Developing a Thai national critical care allocation guideline during the COVID-19 pandemic: a rapid review and stakeholder consultation

Background At the height of the COVID-19 pandemic, Thailand had almost depleted its critical care resources, particularly intensive care unit (ICU) beds and ventilators. This prompted the necessity to develop a national guideline for resource allocation. This paper describes the development process of a national guideline for critical resource allocation in Thailand during the COVID-19 pandemic. Methods The guideline development process consisted of three steps: (1) rapid review of existing rationing guidelines and literature; (2) interviews of Thai clinicians experienced in caring for COVID-19 cases; and (3) multi-stakeholder consultations. At steps 1 and 2, data was synthesized and categorized using a thematic and content analysis approach, and this guided the formulation of the draft guideline. Within step 3, the draft Thai critical care allocation guideline was debated and finalized before entering the policy-decision stage. Results Three-order prioritization criteria consisting of (1) clinical prognosis using four tools (Charlson Comorbidity Index, Sequential Organ Failure Assessment, frailty assessment and cognitive impairment assessment), (2) number of life-years saved and (3) social usefulness were proposed by the research team based on literature reviews and interviews. At consultations, stakeholders rejected using life-years as a criterion due to potential age and gender discrimination, as well as social utility due to a concern it would foster public distrust, as this judgement can be arbitrary. It was agreed that the attending physician is required to be the decision-maker in the Thai medico-legal context, while a patient review committee would play an advisory role. Allocation decisions are to be documented for transparency, and no appealing mechanism is to be applied. This guideline will be triggered only when demand exceeds supply after the utmost efforts to mobilize surge capacity. Once implemented, it is applicable to all patients, COVID-19 and non-COVID-19, requiring critical care resources prior to ICU admission and during ICU stay. Conclusions The guideline development process for the allocation of critical care resources in the context of the COVID-19 outbreak in Thailand was informed by scientific evidence, medico-legal context, existing norms and societal values to reduce risk of public distrust given the sensitive nature of the issue and ethical dilemmas of the guiding principle, though it was conducted at record speed. Our lessons can provide an insight for the development of similar prioritization guidelines, especially in other low- and middle-income countries.

Developing a Thai national critical-care allocation guideline during the COVID-19 pandemic: a rapid review and stakeholders’ consultation

Background: At the height of the COVID-19 pandemic, Thailand had almost depleted its critical care resources, particularly ICU beds and ventilators. This prompted the necessity to develop a national guideline for resource allocation. This paper describes the development process of a national guideline for critical resource allocation in Thailand during the COVID-19 pandemic. Methods: The guideline development process consisted of three steps (1) rapid review of existing rationing guidelines and literature; (2) interviews of Thai clinicians experienced in caring for COVID-19 cases; and (3) multi-stakeholder consultations. At steps 1 and 2, data was synthesized and categorized using a thematic and content analysis approach and this guided the formulation of the draft guideline. Within Step 3, the draft Thai critical care allocation guideline was debated and finalized before entering the policy-decision stage. Results: Three-order prioritization criteria consisting of (1) clinical prognosis using four tools (Charlson Comorbidity Index, Sequential Organ Failure Assessment, Frailty Assessment, and Cognitive Impairment Assessment); (2) number of life years saved; and (3) social usefulness, were proposed by the research team based on literature reviews and interviews. At consultations, stakeholders rejected using life years as a criterion due to potential age and gender discrimination, as well as social utility due to a concern it would foster public distrust as this judgment can be arbitrary. It was agreed that attending physician is required to be the decision maker in the Thai medico-legal context while a patient review committee would play an advisory role. Allocation decisions are to be documented for transparency and no appealing mechanism is to be applied.This guideline will be triggered only when demand exceeds supply after the utmost efforts to mobilize surge capacity. Once implemented, it is applicable to all patients, COVID-19 and non-COVID-19, requiring critical care resources prior to ICU admission and during ICU stay.Conclusions: The guideline development process for the allocation of critical care resources in the context of the COVID-19 outbreak in Thailand was informed by scientific evidence, medico-legal context, existing norms and societal values to reduce risk of public distrust given the sensitive nature of the issue and ethical dilemmas of the guiding principle though it was conducted at recorded speed. Our lessons can provide an insight for the development of similar prioritization guidelines, especially in other LMICs.

Caring or Not Caring for Coworkers? An Empirical Exploration of the Dilemma of Care Allocation in the Workplace

ABSTRACTOrganization and management researchers praise the value of care in the workplace. However, they overlook the conflict between caring for work and for coworkers, which resonates with the dilemma of care allocation highlighted by ethicists of care. Through an in-depth qualitative study of two organizations, we examine how this dilemma is confronted in everyday organizational life. We draw on the concept of boundary work to explain how employees negotiate the boundary of their caring responsibilities in ways that grants or denies care to coworkers. We argue that the possibility of an ethics of care for coworkers requires boundary work that suspends the separation of personal and professional selves and constitutes the worker as a whole person. We contribute to research on care in organizations by showing how care for coworkers may be enabled or undermined by maintaining or suppressing the care allocation dilemma.

Economics, Ethics, and Health Insurance

Evaluating health care institutions and policies should depend on understanding the economic complexities of health care provision and on our values of compassion, choice, efficiency, fairness, and solidarity. These values may conflict, so applying them is difficult. We must also understand the problems with health care allocation, including employing markets. Regulations are needed first because of asymmetric information: doctors know more about treatments than patients and can exploit them. Second, health insurance is a better bargain for those who expect to be sick. Consequently, health insurance policies attract purchasers more likely to make claims. This adverse selection makes claims and premiums skyrocket, healthy people drop out, and private health insurance markets collapse, unless everyone is forced to buy insurance or insurers deny insurance to those with pre-existing conditions. Third is moral hazard: if insurance pays for a health problem, there is less incentive to avoid it or to economize on treating it. Health care policies must be economically sound and morally defensible.

Priority Setting in Health Care with Disease and Treatment Risks

This paper deals with the issue of priority setting in health care under uncertainties about the severity of the illness and the effectiveness of medical treatment. We examine the effect of a disease uncertainty (a treatment uncertainty) on the allocation of health care resources in the presence of a treatment risk (a disease risk) and identify preference conditions under which the social planner allocates more resources to higher risk population. We allow for the simultaneous presence of two risks and investigate the joint effect of two-source uncertainties on health care allocation when the two risks are either small or positively quadrant dependent. The effect of inequality aversion on health care allocation is also analyzed by introducing an equity weighting function. Our work extends the previous model of health care priority to two-risk framework and provides new insights into the problem of health care decision making under uncertainty.

The Norwegian National Council for Priority Setting in Health Care: decisions and justifications

Different countries have adopted different strategies for tackling the challenge of allocating scarce health care resources fairly. Norway is one of the countries that has pioneered the effort to resolve priority setting by using a core set of priority-setting criteria. While the criteria themselves have been subject to extensive debate and numerous revisions, the question of how the criteria have been applied in practice has received less attention. In this paper, we examine how the criteria feature in the decisions and justifications of the Norwegian National Council for Priority Setting in Health Care, which has played an active role in deliberating about health care provision and coverage in Norway. We conducted a comprehensive document analysis, looking at the Council’s decisions about health care allocation as well as the reasons they had provided to justify their decisions. We found that although the Council often made use of the official priority-setting criteria, they did so in an unsystematic and inconsistent manner.