An influenza pandemic has a profound impact on the health care delivery system. Shortages of life-sustaining medical resources, including hospital beds, trained health care providers, intensive care unit resources, medical supplies, equipment, and medications can be anticipated.

Furthermore, rationing of scarce resources and alterations in the standards of health care delivery are widely acknowledged to be necessary components of the response to large-scale health emergencies. And it is likely that many of the medical services normally provided in a community will need to be either severely curtailed or temporarily suspended during a severe pandemic.

A Model for Community Priority Setting

A project conducted by Public Health - Seattle & King County (PHSKC) with a grant from the Centers for Disease Control and Prevention provides a model for engaging the public to better understand their values and priorities regarding the delivery of medical services and how those services will be allocated during a severe pandemic influenza. Public engagement in decision making of this kind helps ensure the incorporation of the community’s values and priorities into the policies, plans, and guidelines that are developed by the health services community.

Objectives

Among the stated objectives were:

• Ensure involvement of diverse communities, including vulnerable populations, in the public engagement process by partnering with community-based organizations
• Enable community participants to express their views, needs, and concerns regarding the prioritization of medical services
• Identify the ethical principles and values informing health and medical care prioritization and allocation decisions
• Increase awareness among public health and health care system decision-makers of community needs, preferences, and opinions.
• Identify strategies for messaging and public information that address community concerns about availability of and access to medical services during a pandemic.

Process

The engagement process included input from 153 participants in four public engagement forums drawn from diverse populations in the community and vested stakeholders, such as health care providers, emergency workers, and community advocates. The meetings were designed with an interactive format to allow individuals to think through the difficult decisions that need to be made by medical professionals during a disaster. They discussed the priorities for the rationing of scarce resources among peers and provided recommendations and insight on how those decisions should be made.

The format was a combination of individual survey, small group discussion, and large plenary discussion — allowing for participants to inform each other’s opinions over the course of each meeting.

Questions and Assumptions

The questions posed to the participants were as follows:

• Should the standard of “first come, first served” be used during a disaster?
• Should those most ill receive priority for treatment?
• Should care be prioritized based on age?
• Should those most likely to survive their illness receive priority for treatment?
• Should one’s role in society be a factor in receiving scarce, live-sustaining treatment?
• Should all doctors and hospitals be expected to follow the same rules for allocation of scarce, life-sustaining treatment?
• What should be the goals in allocating scarce, life-sustaining resources?

The following assumptions were set forth to inform the prioritization process:

• The exercise deals only with life-saving care
• There are not enough of the life-saving medical resources to treat everyone who needs them
• People who do not get life-saving care will most likely die
• The majority of the population will survive the flu pandemic.

Results at a Glance

Although other communities may arrive at different conclusions based on the availability of local health care, their collective values, and other factors, these results from Seattle/King County are of interest. Overall, there was considerable agreement among public participants and key stakeholders regarding the goals of medical service prioritization during disasters and how it should be carried out.

Should we change how medical treatment decisions are made during an influenza pandemic? Yes. Disasters will require implementation of altered decision-making processes and protocols to determine allocation of scarce medical resources.

What should the goal(s) be when decisions are made about medical treatment during an influenza pandemic?

• Treat as many people as possible, saving the greatest number of people even if it means that the standard of care must be compromised.
• Create a prioritization system that is fair and accessible to all people.

How should decisions be made about rationing limited, life-saving resources?

• Saving the greatest number of people should drive decisions.
• Survivability is a priority treatment consideration to help ensure that scarce resources are used most efficiently for those who will benefit most.
• Health care providers and first responders are top priorities because they can help respond to the immediate crisis and help make the best use of the resources available to treat the greatest number possible.
• To a lesser degree, children and pregnant women should receive some priority when all other factors are equal.
• Strategies based on “first come, first served,” randomization, or ability to pay were widely rejected.
• The elderly were not generally perceived as a priority group, although they were recognized by some as offering intrinsic value to society and worth prioritizing.
• Guidelines for rationing should ensure that discrimination cannot enter into decisions.

Withdrawal of life-saving care

• Participants generally struggled with idea of withdrawing life-saving care — even if it meant that other lives would be lost.
• Most people felt that the choice was best made by the patient or patient’s family with input from a doctor or health care provider.

Ensuring Public Trust

To gain the public trust and acceptance of altered standards of care, it is important to highlight the public’s values — especially equity — when introducing and discussing them. The public must perceive that any guidelines ensure equal access, so protocols to enforce equity and deter discrimination should be made explicit, and should be emphasized in communications. The way in which these decisions are made must be transparent so that people can understand the rationale for prioritizing some groups over others, particularly in terms that explain how it may benefit the overall response to disaster and maximize resources.

Finally, to ensure public trust regarding such difficult decisions, messaging about medical service prioritization guidelines must be consistent. Health care providers will play a particularly critical role as sources of information about health care treatment in disasters, given the high level of trust that the public places in them.