H1N1 Crisis Could Swamp Intensive Care Units

Allocating Resources Is A Source of Controversy

Part of the Institute of Medicine's potentially controversial guidelines recommends careful allocation of ventilators, which can be critical for those with swine flu but are limited in number and require skilled staff to operate. Hospitals may need to make those with acute conditions a priority over those with chronic conditions, such as cancer, when it comes to who gets a ventilator.

"It's loony, immoral madness not to plan for that kind of emergency," Caplan said. "But it's one thing to have a plan and another thing to have doctors comply."

Caplan said the conflict lies in a health care provider's ethical obligation to not abandon a patient he or she cares for. And if doctors won't reallocate the resources at their disposal, it can be difficult for a third party to force them.

In a declared emergency, it is often the responsibility of a hospital administrator -- who may or may not be a medical doctor -- to set reallocation protocols in motion.

Ethical Concerns Remain the Same

Still, experts bristle at the thought that groups or individuals who are stewards of resources could be thought of as "death panels."

"The group providing the recommendations is not deciding who lives and dies," said Dr. David Cronin, director of liver transplantation at Froedtert Memorial Lutheran Hospital in Milwaukee. "They are setting a decision tree and allocation system to provide the scarce resources in as just and fair a way as possible. It is the disease that is responsible for the deaths ... I would consider these 'life panels.'"

While the IOM's report does not endorse a particular way to allocate ventilators, it does favor evidence-based triage over first-come, first-serve systems.

"During a catastrophic disaster with insufficient medical and health resources to meet patient needs, we shift our goal for maximizing individual outcomes to helping the most people we can in the entire population," said Dr. Kristi Koenig, director of Public Health Preparedness at the University of California at Irvine School of Medicine. "Therefore, if one person is in cardiac arrest and has almost no chance of survival despite aggressive care and 10 other people need a simple intervention such an unblocking their airway so they can breathe, we would save 10 people and provide only palliative [comfort] care to the person who has almost no chance of survival."

Consistency and Transparency Is Key

The report emphasized that hospital and state officials should strive to keep crisis standards as consistent as possible and as transparent as possible to help allay confusion in an emergency.

"An allocation system has to be transparent to be fair," said Robert Field, professor of law and health management and policy at the Drexel University School of Public Health. "Otherwise, lives could be saved, and lost, based on favoritism. We shouldn't base life and death decisions on rolling the dice as to where the closest ventilator is located."

Doctors and Patients Have Legal Concerns

The report also addressed potential legal concerns of health care professionals who provide care under duress, which Powell said was an emerging and controversial area of law.

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