Rapid Review - Ethical Frameworks for allocation of scare resources in pandemics
Creators: name: O'Sullivan, Lydia
Publisher: name: Open Science Framework
Year: 2022
Subjects: subject: Medicine and Health Sciences
subject: Ethics; Medical Ethics; Pandemics; COVID-19; Resource Allocation; Decision Making.

description: Authors Dr Edelweiss Aldasoro 1 edelweissaldasoro@integratedcarefoundation.org Lydia O’Sullivan 2,3 lydia.osullivan@ucdconnect.ie Áine O’Brien 4 aineobrien2018@gmail.com Dr Clíona McGovern 2 cliona.mcgovern@ucd.ie Dr Maeve Nolan 5 maeve.nolan@nrh.ie Professor Áine Carroll 1, 2,5 aine.carroll@nrh.ie 1 International Foundation for Integrated Care 2 School of Medicine, University College Dublin 3 Health Research Board-Trials Methodology Research Network 4 School of Health Sciences, National University of Ireland, Galway 5 National Rehabilitation Hospital, Dun Laoghaire Corresponding author: Dr Edelweiss Aldasoro International Foundation for Integrated Care Annexe Offices, Linton Road, Oxford, OX2 6UD, England Title Protocol for a Rapid Systematic Review: How can an ethical decision-making tool compliment and assist healthcare decisions in a pandemic? Abstract The COVID-19 pandemic has placed unprecedented pressures on healthcare systems throughout the world. There is a move from patient centred provision to practices primarily guided by considerations of public health well-being. Asked to respond to this crisis in an equitable, reasonable and proportionate way, the adherence of health services personnel to a ‘duty of care’ continues to alter in response to the evolving impact of this pandemic. Unique and challenging ethical issues have been raised as a direct result of COVID-19. These include prioritising access to health care resources, conflicts for health care workers weighing up work obligations and family responsibilities and the implementation of measures to reduce the spread of the disease, while protecting the rights of the individual to free movement. The objective of this rapid review is to identify and assess the available international literature regarding ethical frameworks and decision making to inform the development of a comprehensive ethical framework in Ireland. This framework will aim to support health care professionals, administrators and managers when making decisions regarding the allocation of limited healthcare resources in emergency situations, such a pandemic. Keywords Ethics; Ethical framework; Scarce resources; Pandemic; COVID-19; Coronavirus Introduction Rationale for this Rapid Review The COVID-19 pandemic has placed unprecedented pressures on healthcare systems throughout the world 1 2. In Ireland, as in many neighbouring European countries, there is a move from patient centred provision to practices primarily guided by considerations of public health well-being. Asked to respond to this crisis in an equitable, reasonable and proportionate way, health services personnel adherence to a ‘duty of care’ continues to alter on a realisation of impact of this pandemic. Drawn from experiences in Italy and Spain, such pandemics are catastrophic on healthcare systems, outstripping resources (i.e. protective equipment), and creating a shortage of personnel and of life-saving equipment 3 4. Faced with increasing number of patients requiring acute care, ethical decisions are being made on how to allocate resources and to identify patients who have the most favourable chance of survival. Unique and challenging ethical issues have been raised as a direct result of COVID-19. These include prioritising access to health care resources, obligations of health care workers considering risk to their own health and the implementation of measures to reduce the spread of the disease, while protecting the rights of the individual to free movement. In this context front-line clinicians (including administrators/managers) are looking for ethical decision-making tools that provide key-knowledge sharing opportunities and compliment clinical decisions on patient care pathways; as speedily – but proportionately and fairly; as possible. However, it is recognised that presently no national collaborative effort is taking place to determine appropriate practices or protocols for use in Ireland. This challenging situation calls for an ethical framework and decision-making tool to guide healthcare professionals, administrators and managers when allocating scare resources, such as manpower, personal protective equipment, ventilators etc. Given the unprecedented and emerging nature of the COVID-19 pandemic, there are currently no published systematic reviews summarising the available literature on this subject. Objective of the review The objective of this rapid review is to identify and assess the available international literature regarding ethical frameworks and decision making to inform the development of a comprehensive ethical framework in Ireland. This framework will aim to support health care professionals, administrators and managers when making decisions regarding the allocation of limited healthcare resources in emergency situations, such a pandemic. PICO Problem: In a context of acute healthcare resource limitation , how should limited health resources be rationed or fairly allocated in the healthcare setting? Context includes e.g. national emergency, epidemic, pandemic. Limitations include manpower and healthcare equipment etc. Intervention(s): An ethical framework to support decision-making processes to ensure that the maximum benefit is gained from the available resources in a fair and equitable manner. Comparator(s): Not applicable for this review. Outcome(s): 1. Maximise the protection of patient’s rights to healthcare. 2. Minimise the risk of treatment withdrawal based on unethical reasoning. 3. Support for healthcare professionals, administrators and managers making difficult decisions regarding resource allocation. Methods A rapid systematic review methodology was selected given the time sensitive nature of this project. Rapid reviews have been shown to identify and evaluate the relevant evidence similar to a full systematic review. This Rapid Review protocol was compiled following consultation with the Cochrane COVID-19 Rapid Review Workflow and protocol template. The protocol was reviewed for completeness and transparency using the PRISMA-P Checklist 5. The protocol is not eligible for registration on the PROSPERO database, as the question of interest is an ethical framework, and not a clinical outcome for participants. Eligibility Criteria Articles will be included if they meet the following Inclusion/Exclusion Criteria. Inclusion Criteria: papers will be included if they contain at least two of these three concepts: • Acute Resource Limitation or similar • Rationing / Allocation / Decision-making or similar • Ethical perspective Exclusion Criteria: papers with the following concepts will be excluded if they contain one or more of these concepts: • Accident and Emergency Services • In-flight emergencies • Clinical research taking place during humanitarian emergencies • Ethics in clinical research • Communication strategies • Informed consent • Other clinical emergencies which are not outbreaks/disasters/pandemics • No abstract • Books which were not open access No limits with regard to language will be applied. All study type and article types will be considered, including exploratory qualitative studies, reflective studies, opinion pieces, philosophical pieces. Information Sources Medline, EMBASE and Google Scholar have been selected as the electronic databases. A search of references, relevant Grey Literature, including LitCovid will be also undertaken. National and International Ethical Frameworks which the authors were aware of will also be included. Due to time constraints, authors of individual papers will not be contacted to collect additional information or to request full text of papers. Search Strategy Following an initial scoping search and consultation with an experienced Health Sciences Librarian, the following search terms were agreed upon and will be used to search within the title or abstract: Search string Key words 1 ((“Coronavirus” OR “Covid19” OR “epidemic” OR “outbreak” OR “pandemic“ OR “humanitarian emergency” OR “catastrophes” OR “disaster”) 2 (“Resources” OR “Resource Allocation” OR “Rationing” OR “Shortage” OR “Personal Protective Equipment” “Ventilator” OR “Triage” OR “Withholding”) 3 (“Ethics” OR “Morality” OR “Ethical framework” OR “Health equity” OR “Decision making”). 4 1 AND 2 AND 3 5 Limit Jan 2000 to 6th April 2020 No limits with regard to language will be applied. For Medline and EMBASE, the following limits will be applied: • Humans • Time period January 2000 to 6th April 2020 Within Google Scholar, the first 200 entries will be included. Study Records Data Management and Selection Process All identified papers will be exported to Zotero and duplicates will be excluded. All remaining papers will be imported to Rayaan to undergo review. Two blinded members of the team (LOS and AOB) will independently screen Titles and Abstracts of all of the papers according to the above Inclusion and Exclusion Criteria using Rayaan. Once Title/Abstract screening is complete, a third member of the team (EA) will resolve discrepancies in the screening decisions. Due to time constraints, three members of the team (EA, LOS, AOB) will each review a portion of the full texts. Papers will be excluded if: • The full text is not available • Doesn’t contain any principles relevant to an ethical framework • The topic relates solely to triage procedures in pandemics/disasters • The topic relates to legal aspects, rather than ethical ones • They contains only a case study / case studies • They only give a brief summary of the main ethical approaches, with no details • The topic relates only to pandemic planning Data Items Data extraction will be completed using a customised data extraction form. Due to time constraints, three members of the team (EA, LOS, AOB) will each extract following data from a portion of the papers selected for analysis: • Lead author • Year of publication of paper • Ethical principles relevant to an ethical framework • Synonyms of the named ethical principle • Related ethical principles • Example(s) of a scenario where the ethical principle applies The screening and selection process will be reported in the form of the PRISMA 2009 Flowchart. Outcomes and Prioritisation The following outcomes will be sought using a qualitative review of the selected papers: • Ethical principles which apply in pandemic situation where resources are scarce • Ethical frameworks already in place for pandemic situations where resources are scarce • Examples of scenarios where these ethical principles or frameworks apply • Examples of how the identified ethical principles relate to or clash with each other No outcome (ethical principle or framework)) will be prioritised over another. Risk of bias in individual studies Due to the nature of this Rapid Review (qualitative review of ethical principles and guidelines), no formal risk of bias assessment will be conducted. Data Synthesis Following data extraction, a constant comparative approach will be employed to evaluate the data. A group consensus will then be sought regarding the appropriateness and applicability of the identified ethical principles and frameworks. Meta-bias(es) Not applicable Confidence in cumulative Evidence Not applicable Data Availability Data will be made available upon request. Reporting Guidelines Not applicable. Author Contributions EA: Data curation; Formal analysis; Investigation; Methodology; Project Administration; Writing – Original Draft Preparation LOS: Data curation; Formal analysis; Investigation; Methodology; Project Administration; Writing – Review and Editing AOB: : Data curation; Formal analysis; Investigation; Methodology; Project Administration; Writing – Review and Editing CMcG: Conceptualization; Project Administration; Methodology; Funding Acquisition; Writing – Review and Editing MN: Conceptualization; Project Administration; Methodology; Writing – Review and Editing AC: Conceptualization; Project Administration; Methodology; Funding Acquisition; Writing – Review and Editing Competing Interests The authors of this Rapid Review have no competing interests to disclose. Grant Information This Rapid Review will be supported by funding from the National Rehabilitation Hospital, Dun Laoghaire. The National Rehabilitation Hospital had no role in the development of this protocol. Acknowledgements The Rapid Review Team would like to acknowledge Mr Diarmuid Stokes, Health Sciences Librarian who provided guidance on the search strategy. The Rapid Review Team also acknowledge the Cochrane COVID-19 Rapid Review Workflow and their protocol template, both of which were used for reference and guidance when writing this protocol. References 1. Emanuel EJ, Persad G, Upshur R, et al. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. New England Journal of Medicine 2020 doi: 10.1056/NEJMsb2005114 2. Prevention CDC. Strategies for optimizing the supply of N95 respirators. Atlanta, USA, 2020. 3. Vergano M, Berolini G, A G. Clinical Ethics Recommendations for the Allocation of Intensive Care Treatments, in Exceptional, Resources-Limited Circumstances: Italian Society of Anesthesia, Analgesia, Resuscitation, and Intensive Care, 2020. 4. Mounk Y. The extraordinary decisions facing Italian doctors: The Atlantic, 2020. 5. Moher D, Shamseer L, Clarke M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic Reviews 2015;4(1):1. doi: 10.1186/2046-4053-4-1