1. Four Hot Topics July 16, 2008 Margaret M. Gaffney, M.D. Indiana University Center for Bioethics Indiana University School of Medicine

2. Four Hot Topics Vaccine Allocation and Anti-virals Healthcare Workforce Management Triage Altered Standards of Care

3. Goals of this phase of project Review and update the technical advisory documents (TAD) of each – Expert Panels Apply ethical points to consider Assess feasibility of recommendations – case studies Record and transmit concerns to the ISDH Recommendations are to the ISDH, and concern (primarily) healthcare delivery

4. Ethical Points to Consider Consistency with mission of ISDH and other health care organizations Transparency Public accountability Responsiveness Proportionally Reciprocity Uniformity of implementation

5. Expert Panel Members Healthcare and legal professionals Business and community leaders Public safety and service leaders Teachers, students and other community members Media

6. Recommendations: Vaccines and Anti-Virals Adopt a rank-order prioritization scheme (U.S. Department of HHS, CDHS, or merge) Adopt anti-viral allocation strategy emphasizing treatment rather than prophylaxis Educate all stakeholders about criteria for allocation and prioritization

7. Expert Panel’s Responses Some recommended a “triage scoring tool” for anti- viral distribution Great need to really educate all stakeholders on ranking and prioritization General anxiety about securing supplies At least one expert disagreed with emphasis on treatment

8. Ethical points: Vaccines and Anti- Virals Transparency – of prioritization plan Public accountability – in policy making and review Responsiveness – to public and professional input Reciprocity – for those at increased risk Uniformity of implementation – state wide

9. Recommendations: Healthcare Workforce Management Identify and designate “critically necessary” personnel, clinical and non-clinical Expect healthcare facilities to have adequate equipment and supplies for critical personnel High expectations, low consequences Develop fair policies of reimbursement, incentives and sanctions

10. Expert Panel’s Responses Clear and explicit communication is vital to all employees and professionals Identify who will educate and communicate with providers; when, how, and where Possibly link professional licensure to pandemic influenza training Need uniform incentives for employees to come to work, and fair reimbursement – Special problems if employees “float” – Convene a group to address issue – Statewide or institution – specific guidelines

11. Ethical points: Healthcare Workforce Missions of healthcare professionals and ISDH Transparency - regarding protocol decisions Public accountability – HC workers inform policies, more likely to adhere to them Responsiveness - bi-directional communications Proportionality – critical personnel balance risk and professional duties

12. As sicknesse is the greatest misery, So the greatest misery of sicknesse is solitude. Even the physician dares scarse come. John Donne

13. Recommendations: Triage Adopt a protocol that employs strictly physiologic criteria and rejects age and social role (SOFA) Encourage acute care facilities to use same criteria for admission and treatment Advise acute care facilities to develop procedures to conduct daily retrospective review of all triage and amend protocols if necessary (in real time)

14. Expert Panel’s Responses Special physiologic criteria needed for pediatric patients Strongly urged that age be considered in triage (cited tradition and HC worker resistance) Urged the development of “multi level” triage criteria to use as a “tiebreaker” Urged institutional as well as statewide review and appeal

15. Ethical points: Triage Transparency – public education critical Accountability – objective criteria for triage Responsiveness – appeals process and review Proportionality –increasingly severe measures as pandemic worsens Reciprocity – denial of aggressive therapy, provision of other care Uniform implementation – objective criteria on physiologic data

16. Recommendations: Altered Standards Of Care Develop a protocol for implementing altered standards at some specific point and include legal protections Select potential alternate sites for care – fairly Develop database of healthcare workers, including potential healthcare workers Encourage development of programs to educate healthcare workers on pandemic influenza and their related duties Help develop minimal standards for modifying documentation

17. Expert Panel’s Responses Reality of legal liabilities and protections (addressed separately in next session) Need altered documentation standards for daily patient review as well as admissions, discharge or disposition of patients

18. Ethical points: Altered Standards Transparency – public and healthcare workers need extensive information on all aspects of altered care (burial rituals, funerals, etc.) Responsiveness – treating alternate care sites as partners, with respect Proportionality – alternate sites, care procedures, staffing and documentation are used only if/when necessary Reciprocity – caring for healthcare workers and providing insurance or compensation to selected alternate care sites

19. Conclusions Broad input, vigorous debate Many points of consensus Several points of deep division Critical unknowns: virus, efficacy of anti-virals, lag time until effective vaccine, public and professional response to pandemic Reassurance and gratitude

20. The dogmas of the quiet past are inadequate to the stormy present. The occasion is piled high with difficulty and we must rise to the occasion. As our case is new, so must we think anew, and act anew. Abraham Lincoln