- Hospitals should create guidelines in advance to ensure cancer patients are fairly represented in possible resource allocation decisions — in COVID-19 and other emergencies.
- A cancer diagnosis should be considered as any other underlying health condition.
- Decisions about distributing limited resources should not be made by a patient’s physician.
As the COVID-19 pandemic began surging globally, clinicians and medical ethicists were concerned that the demand for potentially life-preserving resources like ventilators and ICU beds might overwhelm supply. Oncologists, in particular, realized that everyone involved in the oncology community needed thoughtful guidelines for dealing with difficult resource decisions. As a result, the American Society for Clinical Oncology (ASCO) developed a set of ethical guidelines for protecting the rights of cancer patients while also considering the larger demands the pandemic is placing on public health at large.
“The main reason we wanted to do this was to ensure that a diagnosis of cancer would not be an absolute exclusion criterion that would deny any individual cancer patient access to a ventilator or ICU bed,” says guidelines lead author Jonathan Marron, MD, MPH, ASCO Ethics Committee Chair-Elect, pediatric hematologist/oncologist at Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, and clinical ethicist at Boston Children’s Hospital. “Accurate, evidence-based information about each patient’s cancer diagnosis and their prognosis should be considered in these decisions just like any other patient.”
Structure for the impossible decisions
In a public health crisis such as COVID-19, the goal is to provide the greatest benefit to the greatest number, but this can be at odds with a physician’s customary practice of focusing on individual patients.
“It is not a large leap then to be concerned that patients with other medical problems — cancer or otherwise — might worry they would not receive access to the same care as those without those medical problems,” says Marron.
The guidelines are intended to help institutions develop and implement allocation frameworks for making the impossible decisions whether it be in the current COVID-19 pandemic or other public health emergency. These frameworks should be developed consistently and transparently before allocation becomes necessary.
Oncologists are strongly encouraged to be an active voice for their cancer patients when crafting guidelines for their own institutions.
Separation of allocation decision-maker and clinician
At the crux of the guidelines is the recognition that the treating clinician should not be making the resource allocation decision for their own patients. “There needs to be some thoughtful process by which the allocation decision and bedside clinical-decision making are separated and that needs to be put in place ahead of time,” says Marron.
However, clinicians should be closely involved in thoughtfully communicating information about their own patients to those who are tasked with making those decisions.
Cancer is part of the equation, not the focus
Another key message: A cancer diagnosis should be part of the resource allocation equation and on par with other medical information about a patient’s health and prognosis.
“A cancer diagnosis alone should not keep a patient from a fair chance at accessing potentially life-saving medical resources,” says Marron. But it should be considered in the equation, especially if it will very likely result in a patient’s death in the very short-term.
Emphasize advance care planning
Even without the threat of a pandemic, oncologists should reinforce the importance of advance care planning for their patients and families.
“Under any circumstances, advance care planning maximizes the chances that patients’ and families’ goals and values are realized when making these decisions,” adds Marron. “This is incredibly important under typical circumstances and even more so in the setting of resource scarcity.”
Likewise, an institution’s guidelines should reflect the best information available with the hope that they will never be needed in practice.
Guideline co-authors include Steven Joffe, MD, MPH, University of Pennsylvania; Reshma Jagsi, MD, DPhil, University of Michigan; Rebecca A. Spence, JD, MPH, ASCO; and Fay J. Hlubocky, PhD, University of Chicago.
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