Case Discussions for Resource Allocation

by Michael Erdek, MD, MA

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    00:01 Now that we've discussed the topic of resource allocation, let's move on to some case studies to help bring this to light.

    00:07 Case study number one, you are caring for a 28-year-old male who is admitted with bacterial endocarditis and needs replacement of an already existing prosthetic heart valve.

    00:17 After his first replacement, he continued to abuse intravenous drugs.

    00:21 The medical team feels it would be futile and a waste of medical resources to replace his heart valve again.

    00:27 Do you feel that this team's judgment of futility is appropriate in this case? What are the issues under consideration in this difficult case? The first is the one we discussed earlier of utilitarianism versus deontology.

    00:39 Some in fact might argue that the patient's history of drug abuse excludes him from consideration for another heart valve which is a scarce resource.

    00:47 Therefore, the "most useful" or utilitarian decision will be to allocate this precious resource to a more deserving recipient.

    00:56 Others would argue however that our fiduciary duty, our duty to do good, is for each individual.

    01:02 This is done without any regard for passing moral judgment on any individual's character.

    01:08 The other issue under consideration here is the one of likelihood that we treated earlier.

    01:12 How is likelihood applicable in this case? Well, it would seem from the patient's past history that there is a likelihood of relapse into further drug use and a similar outcome that we saw previously and this would be higher than that for someone without this particular history.

    01:28 Although this is true, this is not an absolute truth and this is not a guarantee.

    01:34 Likelihood of relapse or failure can be influenced by several things.

    01:39 Number one, we may institute pre-surgical counseling and addiction treatment to help this patient.

    01:45 Secondly, we may have a support or accountability system in place which is designed to decrease the use of relapse and procedural failure.

    01:56 So, how do we tie this together in this case? Well, it's plausible that this patient will in fact require additional counseling and support services to improve his outcome.

    02:06 However, replacing a heart valve is not as the word was used by the team, futile in this case.

    02:12 There is the chance that there may be success here.

    02:14 It may in fact, however, be possible that the medical team is using bias to judge what they might consider a wasted versus a properly used medical resource.

    02:24 Here, it's very important that we have thoughtful discussion and this may provide an opportunity which is very important for the team to voice their concerns. They need to be heard.

    02:33 However, we need to work through this in a treatment plan that will provide maximal support for this patient's recovery given his risk factors. Let's take a look at a second case study.

    02:44 During the COVID pandemic, one of the feared anticipated situations was the allocation of mechanical ventilators if the need for ventilators would exceed the number that were available.

    02:55 The following case will illustrate some of the considerations necessary one must choose between patients who are demonstrating need for an existing scarce resource.

    03:06 In this case, you are the attending ICU physician during a pandemic and you have one ventilator to allocate.

    03:14 The emergency department calls you and they have three patients, each of which is in need of a ventilator bed for COVID respiratory failure.

    03:23 The patients are as follows, a 76-year-old man with a history of COPD who is requiring home oxygen.

    03:30 The second patient is a 34-year-old man who has dialysis-dependent renal failure as well as alcoholic liver cirrhosis.

    03:39 And then, finally, we have a 26-year-old woman with a history of myasthenia gravis.

    03:44 Which patient should get this very scarce ventilator? This is a difficult decision.

    03:48 Let's look at the issues under consideration for each of these three patients.

    03:52 With regard to the first patient, the 76-year-old man with a history of chronic obstructive pulmonary disease who is requiring home oxygen therapy.

    04:00 Well, the patient's COPD suggests that he may have difficulty weaning from this ventilator should you choose to allocate it to him.

    04:08 His age also suggests that his life expectancy should he survive all of this would be less than that of the other patient's in need.

    04:16 So, but we don't discriminate specifically on the case of age, we do need to consider this as part of his comorbidities in this case. Let's look at the second patient.

    04:26 This is the 34-year-old man with a history of dialysis dependent renal failure and alcoholic cirrhosis.

    04:32 Well, this patient possess two significant comorbidities which negatively impact his overall survival rate.

    04:39 Furthermore, there is the factor that his liver disease was at least partially self-imposed and this raises the issue of value judgements entering into the discussion, much like our first case.

    04:51 The third patient is our 26-year-old woman with a history of myasthenia gravis.

    04:56 Her myasthenia and respiratory muscle weakness clearly represent an impediment to eventual ventilator weaning.

    05:03 This must be taken into consideration.

    05:05 However, we also know that she could be treated with drugs to help alleviate this symptomatology and perhaps, increase her likelihood of weaning from the ventilator should she receive it.

    05:16 In addition, her absence of other comorbidities portends more favorably for her survival.

    05:22 So, in a difficult case like this where you must make a choice, choosing the third patient might be considered a defensible choice under these circumstances.

    05:31 If we were to summarize these two cases, we would say in the first case, we had one existing patient who had some sort of what would be considered a moral or ethical impediment to getting a scarce resource.

    05:41 We worked through how we have to overcome biases to overcome questions of futility that may not in fact really exist.

    05:49 The second case was a more challenging case where we had one existing resource and we had to look at three patients and make a very difficult decision of which patient would obtain that resource.

    06:00 These cases are important because they put these philosophical concepts into practice in our clinical work of ethics and medicine.

    About the Lecture

    The lecture Case Discussions for Resource Allocation by Michael Erdek, MD, MA is from the course Resource Allocation.

    Included Quiz Questions

    1. Cost
    2. Length of the form
    3. Availability of printers in the clinic work area
    4. Number of people who will be harmed
    5. Physician bias
    1. Number of people who will benefit
    2. Medication use
    3. Possibility of overdose
    4. Timeliness of assessment
    5. Timing of intervention
    1. Likelihood of benefit
    2. School schedule
    3. Risk of side effects
    4. Number of people who will be harmed
    5. Need for nursing education

    Author of lecture Case Discussions for Resource Allocation

     Michael Erdek, MD, MA

    Michael Erdek, MD, MA

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