Fair decisions more important when hospitals face crisis like SARS

December 19, 2004

But international medical ethics specialists (appendix 1) who evaluated the performance of one large Toronto area hospital during last year's SARS outbreak conclude that procedural requirements, particularly fair and ethical priority-setting, are even more important in the midst of a crisis.

"Hospitals operate at their best when staff and patients trust the process," says Doug Martin, PhD, who led the study for the University of Toronto Joint Centre for Bioethics (JCB). "But the SARS outbreak raised questions that many hospital administrators and staff had never faced before."

The study group identified a number of decision-making difficulties affecting both SARS and non-SARS patients.

Among them:
  • To what extent should the need to contain the outbreak override other important needs? In early stages of the outbreak, the hospital suspended all surgery and banned visitations, causing considerable hardship to the most seriously ill non-SARS patients and their families; and

  • To what extent should the need for quick decisions override the need for legitimate and fair decision making? Upon resumption of normal hospital operations, there was considerable pressure to move quickly to ease the surgical backlog.

    The group's report, published today by U.K.-based Biomed Central, concludes that "in the midst of a crisis such as SARS where guidance is incomplete, consequences uncertain and information constantly changing, where hour-by-hour decisions involve life and death, fairness is more important rather than less."

    The hospital's decision making practices were evaluated using the "accountability for reasonableness" ethical framework, developed by the JCB to guide fair priority setting in health care organizations. Under this framework, an institution's priority setting is judged fair if four conditions are met:

  • Relevance: Rationales for priority setting decisions must rest on reasons that 'fair-minded' people can agree are relevant in the context.
  • Revision/Appeals: There must be a mechanism for challenge, including the opportunity to revise decisions in light of stakeholder concerns.
  • Publicity: Priority setting decisions and their rationales must be publicly accessible.
  • Enforcement: There is either voluntary or public regulation of the process to ensure that the first three conditions are met.

    Researchers examined more than 200 documents (including e-mails and minutes of meetings) and 35 interviews with senior administrators, physicians, managers, nurses, other staff, a patient and family members.

    The study found there were two distinct phases of priority setting at the hospital during the SARS outbreak, the initial containment phase and the subsequent "ramp up," during which the hospital gradually increased its level of activity.

    Throughout each stage, safety was the primary rationale underpinning priority setting. During the containment stage, decisions made for infection control focused on protecting staff. Measures included sending staff home, canceling all non-SARS related surgeries, and terminating hospital educational activities and patient visitation, the latter resulting in a "major backlash," from family members unable to say goodbye to a dying relative, for example, or patients anxious about the delay of a vital operation, says Dr. Martin. In some cases patients were further exasperated being unable to get through or even to leave a message because the surgeon's voice mail boxes were full.

    The prolonged crisis took a toll on the morale of doctors as well as patients. One surgeon seeing many patients in need of an operation reported depression at being unable for weeks on end to save or improve a life. He likened it to a firefighter with both feet in concrete blocks 100 feet from a burning house unable to save someone inside.

    During the ramp up phase, decisions were based more on a duty to care for patients. Urgent surgeries were scheduled, hospital visits resumed under strictly controlled conditions and other areas of hospital operations began returning to normal. Doctors wrestled with questions of the order in which patients should go into surgery.

    The study group suggests a number of areas where the hospital could improve its priority setting procedures:

  • Patients and families need better access to the reasons behind decisions, including the visitation policy and ramp up of clinical activities;

  • A formal revision/appeals mechanism to improve the quality of decision making and alleviate the unfair influence of "squeaky wheels" -- informal complaints from patients, family and staff, particularly as it related to the surgery queue; and

  • Institutional leaders should maintain two-way contact with front-line staff implementing priority setting decisions, providing support and enhancing accountability for decision making by staff.

    "During the SARS outbreak the hospital's leadership developed and implemented several sophisticated processes to help with their crisis management," according to the study. "Tailoring those processes to meet the four conditions of 'accountability for reasonableness' is not any more difficult or demanding. Moreover, we argue and some of the participants [in the study] also argued, that in the midst of a crisis... fairness is more important rather than less."

    "Even though the crisis created safety concerns and time constraints that impinged on decision making, the hospital in this study endeavored to meet the conditions of fairness," said Sylvia Hyland, a pharmacist and co-investigator of the study.

    "It's been a year and a half since the terrible consequences of the SARS crisis hit Toronto," she added. "It is important to remember and draw lessons from the difficulties inflicted on everyone -- medical personnel, SARS victims, non-SARS patients and their families alike."
    Appendix 1:
    The research team: Jennifer A.H. Bell, BA, Sylvia Hyland, BScPhm, Tania DePellegrin, MHSc, Ross E.G. Upshur, MD, MSc, Mark Bernstein, MD, MHSc, FRCSC, Douglas K. Martin, PhD

    University of Toronto Joint Centre for Bioethics

    Innovative. Interdisciplinary. International. Improving health care through bioethics.

    The JCB is a partnership among the University of Toronto and nine hospitals. It provides leadership in bioethics research, education, and clinical activities. Its vision is to be a model of interdisciplinary collaboration in order to create new knowledge and improve practices with respect to bioethics. The JCB does not advocate positions on specific issues, although its individual members may do so.

    For more information: http://www.utoronto.ca/jcb/

    University of Toronto Joint Center for Bioethics

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