thereafter followed a three-year project of engaging diverse community members and patients regarding their views on how to allocate scarce resources in a pandemic. This project was led by Lee Daugherty-Biddison and Eric Toner at the UPMC Center for Health Security (now called the John Hopkins Center for Health Security). The community engagement efforts yielded broad endorsement of the general features of the allocation framework, as well as important suggestions for modifications (published in Annals of the American Thoracic Society and CHEST), which where were incorporated into subsequent revisions.

Media interview requests and recent news:

For news media interviews or other media inquiries, please contact Arvind Suresh at suresha2 [at] upmc.edu or 412-509-8207.

On March 23, 2020, the allocation framework summarized in the model policy was endorsed by the commonwealth of Pennsylvania as the recommended allocation framework for all Pennsylvania hospitals.

On March 23, 2020, two articles were published in NEJM that support the key principles in the allocation framework.

As of March 24, 2020, this model policy has been adopted or is being considered for adoption by several hundred hospitals across the United States.

On March 27, 2020, Doug White published a JAMA Viewpoint “A Framework for Rationing Ventilators and Critical Care Beds During the COVID-19 Pandemic.” Later the same day, he participated in a JAMA Live Q&A Podcast “COVID-19: Rationing ICU Care.”

On April 1, 2020, JAMA published a Viewpoint, “Potential Legal Liability for Withdrawing or Withholding Ventilators During COVID-19,” authored by Doug White, MD and Harvard Law School colleagues, I. Glenn Cohen, JD and Andrew Crespo, JD.

The New York Times published an op-ed “Protect the Doctors & Nurses Who Are Protecting Us” to coincide with the JAMA Viewpoint on April 1.

On April 6, 2020, the state of Colorado released allocation guidelines for all hospitals in Colorado, which incorporate the key components of the Pitt model policy.

On April 7, 2020, the Commonwealth of Massachusetts released their triage guidelines, which incorporate the key components of the Pitt model policy.

On April 7, 2020, the state of Oklahoma released their state triage guidelines, which incorporate the key components of the Pitt model policy.

On April 8, 2020, the American Society of Clinical Oncology (ASCO) recommended that the approach outlined in the Pitt model hospital policy be used to make difficult decisions about allocation of resources. The full recommendations were published in the Journal of Clinical Oncology.

On April 11, 2020, the state of New Jersey released allocation guidelines for all hospitals in the state, which are based on the Pitt model policy.

On April 30, 2020, Mexican officials formally approved triage guidelines for all hospitals in the country that are grounded in the Pitt model policy.

About Dr. Douglas White, MD, MAS

Dr. White is the UPMC Endowed Chair for Ethics in Critical Care Medicine and professor of Critical Care Medicine, Medicine, and Clinical and Translational Science in the Department of Critical Care Medicine at the University of Pittsburgh. Professor White is director of the CRISMA Program on Ethics and Decision Making in Critical Illness. He and his colleagues conduct scholarly work to understand and improve how medical decision are made for critically ill patients, many of whom are unable to made decisions for themselves.

Further information: Dr. White and Dr. Halpern encourage the leaders of all US health systems to download the model hospital policy to aid their planning for allocating scarce resources across their hospital or health system. They are available for consultation on the policy by sending an email to douglas.white [at] pitt.edu or shalpern [at] upenn.edu.

References

Cohen IG, Crespo AM, White DB. Potential Legal Liability for Withdrawing or Withholding Ventilators During COVID-19: Assessing the Risks and Identifying Needed Reforms. JAMA. 2020 Apr 1.

White DB, Lo B. A Framework for Rationing Ventilators and Critical Care Beds During the COVID-19 Pandemic. JAMA. 2020 Mar 27.

White DB, Katz MH, Luce JM, Lo B. Who should receive life support during a public health emergency? Using ethical principles to improve allocation decisions. Ann Intern Med 2009;150:132-8.

Daugherty Biddison EL, Gwon H, Schoch-Spana M, Cavalier R, White DB, Dawson T, Terry PB, London AJ, Regenberg A, Faden R, Toner ES. The community speaks: understanding ethical values in allocation of scarce lifesaving resources during disasters. Annals of the American Thoracic Society 2014;11:777-83.

Daugherty Biddison EL, Gwon HS, Schoch-Spana M, Regenberg AC, Juliano C, Faden RR, Toner ES. Scarce Resource Allocation During Disasters: A Mixed-Method Community Engagement Study. Chest 2018;153:187-95.

Daugherty Biddison EL, Faden R, Gwon HS, Mareiniss, DP, Regenberg, AC, Schoch-Spana, M, Schwartz, J, Toner, ES. Too Many Patients...A Framework to Guide Statewide Allocation of Scarce Mechanical Ventilation During Disasters. Chest 2019;155:848-54.