Critical-care resource allocation during the coronavirus disease 2019 pandemic in Singapore: A brief narrative review

Abstract

In the midst of the coronavirus disease 2019 (COVID-19) pandemic, where cases continue to increase exponentially every day, it is important to consider the future implications that this may have on the health-care system, the most feared situation being a shortage of critical-care resources, where difficult decisions have to be made about the allocation of scarce resources. In this brief narrative review, we conduct literature searches for COVID-19 ethical guidelines on critical-care resource allocation. Synthesising this information, we evaluate the relevant ethical principles and thereafter provide recommendations contextualised to Singapore. This brief narrative review aims to serve as a useful set of guiding principles for health-care professionals in Singapore, should the need for allocation of scarce resources arise.

The potential problem of scarcity in Singapore

The first case of coronavirus disease 2019 (COVID-19) was identified in Singapore on 23 January 2020. Since then, there has been an exponential increase in the number of cases. ¹ As of 1 May 2020, there have been 17,101 confirmed cases and 16 deaths, with 1.3% of patients in hospital needing critical-care support. ¹

The rapidly growing number of cases globally has created an increasing demand for limited critical-care resources such as ventilators, personal protective equipment (PPE) and intensive care unit (ICU) beds. ² As the number of cases rise, despite circuit-breaker measures in Singapore, the most feared situation is that the number of cases requiring finite resources may overwhelm the system, as it has in many countries, thus requiring difficult ethical decisions to be made about the allocation of resources. Given the exponential increase in cases and the growing community spread in Singapore, we need to prepare for such a situation. It is therefore important to ask how Singapore can fairly allocate scarce critical-care resources during the COVID-19 pandemic.

Methodology

A literature search was conducted which comprised a Google Scholar search, as well as handpicked articles. ‘COVID’, ‘ICU’ and ‘ethics’ along with their related terms were used in Google Scholar and were combined using Boolean logic commands. Subsequently, the snowballing approach was used to identify additional relevant articles. The team also handpicked guidelines and position statements from government websites and health-care organisations worldwide. These articles were analysed in depth and were synthesised to provide an overview of the principles of scarce resource allocation in COVID-19.

How to allocate resources

Primary determinants

Adopting the BMA’s guidance COVID-19: Ethical Issues ³ to guide ethical considerations, we evaluate the potential ethical issues to be balanced in the face of a pandemic. These guidelines suggest that the primary considerations should be fair procedures, meaning that the procedures proposed are transparent, accountable and effectively communicated. We propose that the primary goal should be to maximise the utility of these resources for patients, such that the largest number of lives and life-years can be saved. ⁴ Based upon these considerations, it would pertinent to consider the available means of prognosticating the outcomes of potential recipients of critical-care resources. Evidence-based and objective means of prognosticating outcomes are included below (Figure 1).

Figure 1.

Allocation of resources.

Short-term prognosis

This prioritises patients who are most likely to survive the current acute illness, hence maximising the number of lives saved. Evidence-based prognostic tools used for COVID-19 patients in the ICU include SOFA, ⁵ SAPS 3, ⁶ APACHE ⁷ and the Clinical Frailty Score. ⁸ These are easy to use, can be calculated quickly and are objective, evidence-based and specific for use in evaluating COVID-19 patients. At present, there are no large randomised trials suggesting the superiority of one predictive system over another. ⁹

Secondary determinants

Long-term prognosis

The long-term prognosis prioritises patients who are most likely to live the longest after recovery from the acute episode, hence maximising the number of life-years saved. This is especially important because Singaporeans generally have a long life expectancy but a high prevalence of chronic diseases in old age, such as diabetes, hypertension, hyperlipidaemia and cardiovascular disease. ¹⁰ Available measures of long-term prognosis include quality-adjusted life-years (QALY), disability-adjusted life-years (DALY) ¹¹ and the presence of significant major or life-limiting co-morbidities. ⁴ Life-years is a reflection of the long-term prognosis of a patient in which chronic disease and access to care play a role. It is important to distinguish this from discrimination against age. Thus, triage teams should be blinded to patient age. One limitation to the use of long-term prognosis is that it may be difficult to assess in an emergency situation. ¹² We also advise against the use of QALY, as a patient with an objectively poorer quality of life – for instance, a patient with advanced dementia – may value his or her life-years more than one with an objectively better quality of life. ¹¹

Tertiary determinants

Lottery method

We propose that in cases of patients with similar prognoses, who are placed on equal priority, a ‘lottery’ approach to allocate resources randomly to patients should be considered, ¹² as it can be carried out quickly ¹¹ and ensures that such patients have an equal chance of receiving treatment. ¹²

Recommendations

Together with the above principles, we propose the following recommendations for allocation of scarce resources:

• Early formation of guidelines in consultation with the public

  Guidelines should be formed before cases spike or before scarcity sets in. This allows for time for discussions with the public in order to avoid discrimination against certain minority groups in the decision-making, including the disabled as well as minority racial groups.

• Optimise existing resources before utilising scarce resources

  Singapore has optimised existing resources by decanting stable patients to private hospitals and community isolation facilities in order to help ease patient load in public hospitals. As of 1 May 2020, out of 15,817 patients who still carry the infection, 1714 are in public hospitals, while 14,053 have been moved to community isolation facilities. ¹ This has further been aided by government measures to flatten the curve such as advising safe distancing and implementing a circuit breaker after pre-empting a spike in cases.

• Good societal education on COVID-19

  In Singapore, societal education has been done in various ways, including official news reporting, a WhatsApp service where frequent and reliable updates from the government are sent out, daily updates on the Ministry of Health website, as well as easily readable online comics.

• Formation of good triage teams

  Triage teams, involving health-care professionals (HCPs) and an ethicist, provide triage decisions for teams on the ground that are facing ethical dilemmas. To avoid bias, these teams should be independent of teams on the ground caring for patients and should be blinded to patient demographics.

• Oversight of the process

  The hospital bioethics committee should be independent of triage teams and teams on the ground. It reviews ethical decisions made by triage teams in order to ensure that these decisions were made without bias. This helps reassure the public that decisions are made after careful weighing of resources available and patients’ needs.

• Dynamic monitoring and assessment of the situation

  Teams should monitor the availability of resources around the clock, as a pandemic is an evolving situation which can change rapidly. Dynamic monitoring supported by an efficient transport system enables timely reallocation of resources between hospitals. This helps to maximise available resources and to prevent wastage.

• Reassess, tailor and adapt the response based on the evolving pandemic situation

  Principles and guidelines should be reassessed, tailored and adapted as the pandemic situation evolves^{11 –14} and as the number of patients, number of HCPs and availability of resources change. Singapore uses the Disease Outbreak Response System Condition (DORSCON) framework ¹⁵ to guide management of the situation. The availability of resources as well as changing DORSCON levels can affect whether guidelines for allocation of resources are tightened or loosened.

• Allocation of scarce resources

  In the event of a shortage of resources despite the above measures, we propose allocating scarce resources according to the above determinants.

• Transparency

  Open discussions and clear communication with the public about ethical principles and guidelines for allocation of scarce resources help to address misconceptions, avoid causing panic, boost trust in the public health-care system and build solidarity among the public. Consistent and honest communication between HCPs, patients and their loved ones facilitates contact tracing by ensuring that patients are also open and honest with HCPs about their medical history, and this improves the quality of care delivered.

• Provision of support and palliative care, especially where treatment is withdrawn or withheld

  If withdrawal or withholding of therapy is needed on the grounds of resource allocation, these patients should still receive compassionate and dedicated medical care and attention, with appropriate symptom control, supportive measures and palliative care where necessary. ³ Support must be personalised based on the individual patient’s values, beliefs and attitudes.

• Psychological support for HCPs

  These are decisions that may be difficult or even traumatising for HCPs ¹³ to make, especially when treatment has to be withheld or withdrawn. It is therefore important to evaluate the impact of such decision-making on HCPs holistically so that the appropriate psychological support can be provided. HCPs should also be assured that they will not be held liable for acting according to ethical principles and guidelines.

• Proper channels of appeal

  For families who feel that their loved ones have been denied or withdrawn from treatment inappropriately, an independent appeal team should re-evaluate if the patient truly warrants withdrawal of therapy.

Conclusions

Fair and just allocation of resources in the midst of scarcity must be grounded on consistent and sound ethical principles. Keeping in mind the importance of transparency and the fiduciary relationship, these ethical principles and decisions must be communicated and discussed with key stakeholders. Moving forward, the development of a robust set of guidelines building on the ethical principles and recommendations forwarded in this brief narrative review will help better equip HCPs. This forms an objective framework which can be used as a guide to allocate scarce critical-care resources. Finally, the success of these measures hinges on support and cooperation from all stakeholders: the public, HCPs, health-care institutions and the relevant government bodies.