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The draw of the few: the challenge of crisis guidelines for extremely scarce resources
  1. Jacob M Appel
  1. Psychiatry and Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  1. Correspondence to Dr Jacob M Appel, Psychiatry and Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA; jacobmappel{at}


The COVID-19 pandemic has focused considerable attention on crisis standards of care (CSCs). Most public CSCs at present are effective tools for allocating scarce but not uncommon resources (like ventilators and dialysis machines). However, a different set of challenges arise with regard to extremely scarce resources (ESRs), where the number of patients in need may exceed the availability of the intervention by magnitudes of hundreds or thousands. Using the allocation of extracorporeal membrane oxygenation machines as a case study, this paper argues for a different set of CSCs specifically for ESRs and explores four principles (transparency, uniformity, equity and impact) that should shape such guidelines.

  • COVID-19
  • end-of-life
  • resource allocation
  • allocation of health care resources

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  • Contributors JMA is the sole author of this paper and entirely responsible for its content.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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