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Ethical guidelines for allocating scarce medical resources and services during public health emergencies. It emphasizes the importance of fairness, equity, and beneficence in making allocation decisions, and suggests strategies for minimizing the need for individual judgment calls. The document also addresses legal issues that may arise during the allocation of scarce resources.
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Appendix 9.3 - Michigan Guidelines for Implementation of Crisis Standards of Care
and Ethical Allocation of Scarce Medical Resources and Services
November 2021
Revision Tracking
Revision Date Person Revising Overview of Revisions
8/26/
Lance Gable and the original Ethics Advisory Committee (EAC)
Drafted
10/26/12 Lance Gable and the original EAC
Incorporating substantial updates to the Guidelines and adding Attachments 1, 2, and 3.
Lance Gable, the original EAC Incorporating minor edits and changes along with incorporating external comments. (this was the version that was online for years)
12/10/2020 Lance Gable Making major updates to the Guidelines and Attachments 1, 2, and 3.
1/21/2021 Lance Gable and the new EAC Incorporated edits and updates.
Jennifer Lixey-Terrill, Lance Gable, the new EAC
Incorporated edits and formatting as well as incorporated external comments. 5/4/21 Jennifer Lixey Terrill Added Attachments 1, 2, and 3
5/7/21 Jennifer Lixey-Terrill, Lance Gable, and the new EAC.
Incorporated Guidance Documents to Attachment 2. 8/21/21 Lance Gable and Jennifer Lixey Updates to verbiage
11/29/21 Lance Gable
Minor updates incorporating external comments.
Plan Distribution List
MDHHS Director MDHHS Chief Medical Executive MDHHS Public Health Administration (PHA) Administrative Deputy Director MDHHS Bureau of EMS, Trauma, and Preparedness (BETP) Director MDHHS BETP Division of Emergency Preparedness and Response (DEPR) Director MDHHS BETP Division of EMS and Trauma (DET) Director MDHHS Emergency Management Coordinator (EMC) MDHHS Community Health Emergency Coordination Center (CHECC) Michigan State Police (MSP) Emergency Management and Homeland Security Division (EMHSD) Director Michigan State Emergency Operations Center (SEOC) MDHHS Disability Office
Electronic versions are maintained on BETP Shared Drive and Michigan Health Alert Network within the MDHHS Emergency Operations Plan (EOP). The plan will be posted on the MDHHS website and will be available to the Healthcare Coalitions and the general public.
Introduction
The Michigan Guidelines for Implementation of Crisis Standards of Care and Ethical Allocation of Scarce Medical Resources and Services During Emergencies and Disasters Response Plan serves to inform local, state, and federal governments; Regional Healthcare Coalitions (HCC); relevant agencies and organizations; and other stakeholders of the preparedness and response plans specific to a mass casualty incident within the State of Michigan.
This plan describes the operational intent when responding to a mass casualty incident and details the system that has been developed for operations within Michigan before, during, or after a mass casualty incident.
Community Health Emergency Coordination The CHECC coordinates statewide health-related emergency activities by providing real-time public health information, lending subject matter expertise to inform decision-making, orchestrating the mobilization of health resources, and providing situational awareness to and from the SEOC when activated. In doing so, the CHECC interacts with public health and healthcare partners to render support and assistance, such as mutual aid, equipment and supplies, and risk communication information. The CHECC is staffed primarily by MDHHS personnel with appropriate SME augmentation and operates in full compliance with the National Incident Management System (NIMS).
The CHECC Manual includes a document titled, “CHECC Activation Planning Considerations,” that is maintained with the MDHHS EOP “Annex 2 – Direction and Control.” This document defines the activation of the CHECC through various stages, to include the return to routine operations. Furthermore, this document identifies key activities associated with each stage of activation and provides considerations for the prioritization of activities during long term response and recovery operations.
These planning considerations aim to assist decision makers in determining the appropriate stage of CHECC activation in response to a public health or medical emergency. The identification of indicators, triggers, and activity prioritization are included within the document and strengthen the CHECC’s ability to transition between stages while continuing to support requests for assistance and critical coordination of activities throughout sustained long-term efforts.
CHECC Administrative Preparedness CHECC procedures for the procurement of resources is assigned to the Finance Section. During an emergency response, the MDHHS Grants, and Purchasing Division will work with CHECC Finance Staff to give requests for resources related to the emergency priority and special handling to meet the needs of the situation.
Finance staff assigned to the CHECC will determine how MDHHS will capture and report the cost of response operations, submit requests for reimbursement, and provide other necessary information
regarding budget and finance operations. CHECC procedures include actions for retroactive reimbursement for early preparedness efforts.
Communication In the event of an emergency involving mass casualties resulting in the need to plan for ethical considerations of scarce resources, MDHHS would activate the MDHHS Emergency Operations Plan’s Annex 05: Crisis and Emergency Risk Communication Plan (CERC). The CERC Plan, outlines an all-hazard communication model designed to capture broad elements of a public information response. The plan outlines how MDHHS would develop messages, coordinate outreach, and disseminate information to the public, response partners, and stakeholders. The CERC plan and all appendices are stored on Michigan Health Alert Network (MIHAN) ( path: Documents/Michigan Agencies/MDHHS/EOP/Annex 05_Crisis_Emergency Risk Comm Plan ).
During a mass casualty incident, the communications staff in the CHECC will work with subject matter experts and partners to respond to requests for materials, update the MDHHS website, facilitate coordination of conference calls as needed, and provide situational awareness. This will also include the notification of additional counties being considered as part of the outbreak. A sample notification script is attached and may be utilized via the MIHAN and/or email listservs.
o Michigan Occupational Safety and Health Administration (MIOSHA) will assist in issues involving worker safety, to include providing waste management, sanitation practices, and Personal Protective Equipment (PPE) standards.
Essential elements of information must be reported to MDHHS (and possibly the Department of Health
and Human Services (DHHS), the Centers for Disease Control and Prevention (CDC), state and local
emergency management, and local public health). MDHHS, in collaboration with Subject Matter Experts
(SME), will determine what the EEIs will entail, and will communicate those requirements to applicable
entities as necessary.
Concept of Operations
The Michigan Guidelines for Implementation of Crisis Standards of Care and Ethical Allocation of Scarce Medical Resources and Services during Emergencies and Disasters (Guidelines) presented in this report provide guidance to decision-makers throughout the state of Michigan to assist in making choices about resource and service allocation and prioritization during situations of scarcity that may arise during public health emergencies. These Guidelines do not present a rigid or formalized series of instructions, but rather a set of criteria that can be employed by decision-makers in various circumstances during an emergency or disaster that impacts public health, using their best professional discretion. These Guidelines align with the application of Crisis Standards of Care that may arise during emergencies or disasters. These Guidelines align with the incident management systems such as the Incident Command System (ICS) used by Emergency Management, Public Health, and Healthcare Facilities which are compatible with the National Incident Management System (NIMS).^1 The Guidelines were originally drafted in 2012 but have been revised in 2021 to incorporate updates and changes reflecting medical resource and service scarcity during the COVID-19 pandemic.
This executive summary will provide a brief overview of the Guidelines. The full Guidelines provide additional depth and detail to the discussions of these challenging issues. The full Guidelines should be read and understood before they are implemented.
The Guidelines incorporate the following understandings that help define their scope and purpose:
(^1) More information about NIMS is available at https://www.fema.gov/emergency-managers/nims.
These goals are listed in no order of hierarchy – all are equally important to achieve and should be pursued concurrently.
The committee identified numerous underlying ethical considerations that guide the structure, procedures, and recommendations outlined in these Guidelines. These ethical considerations include beneficence (preserving the welfare of others through affirmative acts to promote well-being and save lives); utility (achieving the greatest good for the greatest number); fairness (applying consistent and non-discriminatory policies); equity (seeking fair and just treatment, access, distribution, and opportunity for all people while pursuing better outcomes for historically and currently disadvantaged populations); transparency (providing open access to information and decision-making processes); accountability (holding decision-makers responsible for their actions); veracity ( truth-telling); respect for persons (upholding individual autonomy, privacy, dignity, and bodily integrity); proportionality (demanding policies necessary and proportional to the scope and severity of the circumstances); solidarity (recognizing shared obligations and social cohesion); and stewardship (preserving the effectiveness and impact of these resources and services as best as possible).
Acceptable Allocation Criteria The Committee identified two general criteria considered acceptable for guiding allocation decisions: medical prognosis and supporting critical infrastructure. These criteria should be considered in conjunction with each other when evaluating allocation decisions.
(^2) Additional guidance on approaches to evaluate medical prognosis to make allocation decisions is provided in Attachment 2, which provides specific guidance for hospitals and other health care facilities. See, in particular, pages 65-90.
Applying the Acceptable Allocation Criteria. The acceptable allocation criteria (medical prognosis and supporting critical infrastructure) may apply to several different groups of people. Scarcity may require additional decisions to be made regarding the prioritization of scarce medical resources and services within and across these groups. The type of resource scarcity may be relevant to determining priority for essential personnel compared with others at risk. The decision whether to differentiate between types of resources in granting priority to essential personnel relative to others should be assessed further by decision- makers implementing these Guidelines.
Problematic Allocation Criteria The Committee identified three criteria— lottery , first-come/first-served, and age —that could be considered to make medical resource and service allocation decisions, but only under limited circumstances due to problematic ethical concerns related to their application. The Committee acknowledges that reasonable decision-makers may disagree on whether these criteria are appropriate to use. Yet, these criteria may be useful if scarcity requires prioritization between people who would be indistinguishable based on the acceptable criteria of medical prognosis and supporting critical infrastructure.
State government, local government, EMS, and health care organizations should develop clear triggers to indicate when circumstances necessitate the use of contingency or crisis standards of care. These procedures and standards should be shared with MDHHS and MDHHS should be notified when they are applied.^6
(^6) See I NSTITUTE OF M EDICINE, C RISIS STANDARDS OF C ARE : A T OOLKIT FOR I NDICATORS AND T RIGGERS. Washington, D.C.: The National Academies Press (2013).
circumstances. Decision-makers who are departing from common guidance should only do so after careful deliberation and documentation.
public health capacity. This current version of the Guidelines and all other materials produced through this project are the result of a state level, multi-disciplinary committee.
The approach adopted by these Guidelines reflects the concerns expressed in other reports that have considered the ethical, legal, and practical aspects of allocating scarce medical resources and services during emergencies or disasters.^8 These guidelines are meant to complement other state of Michigan guidance on responding to emergencies or disasters that impact public health.
The Guidelines take a broad approach to addressing scarcity of resources and services during emergencies or disasters. They are structured to be applicable to emergencies or disasters serious enough to require the imposition of crisis standards of care but will apply to emergencies of varying types and will provide guidance to assist in allocation decisions affecting multiple types of resources. Many states have addressed the ethics of scarce resource allocation with regard to specific types of emergencies (e.g., pandemic flu)^9 or specific types of resources (e.g., ventilators or vaccines),^10 while other states have developed more general crisis standards of care guidelines based on national guidance. These Guidelines adopt the general approach and provide a model that can be applied in numerous different circumstances to address the ethical allocation of a wide range of potentially scarce resources, while acknowledging that different types of resources might require different approaches to achieve ethical prioritization.
Creating an ethical allocation framework that can be applied to multiple emergency situations and varying types of medical resource and service scarcity presents a daunting challenge. To achieve this standard, the Guidelines must simultaneously be flexible enough to provide useful guidance in a variety of circumstances and also sufficiently concrete to provide meaningful support in specific situations. The Ethical Allocation Committee approached this quandary by providing both general goals and ethical criteria in the body of the Guidelines as well as more specific information in the report’s appendices applying these ethical criteria in various situations.
(^8) Most influential are three reports on crisis standards of care produced by the Institute of Medicine between 2009 and 2013. I NSTITUTE OF M EDICINE , GUIDANCE FOR E STABLISHING C RISIS STANDARDS OF C ARE FOR U SE IN D ISASTER SITUATIONS: A LETTER R EPORT (2009) https://www.ncbi.nlm. nih.gov/books/NBK219958/; I NSTITUTE OF M EDICINE, C RISIS STANDARDS OF C ARE : A SYSTEMS FRAMEWORK FOR C ATASTROPHIC D ISASTER R ESPONSE (2012), https://pubmed.ncbi.nlm. nih.gov/24830057/; I NSTITUTE OF M EDICINE, C RISIS STANDARDS OF C ARE : A T OOLKIT FOR I NDICATORS AND T RIGGERS. Washington, D.C.: The National Academies Press (2013). Two more recent reports by the National Academies of Sciences, Engineering, and Medicine also provide important context for these issues. NATIONAL A CADEMIES OF SCIENCES, ENGINEERING, AND M EDICINE, FRAMEWORK FOR E QUITABLE ALLOCATION OF COVID-19 V ACCINE (2020), https://doi.org/10.17226/25917; NATIONAL A CADEMIES OF SCIENCES, E NGINEERING, AND M EDICINE, R APID E XPERT C ONSULTATION ON C RISIS STANDARDS OF C ARE FOR THE COVID-19 PANDEMIC (2020), https://doi.org?10.17226/25765.
(^9) Ethics reports produced by authors in Canada as well as the states of Minnesota and Indiana, all of which focus on pandemic influenza. Dorothy W. Vawter et al., “For the Good of Us All: Ethically Rationing Health Resources in Minnesota in a Severe Influenza Pandemic” (2009). Available at: http://www.ahc.umn.edu/mnpanflu/preliminary/rationing/home.html. Indiana State Department of Health. 2008. Confronting the Ethics of Pandemic Influenza Planning: Communique from the 2008 Summit of the States. Available at: http://www.bioethics.iu.edu/communique_2008_summit_of_the_states.pdf
University of Toronto Joint Centre for Bioethics. (2005). Pandemic influenza and ethics – stand on guard for thee: Ethical considerations in preparedness planning for pandemic influenza. Available at: http://www.utoronto.ca/jcb/home/documents/ pandemic.pdf.
(^10) New York, for example, has produced an allocation planning document dealing specifically with ventilators. See New York State Workgroup on Ventilator Allocation in an Influenza Pandemic (2007). Allocation of ventilators in an influenza pandemic: Planning document draft. Available at; http://www.health.state.ny.us/diseases/communicable/influenza/pandemic/ventilators/docs/ventiltaor_guidance.pdf
The Guidelines focus on the state of Michigan and are designed to provide targeted guidance to practitioners and officials. From its inception, this project has endeavored to ensure that ethical discussions reflect the values and decisions of the residents of Michigan. Consistent with this goal, these Guidelines have been developed with extensive input from representatives from a variety of constituencies across the state, reflecting a diversity of expertise, geography, and knowledge.^11
The Guidelines consider the ethical implications of allocating scarce medical services as well as scarce medical resources. While the availability of medical resources (such as medication, medical equipment, ICU beds, health care personnel) and medical services (such as routine wellness care, elective surgery) is often closely connected, the factors in making these allocation decisions may raise different ethical and practical considerations.
These Guidelines are not envisioned as a formalized series of instructions but rather a set of criteria that can be employed by decision-makers in various circumstances during an emergency or disaster, using their best professional discretion. It is expected that these Guidelines will be utilized to develop more detailed allocation plans at various levels throughout the state. Thus, the criteria offered within these Guidelines are meant to be adaptable and functional. However, extreme, or unforeseeable circumstances may challenge the foundations of the framework. In those situations, decision-makers will be expected to use their professional training and prudence to guide allocation decisions. The criteria offered here may have to be amended to address unforeseen circumstances and should be periodically reviewed and updated to incorporate new information gained from practical experience. Successful implementation of the Guidelines will demand ongoing deliberation, transparency, public education and input, and careful evaluation and oversight.
There are many relevant ethical and practical considerations to be taken into account in developing appropriate guidelines for allocation of scarce medical resources and services during emergencies and disasters. The sections below outline some of the factors being used to inform the discussion of the Guidelines.
(^11) These Guidelines took into account other efforts to address the ethical issues that may arise during an influenza pandemic at the regional and hospital levels in Michigan. Three reports in particular were helpful in our initial drafts of these Guidelines: 1) Spectrum Health, Caring for the Community: Preparing for an Influenza Pandemic, Ethics Committee Report (2009) further referred to as “Spectrum Ethics Report”; 2) University of Michigan Hospitals and Health Centers Pandemic Planning Committee Ethics Team, Guidelines for Allocating Life-Saving or Critical Resources During a Pandemic (working draft, August 28, 2009) further referred to as “University of Michigan Ethics Guidelines”; and 3) William Beaumont Hospital, Protocol for Allocation of Scarce Critical Care Resources During a Pandemic Influenza Emergency (draft December 16, 2009) further referred to as “Beaumont Ethics Protocol.” (^12) The Michigan Public Health Code (MCL §§ 333.1101 et seq.) and the Michigan Emergency Management Act (MCL §§ 30.401 et seq.) both have detailed provisions for authorizing legal powers during emergencies and disasters.
