Original Articles

By Dr. Daniel Howes , Dr. Ellen Tsai
Corresponding Author Dr. Daniel Howes
Emergency Medicine Queen's University, 20-202 102 Stuart St - Canada K7L 2V6
Submitting Author Dr. Daniel Howes
Other Authors Dr. Ellen Tsai
Department of Pediatrics, Queen's University, Kingston General Hospitaln76 Stuart StnKingston, ONnCanada - Canada K7L 2V7


ethics, resource allocation, pandemic, critical care, emergency medicine, ventilator

Howes D, Tsai E. Ventilator Allocation In A Pandemic: Discussion And A Model For Rationing Restricted Resources. WebmedCentral MEDICAL ETHICS 2010;1(12):WMC001258
doi: 10.9754/journal.wmc.2010.001258
Submitted on: 01 Dec 2010 04:31:31 PM GMT
Published on: 03 Dec 2010 05:37:57 PM GMT


In a state of emergency, increased demands for limited resources force a shift in the standards of care. With preparation and thoughtful deliberation, we can ensure that these changes in care continue to be consistent with our ethical principles.

In a respiratory infectious disease outbreak or other disaster, the demand for ventilators may outstrip the supply. Once efforts to shift demand or increase supply have been exhausted, clinicians may be put in the very difficult position of rationing this life-sustaining resource. The values and principles of these situations have been well outlined in the work of the University of Toronto Joint Centre for Bioethics (JCB) in their document Stand on Guard for Thee - Ethical considerations in preparedness planning for pandemic influenza, but it has been challenging to develop a practical method of implementing the values they describe.

 We build on the values outlined by the JCB with addition of the very practical value of expediency. We outline also a protocol to maximize benefit from a limited resource during a crisis (ventilators in a flu pandemic) with a discussion that focuses on ethical and practical implementation.


During an infectious disease outbreak or disaster, clinicians may find themselves in the difficult position of having to choose who among multiple patients in their care will be allocated a limited resource[[i]]. This may put them in a real or perceived conflict of interest. Protocols for this decision-making process can help assure the public that resource allocation is fair both in terms of procedure and outcome, while providing a reasonable, attainable standard for decision-makers.
In 2010 the European Society of Intensive Care Medicine’s task force for ICU Triage during an Influenza Epidemic or Mass Disaster[[ii]] provided recommendations for these situations. Their recommendations include the implementation of an executive control group with authority over resource allocation; they note that usual care standards may be impossible to achieve, and that some treatments may have to be withheld or withdrawn resulting in patient death. They recommend that decisions be made by a triage officer using a protocol that is objective, ethical, transparent and equitably applied, but they were unable to conclude whether triage should be based on a ‘first come, first served’ basis or in a manner to provide the most benefit.
In Canada a number of provincial pandemic and emergency plans address the issue of resource allocation and decision-making with general guidelines. Most of these are based on the principles outlined in the work of the University of Toronto Joint Centre for Bioethics (JCB) in their document Stand on Guard for Thee - Ethical considerations in preparedness planning for pandemic influenza[[iii]]. They identify four substantive values and five procedural values that are most applicable to situations of rationing (table 1). Attempts to recommend procedures based on these values has resulted in inclusive but impractical decision-making recommendations[[iv]]
Christian et al[[v]] and Tia et al[[vi]] have proposed the use of a triage-scoring tool for allocating ventilator resources during a pandemic. Triage tools are consistent in how they are applied and how decisions are made over time. They involve stakeholders, can be used quickly, and release clinicians from some of the psychological burden of making difficult choices. The disadvantage of static triage tools is that they do not adjust to the variations in resource availability, and may not represent the values of the community. Frolic et al. [[vii]] found significant gaps in the recommendations when they tried to implement these tools, in that they lack precision, haven’t been validated, and don’t consider a number of non-clinical variables.
We propose a process where an individual triage officer uses a dynamic triage tool that is kept current and supported by a two-tiered committee. The tool includes triage-scoring information for patients already on ventilators as well as direction on how to deal with nonclinical issues. The goals of the protocol are to meet the nine values outlined by the JCB with the additional value of expediency, and to be practical enough for urgent implementation during a crisis.


Principles and Values:
The European ICU triage guidelines [2] were unable to come to consensus whether the limited resource should be allocated to those who will benefit most or a ‘first-in-line’ basis. We functioned under the premise that publicly owned or supported health care resources (such as ventilators) are shared by all members of the supporting society, and that the goal of access to shared resources is to improve health. For that reason, the overriding principle is a utilitarian ethic, that the allocation of resources should produce the greatest health benefit. This material principle is chosen over a predominant alternative, which is allocation on a first-come, first-served basis.
The first-in-line alternative is tempting for its potential to free decision-makers of emotional stress. After some consideration, however, it seemed unlikely that an otherwise healthy patient with a high likelihood of successful treatment would be palliated as another patient with poor baseline health and a small chance of survival continues their treatment. Adoption of this alternative seemed to conflict with societal goals and risk putting decision-makers at odds with the protocol.
The values used to develop the protocol guideline are listed in Table 1. As noted in the introduction, the values are derived from the JCB recommendations [3] with the addition of the procedural value of expediency. One of the additional challenges in the allocation of critical care resources such as ventilators is that the decision must almost always be made quickly. If the protocol cannot function at the speed that clinician needs the decision, it is of limited value in this environment. The clinician will remain trapped in a conflict of interest that the guideline was meant to mitigate, and will be unable to adhere to a recommended yet unattainable standard, increasing the stress of an already very difficult situation.
Protocol Activation:
The protocol should only come into effect when resources are unable to meet the demand. Prior to invoking the protocol, the institution or regional health authority should make all reasonable efforts to secure additional resources and redistribute the demand.
Decisions covered under the protocol:
While the protocol is in effect, all decisions about ventilator use should be made using the ventilator allocation protocol. The protocol should specify the ventilator pool covered by the protocol. Ideally the decision-making should be centralized for a given resource pool; for example, if for a given region there is the ability to move patients between centers or to move ventilators between locations, decisions should be made centrally to minimize variations in care between hospitals.
Decision makers:
Physicians providing patient care should not be the decision makers. Their role of patient advocate for all of the patients competing for the resource puts them in a position of perceived conflict. Other groups [[i], [ii]] have advocated for decision by committee to help minimize the burden of decision. We felt that this process would interfere with our value of expediency, and that the experienced Critical Care physician might be better equipped to deal with the emotional burden than committee members taken from other stakeholder groups.
We propose a solution with a three-tiered approach. Time-sensitive decisions are made by a “triage officer,” an intensivist on-call for a 24-hour period. The decisions are assisted by a dynamic triage tool and reviewed by a three person administrative committee, with oversight and guidance from a broader stakeholder based protocol committee who creates Hard and Soft Guidelines.
The triage officer is an attending critical care physician who does not have any patient care responsibilities during their on-call period. During their 24-hour on-call period the triage officer makes all decisions about ventilator allocation for the resource pool.
The administrative committee is a group of three clinicians who rotate on-call duties as triage officer. The committee meets daily to review the decisions for the last 24 hours and to review the current status and create a ranking of the ventilated patients using a tool such as the modified SOFA score described by Christian et al[[iii]].
The decision-making values, triage tool, and documentation templates are developed, reviewed and maintained by the protocol committee. The protocol committee is composed of relevant stakeholders, including caregivers and members of the public and is responsible for protocol development and oversight of the administrative committee.
Decision-Making Process:
A narrative of the decision process is outlined in Appendix II.
The decision to offer, withhold or remove ventilatory support is a complex one. Standardization of the process using scoring tools has the advantage of transparency and reproducibility and mitigates invisible rationing. It also helps protect the decision-maker from some of the emotional and potential legal burden of the responsibility.
Unfortunately, there is no scoring system currently available that is able to incorporate all of the variables that should be considered in these types of decisions. The triage officer is guided by patient information that includes past medical history, severity of illness scores and indicators, an understanding of the current ventilator supply and demand, and the severity of illness of patients currently being ventilated.  The decision is also guided by the ethical principles and values detailed by the protocol committee.
The Protocol committee’s values and principles are communicated as Hard Guidelines and Soft Guidelines. Hard Guidelines include the Substantive values of the protocol (Equity, Trust, Solidarity and Stewardship) and human rights law (e.g.: decisions not be made on the basis of gender, sexual-orientation, race, religion, or age.)
The soft guidelines direct the triage officer around ethical issues that they are likely to encounter based on the discussions of the protocol committee at their inception. The committee will determine its position on issues like: prioritization of healthcare workers, prioritization of caregivers, fair-innings/life-cycle principle, heroism, and populations at risk[[iv]]. 
Reallocation of resources
In our protocol, we decided that allocation of a ventilator does not confer a guarantee that the patient will continue to have access to the resource. This position is important to the ongoing decision-making process. If resource allocation is committed for the duration of the patient’s illness, triage officers will have to anticipate future demands and predict the illness course of each patient. Neither of these is likely to be accurate, and decision-makers might be put in significant moral distress.
The decision to withdraw the resource should trigger a procedure that provides palliation for the patient as well as support for the family.
Appeal of decisions
Due to the urgency of these decisions, an appeal process that defers the decision is not practical. If the clinician disagrees with the triage officer’s decision and there is a reasonable way to temporize the patient without removing a resource from another patient, the administrative committee could be assembled to hear the appeal. If there is disagreement and the conditions for hearing the appeal outlined above are not possible, the decision of the triage officer will be final, and be reviewed at a later date by the administrative committee.
Families and personal representatives of the patient should not be allowed to directly appeal to the administrative committee. Such an appeal would most likely be for presenting information that should be specifically excluded from the decision-making process (e.g., social status, worthiness).
It is important to ensure that the triage officer and administrative committee members are not unduly influenced by emotional appeals, physical or legal threats.
During a disaster situation, it will be important for institutions to provide information to patients and their families about the increased demand and lack of sufficient resources. It will be particularly important that patients and families are aware of the unpleasant possibility that the patient may have to be removed from the ventilator under certain circumstances. The nature of the protocol, the decision-making process, as well as the values on which the protocol is based should be transparent and well communicated.


In a state of emergency, increased demands for limited resources compel a shift in the standards of care. With preparation and thoughtful deliberation, we can ensure our decisions continue to be consistent with our ethical principles. Efforts to guarantee fairness must be tempered with practical considerations. Decision-makers should be well supported and given guidance, but ultimately the system will have to trust them to do their best in a difficult situation.


JCB - Toronto Joint Centre for Bioethics

Authors Contribution(s)

Dr. Howes created the original draft of the manuscript. Both authors reviewed and edited the manuscript as well as the protocol.


1.Eggertson L. Critical care doctors want escalated pandemic planning Can. Med. Assoc. J., 2009; 181: 253-254.
2.Christian MD, Joynt GM, Hick JL, Colvin J, Danis M, Sprung CL. Chapter 7. Critical care triage. Intensive Care Med. 2010; 36 (Suppl 1):S55-S64.
3.University of Toronto Joint Centre for Bioethics Pandemic Influenza Working Group. Stand on Guard for Thee: ethical considerations in preparedness planning for pandemic influenza. Toronto: University of Toronto Joint Centre for Bioethics; 2005.
4.Nova Scotia Health System Pandemic Influenza Plan: Reference 1: Ethical Considerations and Decision-Making Framework. May 2007.
5.Christian MD, Hawryluck L, Wax RS, Cook T, Lazar NM et al. Development of a triage protocol for critical care during an influenza pandemic. Can. Med. Assoc. J. 2006; 175: 1377-81.
6.Powell T, Christ K, Birkhead GS. Allocation of Ventilators in a Public Health Disaster. Disaster Med Public Health Preparedness. 2008;2:20-26.
7.Frolic a, Kata A, Kraus P. Development f a Critical Care Triage Protocol for Pandemic Influenza: Integrating Ethics, Evidence and Effectiveness. Healthcare Quarterly 2009. 12(4): 56-64.
8.Nova Scotia Health System Pandemic Influenza Plan: Reference 1: Ethical Considerations and Decision-Making Framework. May 2007.
9.Frolic a, Kata A, Kraus P. Development f a Critical Care Triage Protocol for Pandemic Influenza: Integrating Ethics, Evidence and Effectiveness. Healthcare Quarterly 2009. 12(4): 56-64.
10.Christian MD, Joynt GM, Hick JL, Colvin J, Danis M, Sprung CL. Chapter 7. Critical care triage. Intensive Care Med. 2010; 36 (Suppl 1):S55-S64.
11.  Frolic a, Kata A, Kraus P. Development f a Critical Care Triage Protocol for Pandemic Influenza: Integrating Ethics, Evidence and Effectiveness. Healthcare Quarterly 2009. 12(4): 56-64.

Source(s) of Funding

No funding was required for the completion of this manuscript.

Competing Interests

Neither Author has any competing interests


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