Too Many Patients, Too Few Resources

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Imagine, it is February 2016: At the beginning of the month a new strain of influenza (flu) appears in several U.S. states. People begin streaming into hospital emergency rooms complaining of high fever, confusion, and shortness of breath. Many patients develop severe pneumonia within three days of first becoming ill. Patients with severe pneumonia need a breathing machine called a mechanical ventilator. Without a ventilator, these patients will die.

By the last week of the month the deadly new strain of influenza is hitting Baltimore hard. All hospitals have initiated plans for making the best use of their existing ventilators and intensive care beds. Hospitals change empty operating rooms into makeshift intensive care units, and they cancel non-emergency operations that require the use of ventilators and intensive care beds. In the middle of the week, the state of Maryland reports that its entire stockpile of emergency ventilators has been given to hospitals.

Background:  In a widespread public health care emergency, there will be more people who need healthcare than there are resources available to help them. Making decisions about how to use these limited resources will be difficult. Hospital personnel and public health officials need to know how to make decisions in these difficult moments in a way that reflects the values of the communities in which those decisions will be made.

Purpose: The purpose of this research study is to engage citizens of Maryland in a dialogue about which values they feel ought to guide decisions about allocating scarce medical resources during a disaster like a pandemic flu.

Approach: 13 approximately five-hour meetings were held across the state to explore how to allocate scarce medical resources during disasters.  

Following two pilot sessions (Baltimore City, Howard County), the first phase of the project included six community meetings held with Maryland citizens.

  • January 26, 2013: Eastern Shore – 13 participants
  • February 9, 2013: Baltimore – 14 participants
  • March 9, 2013: College Park – 27 participants
  • April 6, 2013: Hagerstown – 19 participants
  • April 27, 2013: Bel Air – 38 participants
  • May 5, 2013: Pikesville – 45 participants

In the second phase, another round of sessions took place around the state of Maryland between June of 2013 and June of 2014. These involved only healthcare providers and emergency planners who work in Maryland.

  • June 17, 2013: Baltimore City “pilot” – 8 participants;
  • October 9, 2013: Hagerstown – 13 participants;
  • November 13, 2013: Olney – 12 participants;
  • February 12, 2014: Baltimore City – 8 participants;
  • March 26, 2014: Baltimore (Rosedale) – 14 participants;
  • April 30, 2014: Salisbury – 17 participants; and
  • May 14 2014: Annapolis – 11 participants.

At each meeting, participants broke into small groups with a facilitator and note taker present to help them learn about and discuss:

  • The possible ways that decisions could be made to allocate scarce medical resources during a public health disaster; and
  • The extent to which these various decision–making frameworks reflect their personal and community values.

Unlike typical public engagement processes where the public merely reacts to an issue, here participants engaged in small-groups that encourage sharing opinions after a period of informed deliberation and discussion about allocation-related issues.

Products: After two pilot sessions, six community meetings, and seven provider forums, this project has gathered a great deal of data on participant views regarding how to allocate scarce medical resources in an emergency.

We have compiled and summarized this data and we are consulting with groups of experts to use the results of our engagement project to develop recommendations that will be offered to the State of Maryland to help policymakers and healthcare providers make decisions about the allocation of scarce medical resources during a disaster in a way that is consistent with the values of the communities in which those decisions would be made.

Publications:

The community speaks: understanding ethical values in allocation of scarce lifesaving resources during disasters. Daugherty Biddison EL, Gwon H, Schoch-Spana M, Cavalier R, White DB, Dawson T, Terry PB, London AJ, Regenberg A, Faden R, Toner ES. Ann Am Thorac Soc. 2014 Jun, 11(5):777-83.

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