Chest
Volume 153, Issue 1, January 2018, Pages 187-195
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Original Research: Disaster Medicine
Scarce Resource Allocation During Disasters: A Mixed-Method Community Engagement Study

https://doi.org/10.1016/j.chest.2017.08.001Get rights and content

Background

During a catastrophe, health-care providers may face difficult questions regarding who will receive limited life-saving resources. The ethical principles that should guide decision-making have been considered by expert panels but have not been well explored with the public or front-line clinicians. The objective of this study was to characterize the public’s values regarding how scarce mechanical ventilators should be allocated during an influenza pandemic, with the ultimate goal of informing a statewide scare resource allocation framework.

Methods

Adopting deliberative democracy practices, we conducted 15 half-day community engagement forums with the general public and health-related professionals. Small group discussions of six potential guiding ethical principles were led by trained facilitators. The forums consisted exclusively of either members of the general public or health-related or disaster response professionals and were convened in a variety of meeting places across the state of Maryland. Primary data sources were predeliberation and postdeliberation surveys and the notes from small group deliberations compiled by trained note takers.

Results

Three hundred twenty-four individuals participated in 15 forums. Participants indicated a preference for prioritizing short-term and long-term survival, but they indicated that these should not be the only factors driving decision-making during a crisis. Qualitative analysis identified 10 major themes that emerged. Many, but not all, themes were consistent with previously issued recommendations. The most important difference related to withholding vs withdrawing ventilator support.

Conclusions

The values expressed by the public and front-line clinicians sometimes diverge from expert guidance in important ways. Awareness of these differences should inform policy making.

Section snippets

Study Approach

The study used a constructivist theoretical outlook and a deliberative democracy methodology based on the assessment that how best to apportion limited life-saving resources in a disaster is a potentially divisive policy issue, as well as one in which technical and normative aspects are tightly interwoven.9 Democratic deliberation provides a structured process through which citizens can learn relevant facts about a public policy matter and explore their own views and those of their peers in an

Results

We convened eight lay forums, including two pilot forums, and seven health-care and disaster worker forums. Of the total 324 forum participants, demographic data were available for 311 (Table 4). Of note, when appropriate we have included the responses of the pilot meeting participants in the overall analysis of findings included here. Key forum themes gleaned from the qualitative portion of our study are summarized in the following section.

Discussion

This novel application of deliberative democratic methods in exploration of a challenging sensitive health policy issue allowed identification of key principles from which to build a functional framework that would have a high likelihood of broad acceptability. Moreover, it generated a nuanced qualitative understanding of citizens’ perspectives on key principles, demonstrating places and ways in which those perspectives vary across one diverse state. This understanding is essential to building

Conclusions

Our effort to engage the community in a discussion about key principles prior to drafting a framework for allocating scarce life-saving resources in a disaster represents an important shift. We believe that listening to the values of the community that an allocation framework intends to serve will strengthen its development. Eliciting and incorporating community input should also have the practical benefit of enhanced public “buy-in” and support for the framework, which will be especially

Acknowledgments

Author contributions: E. L. D. B. had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. E. L. D. B., H. G., M. S. S., A. R., R. F., C. J., and E. T. contributed substantially to the study design, data analysis and interpretation, and the writing of the manuscript.

Financial/nonfinancial disclosures: None declared.

Other contributions: The authors would like to acknowledge Jacquie Toner, PhD, for her efforts as

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FUNDING/SUPPORT: This study was funded by the Maryland Department of Health and Human Services through the Hospital Preparedness Program. Johns Hopkins Medicine Institutional Review Board IRB-X approved this project (protocol numbers NA_00070411 and IRB00065482).

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