Good morning, everyone, and thank you for joining us. I'm Mary Faith Marshall, a member of the Society of Critical Care Medicine Ethics Committee, and it's my absolute delight to introduce Dr. Douglas White, who will present this year's Aki Grinbeck Memorial Lecture. Dr. White is the University of Pittsburgh Endowed Chair for Ethics in Critical Care Medicine, where he's also the Director of the Program on Ethics and Decision-Making in Critical Illness, which is the first of its kind in the country. He's also Vice Chair for Faculty Development in the Department of Critical Care Medicine. Dr. White graduated summa cum laude from Dartmouth College with a degree in English. That means he has serious chops as a medical humanist. He received his medical degree from UCSF, where he was elected to the Alpha Omega Alpha Honor Society. While at UCSF, Dr. White completed a residency in internal medicine, a fellowship in pulmonary and critical care medicine, a master's degree in epidemiology and biostatistics, and a fellowship in clinical ethics. And a way cool thing about Dr. White is that while he was in medical school, he was the expedition medical officer of the 1998 American Mount Everest Expedition, mountaineering chops. Dr. White's scholarship focuses on ethical issues arising in the healthcare of critically ill patients and on developing interventions to improve surrogate decision-making for incapacitated, seriously ill patients. He's published more than 150 peer-reviewed articles and has received numerous awards for his scholarship, including the Grinvick Award for Ethics from the Society of Critical Care Medicine and the Distinguished Research Mentor Award from the University of Pittsburgh. He's an elected fellow of the Hastings Center and the American Society for Clinical Investigation. Today, Dr. White will present the role of critical care professionals in allocating scarce resources. Doug has shown extraordinary leadership during the COVID pandemic and considering the role of health disparities and social justice in the allocation of scarce resources, not only at the bedside, but also in the public health arena. Please join me in welcoming Dr. Douglas White. Mary Faye, thanks so much for that really lovely and funny introduction. Again, I'm Doug White from the University of Pittsburgh. These are my financial disclosures, none of which pose a conflict with what I'll be presenting today. And I'd like to start by just saying how honored I am to be giving this lectureship named for Aki Grinvick, who died in September of last year. Aki was a giant in critical care. He was a founding member of SCCM. He was a past president of the society. He was a world-class scientist and head of the largest critical care medicine training program in the United States. And on a personal level, I had the pleasure of getting to know Aki as a colleague when we overlapped for several years in 2009, when I joined the faculty at Pitt and before he retired. And even after he retired and over the years, he was a steadfast supporter of my effort to build a research program focused on ethics and decision-making and critical illness. And just, I must say, over those years, he always had thoughtful comments about the work that we were doing. And so he made an indelible mark, not only on me, but on many trainees over the last 40 or 50 years at Pitt and beyond. So again, I'm so honored to be giving this named lecture in his honor. All right. So today I'll be talking about the role of critical care professionals in allocating scarce resources during a public health emergency. And so I'll first briefly outline the ethical challenges that arise for critical care professionals when there aren't enough resources for all patients in need. And then I'll outline four roles for critical care professionals to ethically respond to resource scarcity, some of which are directly at the bedside. And some, as you'll see, are very far from the bedside. All right. So the core ethical challenge for us as critical care professionals that are created by the kinds of scarcity of ICU resources that we've seen during the COVID pandemic is that it essentially renders us unable to fulfill our usual ethical obligations to individual patients. And so what do I mean by this? Well, in everyday clinical practice in well-resourced countries, we generally provide life-sustaining critical care treatments to all patients who wish to receive them and would likely benefit from them. And this allows us to fulfill what is the primary ethical duty of clinical medicine, which is to promote the well-being of our individual patients. And this ethical duty is grounded in beneficence, respect for autonomy, and also our special fiduciary relationship with our individual patients, to the extent that that obligation is somewhat greater to the patients in front of us than the potential patients or the patients that are not, quote unquote, our patients. But during a public health emergency, things shift. When there are not enough resources for all, there's a shift from a balance in the ethical focus being on respecting individual autonomy and doing all we can for each individual patient, to an emphasis on promoting the common good. And this is a real challenge for ICU physicians who are, I think, deeply, and clinicians in general, who are deeply focused on the well-being of their individual patients. One way to conceptualize how these ethical principles shift is the state of Minnesota's crisis standard of care ethical framework includes two high-level ethical objectives. First, to protect the population's health by allocating resources to reduce morbidity and mortality. And then second, to strive for fairness and protect against systematic unfairness, such as reducing between group differences in mortality and morbidity, and then appropriately reciprocate to groups accepting higher risk in service of others. So frontline clinicians and also frontline workers in grocery stores, bus drivers, food services, for example. But what you don't see here, what's not listed in this ethical framework, there's no mention of the traditional special duties of clinicians to individual patients already under our care. And so this, as I said, is a major shift in the ethical framework, away from a clinical ethics frame purely toward a frame that combines, I would say, clinical ethics and public health ethics. All right. So let's move on to talking about four roles that I think critical care physicians should play. And as I said, some of these roles are very far from the bedside and some are quite close. And what I'll do is I'll start by the roles that are far from the bedside, and I'll spend actually the most time on the first two, and then a little bit less time on the bedside roles, because I think that the ones that are different for us to think through are the ones that are away from the bedside. All right. So the first role critical care professionals should play is to advocate for and lead efforts to load balance across hospitals within a region and actually beyond a region. So what do I mean by load balancing? Well, a group that's done really remarkable work on this topic and on critical care resource allocation in general is the Task Force for Mass Critical Care that's led by Jeff Dichter, Asha Devereaux, and Ryan Maves. And they define load balancing as the process of coordinating emergency response by sharing resources across hospitals or transferring patients across hospitals. And so in theory, this is, you know, quite straightforward. If there are too many patients in one hospital and open beds in another, transfer the patients from the overwhelmed hospital to the hospital with beds. That's the essence of load balancing. But there's growing evidence during the pandemic that load balancing often did not occur when it needed to and is not reliably occurring. Sherry Fink's and Jim Dwyer's investigative reporting in the New York Times during the first surge of the pandemic in the spring of 2020 revealed that when hospitals in LA and New York City were overwhelmed and overrun with patients and there were not nearly enough resources to treat them, this is in the poor neighborhoods of New York City, nearby private hospitals had available beds, had plenty of nurses, and were able to generally deliver a much higher standard of care. And there was no formal load balancing mechanism in place, unfortunately. And their reporting detailed numerous instances of patients dying in the safety net hospitals or hospitals in poorer regions of those cities of potentially treatable conditions because they simply were stuck in a hospital that didn't have the resources to treat them. And now we have fairly high quality evidence that patients cared for at overloaded hospitals during COVID surges are in fact at increased risk of death. So for example, in this study of more than 144,000 COVID patients in 558 U.S. hospitals during spring 2020, Kadri and colleagues found that approximately one in four COVID-19 deaths was potentially attributable to hospitals strained by surging caseload. And what's important about these data is that they suggest that even if overt rationing is not occurring, unequal outcomes are occurring and will occur between patients treated at overloaded hospitals and those treated at hospitals that are not overloaded. And so why is this ethically important and what does this have to do with our role as critical care professionals? So simply put, it raises important concerns about inequitable care. And just for definitional purposes, equitable care is when quality does not vary because of personal characteristics such as gender, race, ethnicity, geographic location, or socioeconomic status. But when patients in the same region are receiving very different levels of care quality, that is the definition of inequitable care. And unfortunately, there are very good reasons to worry that these failures of load balancing that we're seeing in the United States and beyond will disproportionately harm already disadvantaged groups. Why is this? Well, first racialized minorities and the poor are more likely to seek care at safety net hospitals, which have been especially strained during COVID-19 surges. And because of budget constraints at these hospitals have less ability to increase their surge capacity to treat patients compared to, say, large private health systems. And then second, racial and ethnic minorities and the poor are disproportionately uninsured or underinsured, which may be an added barrier to transferring these patients outside of the safety net hospital that they're in. And so for example, the Wall Street Journal obtained records from government officials in California that revealed multiple instances in California in which critically ill patients at safety net hospitals were denied transfer from those hospitals to private systems that had available beds essentially due to a lack of insurance. The same issue is I think particularly also relevant for rural populations with poor health care access. So as you know, many rural individuals receive care at critical access hospitals. And many of these critical access hospitals don't have ICUs and don't have specialists. So if a patient presents for care at this hospital, and say, for example, they develop acute respiratory and can't be transferred as has happened in states like Idaho and Montana, they'll face a high risk of an otherwise avoidable death. You know, this is a phenomenon that I've heard public health officials now call sort of grimly dying in place, you know, that they get to the hospital that they get to and they can't get out. So that's where they die if they can't be transferred. All right, so what can critical care professionals do to facilitate regional load balancing during the pandemic? I have two main suggestions. First, we should advocate to governmental agencies for the implementation of statewide load balancing systems with required participation of all hospitals in the region. And second, falling short of that if state officials don't rise to that challenge, we should lead efforts on voluntary regional lead efforts on developing voluntary regional medical operation centers or transfer centers. And I've put here a link to an ASPR resource that has a great summary of the needed resources to establish and maintain these kinds of regional medical operation centers. Okay, so let me just give you a couple examples of this, of load balancing and how it's really worked. One of the best I've seen is the coordinated regional response that occurred in the Emilia-Romagna region of Italy in the spring of 2020, when hospitals in the city of Piacenza were overwhelmed with COVID patients. And within days, EMS and critical care clinicians in that region of Italy collaborated and built on the pre-existing national health infrastructure to facilitate the transfer of 160 patients from Piacenza all across the region by ambulance, by bus, by car, and thereby likely saved many, many lives. And you might say, well, okay, that's great in a place like Italy or Canada or the UK where there's a national health system. And you might say, well, in the United States, this is easier said than done. And I think that's right. At the organizational level in the United States, we have a number of barriers to load balancing. Organizationally, the United States healthcare is delivered in multiple independent systems that generally perceive their primary obligation to be a specific covered population rather than the community at large. And a common refrain that we've been hearing from health systems during the pandemic has been, listen, we can't accept transfers because we need to preserve our capacity for our own population in case things worsen. The other part of it that comes up is that the prospect of financial losses for health systems, if they accept and transfer uninsured patients or those with insurance that reimburses at lower rates. And then finally, at the organizational or operational level, most U.S. states really don't have the needed infrastructure to implement a statewide load balancing system. And this would require things like real-time information about bed capacity across all hospitals and state, common reporting methods of patients in need, medical expertise to prioritize transfers, and then a mechanism to fairly distribute patients across hospitals with bed availability. So you may be thinking to yourself, listen, this is great in theory, but unworkable in the United States. But I would just respond by pointing out that under the leadership of actually a Republican governor, the state of Arizona has successfully implemented a statewide load balancing process. And the results have been dramatically improved access to ICU care for racial minorities and rural populations. So specifically, the Arizona Department of Health Services developed what's called the Arizona Surge Line, which is a centralized hospital capacity management system to coordinate the statewide transfer of patients from overloaded hospitals to those with capacity. And Governor Ducey also issued an emergency order that required all hospitals in Arizona to participate in the Arizona Surge Line. And so, as I said, this load balancing effort has been lifesaving, particularly among Native American Indian populations who would otherwise have been dependent essentially on the largely underfunded Indian health service for care. And so, some of the data were reported recently in New England Journal-Catalyst. Since April 2020, the Surge Line has transferred almost 8,000 patients from overloaded hospitals to those with beds available. And nearly half of those patients that were transferred were American Indians. Okay, let me move on to the second role for critical care professionals. And again, this is an advocacy role. We should advocate for state or province or territory-wide triage guidelines that should be developed via a process of public reasoning, and I'll explain that in a second, rather than ad hoc allocation decisions by individual clinicians or having each hospital develop its own allocation strategies for scarce resources. Okay, so what do I mean by public reasoning? Well, this is a term of art from political philosophy that refers to a process of decision-making about the allocation of public goods made by legitimate authorities grounded in principles of liberal democracy. So, in our context, this means that decisions about how we allocate scarce critical care resources should reflect citizens' values and be constrained by fundamental rights like non-discrimination. And this process should be overseen by government agencies with the appropriate authority to make these allocation decisions for populations, such as state departments of health or territory or regional departments of health. And so this logic might seem quite natural to those of you from countries with national health systems. In the United States, as I said, we have this web of private hospitals and health systems that make it pretty challenging to actually conceptualize the need for public rationing when developing allocation strategies. You know, our hospitals are given, in the United States, substantial discretion to decide how they'll deliver care. For example, how much of any charity care to provide or whether they'll focus on growing their cancer program or their cardiac care program. But actually, what's less obvious about the U.S. health care system is that U.S. hospitals also already have a public role in implementing national health policy. And the most clear example of this is, in the United States, hospitals that receive public funding, like Medicare reimbursement, are required to play a public function for emergency care via regulations like the EMTALA legislation. And in a declared public health emergency like the COVID pandemic, that public function arguably requires the use of public reasoning for allocation frameworks. So what are the implications of this for critical care professionals? Well, first, hospitals and individual clinicians shouldn't base allocation decisions on their own private values. And instead, they should advocate for governmental agencies to oversee the formulation of triage policies that reflect public values and protect fundamental rights. And then third, critical care professionals should engage with the public in developing allocation strategies. And there have been a couple, you know, really great examples of critical care professionals leading robust public engagement efforts. Professor Marshall, the moderator of this session, was part of a team in Minnesota that engaged hundreds of residents of Minnesota over several years to determine their perspectives on how to allocate scarce resources during a pandemic. And this effort resulted in the foundation of a robust ethical framework that's now been used to develop more specific allocation frameworks for a variety of health resources in Minnesota. And importantly, these frameworks are now explicitly grounded in the values of residents of the state. Another example is the work by Lee Daugherty-Bedison. Lee is a critical care physician at Hopkins who also led an arduous years-long effort, and she used what are called deliberative democratic methods to characterize the values of a diverse sample of residents of Maryland. And this work that played out through multiple half-day-long sessions with representative groups of Marylanders developed and informed a framework created by a consortium of hospitals for the allocation of scarce ICU resources in Maryland. So again, both really great examples of critical care professionals away from the bedside making really important policy impacts. All right, let me just quickly touch on the last two roles that I wanted to highlight for critical care physicians. The third role is to take on the burden of making allocation decisions. And this may feel dissonant with what I've just said, but let me unpack that a bit. So, triage teams are a thing that you'll see in most guidelines and that they are recommended for how we should allocate our scarce resource and who should be making these decisions. So, rather than the frontline clinicians making these decisions, there's a role separation so that a triage team that is not involved in the care of patients is the one making allocation or triage decisions. And I think there's real ethical importance in this role separation. So, first, having a separate triage team promotes consistent, accurate application of the framework because this is all the triage team is doing and they presumably will have received advanced training in applying the technique and the framework. And second, this separation of roles allows the triage team the time to really engage in gathering the situational awareness that's needed to make good triage decisions. So, both awareness within the hospital of where resources are, but also communication between different hospitals in a region to achieve the kind of load balancing that I was talking about. And then finally, there's, I think, real ethical value in taking steps to minimize the moral distress that frontline clinicians would feel from what I think many will view to be a conflict of commitments between if they were asked to be making triage decisions and take care of patients, the conflict between their obligation to public health and their obligation to individual patients. So, this is, I think, an important role for critical care professionals to take on the burden of triage decisions when they are in the role of the triage officer. And then finally, let me just say actually why I think critical care professionals are really well-suited to this role. We are used to managing critically ill patients. We have the appropriate medical expertise to do that. We also, in general, have a lot of experience running interprofessional teams. This is essentially the essence of good critical care now is an interprofessional enterprise. And I think that's the same set of skills that really arises, including the ability to manage conflict that really arises in the application of triage frameworks. Okay. And then the last role that I wanted to talk about is advocating for your individual patients. So, before I talk about what I mean by that, I want to talk about what I mean, what I don't mean by that. And let me give you an example. And this is one of my all-time favorite papers now from 30 years ago. And again, this is Mary Faith Marshall's work. She and her colleagues studied how decisions were made about ICU admission in one hospital's surgical intensive care unit when there was a temporary nursing shortage, which created the need to ration surgical ICU beds. And what they expected was that the beds would go to the sickest patients who were potentially savable on the logic that this would be the way to derive the most benefit from the scarce ICU beds. And instead, what they found was that there were not concerted efforts to reserve ICU beds for the sicker patients. And they actually found that the severity of illness went down during periods of scarcity rather than up. And as they dug a little further, they found that other considerations overrode what they called medical suitability, such as the power wielded by certain surgeons within the SICU and the institution. And also, interestingly, I think there are some important parallels here with load balancing challenges, economic pressures that the institution felt to continue elective surgeries that were coming from a lucrative network of regional referral centers with smaller hospitals. So this notion of the web of referral relationships needing to be maintained is a real pressure that might work against, in this case, the allocation of SICU beds. But I think in the pandemic case, the appropriate allocation across a region of patients to staffed beds. Okay. So then when I say to advocate for your patients, then what do I mean? Well, I specifically mean that when one is in the clinical role as the frontline provider, I mean advocating for your patients within the constraints of the established allocation framework that's in place. So in concrete terms, one example is to ensure that the allocation framework is appropriately applied to your patients. You'll recall that many states have advocated that ICU beds are allocated to patients on likelihood of survival. So those most likely to survive with intensive care should get priority over those less likely to survive with intensive care. And many states use the SOFA score for this. One element of the SOFA score is the neurological subscore, which in essence penalizes patients who are unable to verbally respond to commands on the grounds that this often signifies a worse neurologic prognosis. But when this criterion is say bluntly applied by a computer or sort of unthinkingly applied by someone who doesn't know the details of the individual patient, it would unfairly disadvantage patients with, for example, stable cognitive deficits, such as persons with mutism, which impair speech, but don't actually affect chances of survival. So a really important advocacy role for frontline critical care professionals would be to ensure that triage teams appropriately in this circumstance and in related circumstances disregard subscores that do not actually have the prognostic significance that they're meant to have. And then another critically important way to advocate for your patients as a bedside clinician is to assure non-abandonment. Even when a patient won't receive a scarce resource like a ventilator or dialysis, even though that one resource can't be provided, critical care professionals have a really important role in continuing to provide intensive symptom management and family support in keeping with their beneficence-based obligations. Okay, so those are the four roles that I think critical care, four of the roles, I think there are others, but four important ones that I think critical care professionals should be playing during the pandemic. And so to conclude, let me just summarize by saying scarcity during a public health emergency may make clinicians unable to fulfill our usual ethical obligations to patients. And there are four important roles we should be playing. Advocating for the implementation of regional load balancing strategies, advocating for uniform allocation guidelines developed via processes of public reasoning that reflect public values and are non-discriminatory. Within the triage role, taking on the burden of making allocation decisions separate from the clinical role. And then in the clinical role, advocating for your patients. Thanks very much. And I look forward to the discussion. Thank you. Doug, thank you for an absolutely stellar presentation. One, it was a beautiful overview of the challenges and the processes that we have used during this pandemic. And I think also, I hope, a catalyst for all of us to be engaged professionally in thinking about disaster preparedness in the future, and the best way to prospectively plan for equitable ways of going about that. I wanted to say also that I think your presentation should be required viewing for members of state health departments, especially those who are engaged in disaster planning, members of health systems, those responsible for thinking about disaster preparedness and pandemic planning, hospitals, and perhaps most importantly, members of societies and the leadership in those societies in advancing all of the things that you talked about that will in the future, I hope, make us have a more informed and equitable approach to disaster preparedness. And I wanna say that what has happened during this pandemic in terms of social inequities, health disparities, social justice issues is nothing new. I mean, these issues have been around as long as we have data about pandemics. And so I think part of that is shame on us because there have been calls in the past for better thinking about pandemic preparedness and ways to address these sorts of issues. There are a number of them. My colleague, Deb DeBruin, and I published a paper on social justice and pandemic preparedness. But way back in 2012, and one of the things that we said was that we focus too much at the national, at the state, at the regional and local level at procedural justice. This idea that we are, that justice requires to treat each person in the same way, right? Or that that's what fairness is all about rather than being concerned with how we perpetuate health inequities and social injustice, and don't think about leveling the playing field so that we actually can then be fair when it comes to actually allocating scarce resources. So I wanted to maybe just ask you about that or you addressed it, I think, certainly in your talk, but if you have any additional thoughts about that. No, I think you've raised the crux of the issue for people emotionally as it relates to ICUs and ICU beds and ventilators, because promoting equity at the level of the ICU would require advantaging certain populations in ways that frontline clinicians would look at and say, I need to treat everyone the same. I can't imagine doing anything else. And so I'll just flag that in the coming months, a paper is gonna be coming out that's a pro-con between myself and Bernard Lowe and John Hick and Dan Hanflin on this exact topic. Should we incorporate social determinants of health into allocation decisions? And listen, I think it is absolutely the cleanest and a very strong argument to say we need to be allocating vaccines and monoclonal antibodies and other therapies to disproportionately to disadvantaged populations, because if we don't, we will actually continue to magnify the disparities and outcomes because these groups are so disproportionately affected. I personally think that that same logic carries through to the allocation of scarce critical care resources. And I will flag that that is a highly controversial issue and one that I think needs more air behind it. And what I'll just say is, if we don't promote, incorporate equity strategies into how we allocate scarce resources in the ICU setting, it will exacerbate disparities. There's no approach if we just say, listen, we'll just save the most lives and that gives everyone an equal shot. That's not the case. You'll end up exacerbating disparities with the save the most lives strategy. And so I think that's where we need to start that conversation, is are we willing to have an allocation framework in the ICUs that leaves disadvantaged populations worse off than they were? I couldn't agree with you more, Doug. And so let me maybe drill down on that just a little bit. I know that you were advising the Public Health Department in Pennsylvania on these issues during the pandemic and that you all used, correct me if I'm wrong, the Area Deprivation Index at the statewide level. So from a public health perspective in how you were going to allocate remdesivir, I believe. The Area Deprivation Index is basically an index of poverty. And it grew up at the University of Wisconsin and it's been used primarily at the level of the social level of public health. But the question arose during the pandemic, can we use it not only at the level of public health, but also perhaps in individual institutions in allocating, developing frameworks for how we're gonna allocate scarce resources. And I'll say, we did this at the University of Virginia. It was controversial there among those of us who are fashioning our mechanisms for allocating scarce resources. But we decided to use it and to put it into place and to use it to balance the inequities that we saw in the SOFA scoring system, which we, and as you mentioned, many others use. So I just wanted to get any thoughts about that. Yeah, this was a really interesting process with the Department of Health in Pennsylvania. And I have a few reflections on that. One, I just wanna flag how important it was that the decision-making about the allocation framework happened at the level of the state, rather than a bunch of individual hospitals in Pennsylvania making ad hoc decisions about, are we gonna weigh this factor or this factor or this factor? I give really big credit to the Pennsylvania Department of Health for convening a very diverse task force on this issue and engaging the public in the process and articulating a set of values that should guide allocation. And they were very explicit that one of those values is to mitigate the present day disparities in health outcomes that are occurring because of structural disadvantage. So that's point number one, is I think it was really important that this was, when we talk about public reasoning, that that is what gave license to other, to hospitals within the state to incorporate things like the ADI into their allocation frameworks. The second thing I'll say is that we did use this at my institution as part of a multi-principle allocation framework in the form of a weighted lottery. It was absolutely feasible to use. And the purpose was not to put any group ahead of another. I think this is where people, their hackles really come up is they think, oh, you're just trying to, you're trying to put this group ahead or this group ahead. And that's not the case. The case is to try to make it so already disadvantaged groups don't end up even farther behind. You know, even the equity interventions that we put into our allocation frameworks are not going to put these groups ahead. They're still going to end up at the end of this pandemic with profound disparities. And so I wanted to flag that. And then the third thing I'll say is a little less optimistic about this, is that for Remdesivir, Pennsylvania did an amazing job with creating an infrastructure and clear recommendations for how it should be allocated and then gave the supplies of Remdesivir to individual health systems to enact that. However, what we're seeing now with how PaxLivit is being allocated is essentially has undercut the ability to even enact that framework at all. And the issue is that PaxLivit is going directly to pharmacies. So health systems have no ability to control how the drug is allocated. And there's not even a requirement in Pennsylvania, for example, that it goes to high risk patients. So I actually called one of the pharmacies in Pittsburgh the other day and said, hey, I'm a physician here in Pittsburgh, what do I need to do and document to get PaxLivit to a patient? And they said, you just write a prescription for it. And it's quite scarce still, but I would just say this represents a sort of a failure late in the process of sticking to the same ethical values that we instantiated at the beginning. And I get it, I think people are tired and there's a waning of energy for these things, but I just want to flag that here we are and what's happening now is highly inequitable. I agree, it's tragic, really, that's such a shame. And I would go further and say that when we don't attend to health disparities and inequities in disaster and pandemic planning, that what we're doing is we're perpetuating not just structural inequalities, but I think structural violence, which is a systemic thing and issue. I do want to say, you mentioned the excellent work that was done most recently in Minnesota and that was done earlier in Minnesota. And I do want to call out the State of Minnesota's Department of Health, which is very forward-thinking and was back then, because they are the ones who initiated the process of bringing a group of ethicists from the University of Minnesota together. And they asked for a framework, they asked us to develop and they funded that work. And in addition to the usual things that we were asked to look at, ventilators, personal protective equipment, medications, et cetera, we actually added one of our own or specified that if we're going to do this, then we have to talk about allocating widely packets or ways to palliate patients who are dying, who during a severe pandemic or disaster are going to be dying in, not in hospitals, but in grocery stores or in large arenas or places that have been fashioned to take care of large numbers of people. The H1N1 pandemic happened during that two-year process of our work. And we were sorry to see that yet once again, the Native American population and those who live in poverty were disproportionately affected by the pandemic. But Minnesota has moved beyond that in a very positive way. I want to- I think that was efficient by the way of Minnesota to focus not only on, we all get caught up by the bright shiny object of the ventilator or dialysis or the next drug, but to also say, we need to think carefully about how we can ensure a basic level of symptom management when we have an overwhelming pandemic and patients dying. And so to have an infrastructure that not only pays attention to the sophisticated technology, but also to the clinicians, palliative care clinicians or frontline clinicians who do need basic therapies, I think was really forward-looking. Or to members of the public, right? They're going to be the ones in a large disaster who may be taking care of people on the state fairgrounds or wherever patients or persons who are dying are housed. So I want a couple of questions that I think are important and wanted to ask you about. How is the allocation process best explained to patients or their families or their surrogates? Yeah, yeah. Well, let's see. I think the clearest example that I have is where we have actually had to do it. And that is with the allocation of remdesivir. And so it raises important issues about who should do this. I talked about a clear separation of the triage role from the clinical role. And what we found actually, yeah. What we found in practice is I think that the decision-making part of that, I think there needs to be a clear separation. The communication with patients and families, I'm not sure that it should be the triage officers doing all of the communicating. And instead we've advocated for an approach that is much more contextualized to the particulars of that relationship with the patient. So for example, let's imagine a patient is entered into the remdesivir lottery and is not allocated remdesivir. The question is who should tell the patient and the family that. And on the one hand, you could say, well, listen, that's a public health decision about how we allocate a scarce resource. It shouldn't be the frontline clinicians because that will confuse patients and families. It should be the triage team. I think that makes good logical sense. But on the other hand, the frontline clinicians could also be the ones to actually explain the logic and support the family and the patient through that bad news. And so my view is that for each of these conversations, there should be a bit of a dialogue between the triage team and the frontline clinician and make an individualized determination of who's best to share that with this family. So, you know, if it's a family that there's already a sort of a fractured relationship with the clinical team, then maybe the right approach is to have the triage team sit down with the family and explain it and explain the basis for the decision as one that it's not the fault of your clinician, your doctor or your APP, this is a public health decision. And so your anger should be directed at me, the triage officer and at the state, not the frontline clinician. Yeah. And it begs the issue that you brought up earlier about the importance of public engagement in the process of, you know, in the upfront process. And I think as well, you know, in communicating with the community at large, the fact that if we have to engage crisis standards of care, that we are gonna be allocating scarce resources and that some will get and some won't. And so that the community is notified, if you will, that you've been involved in this process, that there will be a process that you need to know about it upfront. Yeah. You can talk about that. Oh, no, I completely agree. And what I would say is amazing about this, about the COVID-19 pandemic is that, you know, in the last 20 years we've been through SARS and H1N1, you know, all sorts of flus and threats of scarcity. This is the first time I've ever seen hospitals put on their websites, we are in crisis care modes. We won't be able to provide you or your loved one with the same level of care if you come to the hospital. And in fact, we've also seen states do this. So Idaho publicly released that they had entered crisis standards of care and they made statewide declarations and had tailored messaging to citizens about what are the implications of that. And, you know, that is a, it's still a sobering reality that we got to that and that there were in fact triage decisions made throughout US states about patients who would normally get ICU resources who were not provided them due to scarcity. Yeah, yeah. It's so important because really it's our collective problem, right? As citizens in this country who care about one another. I wanted to ask you, should we and how best would we go about educating student clinicians, medical students, nursing students, students of pharmacy, the other health professions about this very issue, right? About the fact that when there are disasters, when there are pandemics, crisis standards of care have to be implemented, that we have to make hard decisions. How do we best educate? Yeah, that's a great question. I mean, I don't have a pat answer for that Mary Faith, but what I would say is that I have, although it oversimplifies things, I have found drawing the distinction between public health ethics and clinical ethics and really parsing out the population focus of public health ethics and the bedside focus of clinical ethics to be a helpful tool to help individuals who don't think about this all the time, get their heads around, there has been a shift here. And then to understand, I think it actually helps sharpen one's view of what are our professional obligations under normal circumstances and how those shift and what are the conditions under which those shifts should be made. And in particular, we shouldn't be in an ad hoc way having one hospital flip to crisis standards. This should be part of an organized public health response where there's a statewide declaration that happens only after extensive load balancing. And so doing it, I think we sharpen both what it means to be a clinician in usual times and what it means to be a clinician that's functioning as part of a collective responding to a public health emergency. Any final words on how best to motivate professional societies, critical care professional societies to engage the public, right? And engage their members in the things that we've been talking about, the importance of, let's say, overall social justice issues in pandemic planning or in disaster planning. Yeah, well, let's see. I mean, I think SCCM has done a very good job in taking the role as a professional society and in framing out for both clinicians and for the public what this all means. I think I still have vivid memories burned in my head of those early graphics of the sort of the ICU physician on top with other kinds of physicians underneath and other kinds of extenders as a way to provide care for many more patients. So I would say that that's happening. How we continue to encourage a focus on justice I think is a hard question because our society has a lot of embedded injustices. And I would say the inertia is back to the status quo. And so part of it is just sort of settling in for the long haul, I would say. And then saying this will not get sorted out overnight. This is not gonna get sorted out over a year or two years or three years. This is going to need to be, frankly, a decades long commitment to equitable treatment of patients in society. And that's, I think having professional societies make a commitment to that way of thinking about it and to continue to program educational opportunities that really delve into what do we mean by justice and what's really hash out what it means to fairly treat populations. I think that's the only path forward. Yeah, wonderful. And perhaps joining with our colleagues around the world, right, sort of globally with our critical care colleagues around the world. So Doug, thank you again for an absolutely gorgeous presentation and for all of the challenges that you've given us and that we need to take up in a serious way. So thank you so much. Thank you, Mary Faith. It's nice to have had this conversation with you. I wish we could have had it in person, but it's still lovely. Thank you.

critical care professionals

resource allocation

public health emergency

ethical challenges

advocacy

triage guidelines

load balancing

health disparities