ASCO releases guidance on resource allocation during COVID-19 pandemic
Oncologists have a responsibility to help their patients make the best decisions possible in terms of cancer treatment.
However, as the COVID-19 pandemic strains resources and capacity at health care facilities, there is one decision an oncologist should not have to make.
“I absolutely could not be looking at the patients in front of me, trying to take care of them, and also thinking, ‘OK, I have to decide which of these six patients get these five ventilators,’” Jonathan M. Marron, MD, MPH, pediatric hematologist-oncologist at Dana-Farber Cancer Institute and Boston Children’s Hospital, instructor in pediatrics at Harvard Medical School and chair-elect of ASCO’s Ethics Committee, said in an interview with Healio. “It would be impossible to expect any one person to be able to consider these two frameworks simultaneously without it affecting the outcome. Whether consciously or subconsciously, there are going to be biases and conflicts of commitment there.”
As cases of the novel coronavirus continue to mount in the United States, professional societies such as ASCO anticipate demand for medical resources ultimately will exceed supply. This could require rationing of ventilators, hospital beds and medication.
To that end, ASCO has drafted recommendations for the allocation of scarce resources for patients with cancer should it become necessary.
Marron spoke with Healio about the rationale for the recommendations, the oncologist’s responsibility to provide information about patients to other clinicians, and the need for fair decision-making that takes into account the dignity of all patients.
Question: What prompted ASCO to develop these recommendations?
Answer: When things were starting to ramp up with COVID-19, the concern was that our critical care resources — namely, ICU beds and ventilators — would not be sufficient for the demand. It was becoming a very real possibility that medical institutions would have to make very difficult — if not impossible — decisions about who would receive these resources and who would not. We talk about that academically quite often, in ethics. Luckily, we are rarely faced with a large-scale situation like this. So, institutions and states had to hurriedly put together allocation schematics. This is a very different way of thinking about health care than we are used to, as individual clinicians. Rather than focusing on maximizing health care outcomes for the patient in front of you, the larger goal becomes to maximize health care outcomes for everyone, for society. Ultimately, one of the questions becomes: “What happens to people who have underlying medical illness or disability?” These patients might not be expected to live as long as other patients. One of our big concerns was that oncologists would be stressed by the idea of having to make these horrible decisions and make them quickly. We wanted to provide reassurance to the general oncology community that we have a foundation in place to navigate these questions.
Q: How would a cancer diagnosis factor into allocation decision-making?
A: It should be part of the decision-making calculus in a similar way as cardiovascular disease, high blood pressure, diabetes or any number of other medical problems. However, it should not immediately exclude someone from being considered for these limited resources. Ultimately, these decisions will be made based on the best data we have. It should be evidence-based, both at the population level and the individual patient level. That means not just considering that they have cancer, but also the kind of cancer they have, their specific prognosis and whether they can be expected to benefit less, more or equally from these resources than someone who does not have cancer or has another medical problem.
Q: How did ASCO arrive at the recommendation to separate allocation decision-making from bedside decision-making?
A: This is a standard principle of many decision-making frameworks, both when thinking about scarce resources and more generally. It is similar to the way we typically recommend that doctors not take care of family members. It’s impossible to simultaneously play the role of doctor and the role of family member without those roles inevitably overlapping and the lines between them blurring. You shouldn’t be faced with these dueling allegiances or competing interests, whether you recognize them as such or not. It’s unnecessarily burdensome on the person making those decisions.
Q: What should the role of the oncologist be in this allocation process?
A: A big part of the oncologist’s role is in providing patient-level information to the person making allocation decisions. Information might include the patient’s age, comorbidities, specific cancer diagnosis, what treatment they have been getting, how they responded to it, their likelihood of survival, and how sure we are about that. You could say, for example, that this person is likely to survive for 6 months, but if you had to put a confidence interval around that, it could be 2 months or it could be 10 years. That’s a very different situation than if you say they’re likely to live 6 months, with a confidence interval of 5 to 7 months. The level of certainty about this becomes incredibly important. All of that information could be helpful to the individuals who have to make these difficult allocation decisions.
Q: What other factors might be considered in allocation decision-making?
A: Patient-level values and goals of care are incredibly important. That’s one thing we tried to highlight in the guidelines — talking to patients and families about what matters to them. It’s important to know — if push came to shove and a patient needed to be put on a ventilator or be supported by medical technology — whether they would want that. Having these conversations about advanced care planning and goals of care is important to oncology care and medical care in general, and it may be even more important in the setting of resource scarcity. If there is one ventilator and two patients, and you know ahead of time that one of those patients would never want to be on a ventilator, your decision is more straightforward than it would have been otherwise. Knowing a patient’s values and preferences is more important than ever under these challenging circumstances.
Q: Are there any other aspects of the recommendations that you would like to highlight?
A: An important distinction that I think is easy to misinterpret is what we mean when we talk about fairness in a situation like this. It doesn’t necessarily mean we treat everyone the same. Rather, it means that patients who are most like each other will be treated in the same way. If, for example, I come in with coronavirus and need to be admitted to the ICU but I also have progressive, widely metastatic cancer and I am certain to die in the next few months, and another patient comes in with coronavirus but is perfectly healthy otherwise and expected to live another 80 years if they get that ICU bed and recover from coronavirus, most people would argue that it would not be the best use of resources to give the one remaining bed in the ICU to me. I shouldn’t be treated the same as this other patient because that isn’t the best use of that final available ICU bed. This is controversial, though. Some people would argue that, in considering these medical comorbidities, we are going too far in trying to predict these things. It is difficult to predict, but one of the important pieces is doing the best we can to steward these resources the best way we know how. – by Jennifer Byrne
Reference:
Marron JM, et al. J Clin Oncol. 2020;doi:10.1200/JCO.20.00960.
For more information:
Jonathan Marron, MD, MPH, can be reached at Dana-Farber Cancer Institute, 450 Brookline Ave., Boston, MA 02115; email: jonathan_marron@dfci.harvard.edu. Follow him on Twitter @JonMarronMD.
Disclosure: Marron reports no relevant financial disclosures.
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