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Streit um die Frage einer eventuellen Rationierung von Beatmungsgeräten im Falle einer schweren Pandemie

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  • Streit um die Frage einer eventuellen Rationierung von Beatmungsgeräten im Falle einer schweren Pandemie

    Während einer für die Öffentlichkeit zugänglichen Konferenz, die am Montag von einer Beraterkommission der CDC abgehalten wurde, ist ein heftiger Streit entbrannt. Es ging in der Konferenz um die Frage einer evtl. Rationierung von Beatmungsgeräten im Falle einer schweren Pandemie.

    Aus dem Auditorium kam ein Zwischenruf von Marcia Baker, die Parallelen zum Dritten Reich aufkommen sah und die Überlegungen als „Hitler-ähnliche Methoden“ bezeichnete. Sie erhob die Forderung, man müsse so viele Beatmungsgeräte wie nötig beschaffen, egal was es koste.

    Die Vorwürfe wurden von Ron Bayer (Columbia University's Mailman School of Public Health), einem Mitglied des Beraterkomitees, zurückgewiesen. Ein anders Mitglied der Expertenrunde, Norman Daniels von der “Harvard School of Public Health“, sagte, es sei „einfach unrealistisch und vermutlich nicht einmal klug“, in einer Epidemie, bei der Millionen erkranken könnten, beliebig viele Beatmungsgeräte vorzuhalten für jedermann, der ein solchen Gerät benötigen könnte.

    Der Entwurf einer unautorisierten Vorabversion entsprechender Leitlinien wurde von der Organisation „Propublica“ der Öffentlichkeit zugänglich gemacht.

    Credits to Snowy Owl:
    CIDRAP - Daily News – November, 2009 (November 25, post # 29)

    CDC advisors pressed on ventilator allocation

    A conference call among advisors to the Centers for Disease Control and Prevention (CDC), held to discuss rationing of ventilators in a severe pandemic, turned contentious Monday, according to the Web site Politico. One member of the public who asked questions during the call said the strategy was "Hitlerian" and called for buying as many ventilators as would be necessary to treat potentially millions of patients, regardless of the cost. An adviser called that approach unrealistic. [Nov 23 Politico report]

    November 23, 2009

    CDC ventilator rationing panel rejects attack

    Members of a federal panel advising the Centers for Disease Control on guidelines for how ventilators should be allocated in the event swine flu worsens responded forcefully and, in one case angrily, on Monday to suggestions that the effort would cavalierly snuff out the lives of those deemed unworthy.

    During a meeting of a CDC ethics subcommittee held via conference call Monday, a member of the public urged that, rather than focusing on who should and shouldn't get ventilators in a crisis, the focus should be on building up health care infrastructure to avoid such shortages.

    "We dont even have enough beds per thousand in a lot of parts of the country," Marcia Baker said during the public comment period, before suggesting that the effort was akin to the kind of "rationing in England."

    Baker, who did not further identify herself, later went beyond the England references, raising parallels to the Third Reich.

    "If we otherwise keep presuming we’re not going to build for the peak of a severe pandemic, in case this current one even if it comes back in waves isn’t, then we end up going down this road," she said. "It's kind of Hitlerian. You’re going to have to decide who isn’t worthy to live and I think that’s the basic ethical consideration that should be raised and not just accept the kind of triage decisions you’re making. There’s triage in the case of absolute catastrophe, but not self made catastrophe."

    Initially, the CDC's chief science officer, Drue Barrett, said the thrust of Baker's comment was a valid one.

    “That’s a good point,” Barrett said. “It’s something we do address…in terms of the importance of building infrastructure and being prepared for the next emergency. Our document does refer to that it also refers to the need to balance pandemic preparedness requirements with other health care and public health needs.”

    However, one member of the panel took offense at the Nazi reference.

    "Listen, I’m a member of the committee and I have to say, although you’re perfectly free to express your point of view, I resent your assertion that anything we’ve done bears any resemblance to Hitlerian thinking," said Ron Bayer of Columbia University's Mailman School of Public Health.

    Another panel member, Norman Daniels of the Harvard School of Public Health, suggested it was simply unrealistic and probably not even wise to stockpile enough ventilators to serve everyone who might need one in a severe flu epdiemic that could sicken millions.

    "I am really very puzzled at what you're suggesting," Daniels said to Baker. "It seems to me that you're suggesting we could purchase ventilators that would meet any crisis in number, regardless of how serious it was. And I'd like to know whether you'll want to pay the taxes?"

    Earlier in the meeting, the subcommittee voted without dissent to adopt the proposed guidelines and send them on to the main advisory committee for approval. ProPublica has a write-up of the guidelines here* and the near-final text here**.

    Panel members stressed Monday, at the request of CDC management, that the guidelines on rationing ventilators are not intended to be used at the moment, but only if hospitals and nursing homes become overburdened with severely ill flu patients.

    "This document really applied to a time when the pandemic is so severe that the supply and resources are really overwhelmed," Barrett said. "At this point, it is not a severe pandemic."

    Posted by Josh Gerstein 07:22 PM

    * Link to write-up of the guidelines:
    Your Chance to Weigh In on Ventilator Rationing for a Severe Flu Pandemic

    by Sheri Fink, ProPublica - November 23, 2009 8:45 am EST

    On Monday, ordinary Americans get a rare opportunity to weigh in on a life-and-death issue: Who gets access to scarce, life-saving treatments during a disaster?
    The public has been invited to participate in a teleconference [1] (PDF) in which advisers to the Centers for Disease Control and Prevention will discuss ethical guidance they have drawn up for rationing mechanical ventilators in a severe influenza pandemic. (As we've reported [2], many states have been quietly laying plans for such a scenario. For example, Florida has considered excluding certain patients [3] from ventilators.)
    Chances are, few people will phone in to join Monday's meeting. CDC officials have not advertised the session outside of a notice published late in the Federal Register.
    But you can join in. The hourlong conference takes place at 3 p.m. EST and anyone can listen to the proceedings by calling (866) 919-3560 and entering passcode 4168828. According to the agenda, the committee is scheduled to vote on the guidance before it opens the meeting to public comments. The document will then go to the full advisory committee to the director of the CDC for approval.
    The views of the advisory committee to the CDC director are not binding on states, which have ultimate authority over how to handle health emergencies. But the guidance is intended to serve as a "foundation for decision making" for health policymakers "at all levels -- federal, tribal, territorial, state, and local," according to the document.
    The draft guidance document [4] (PDF) to be discussed on the call has not been widely released and was provided to ProPublica only after requests to several members of panel.
    The document, dated Oct. 30, 2009, has some intriguing features. It parts company with several aspects of the guidelines drafted by states like New York and Florida, but it still envisions, at a time of extreme emergency, taking off of ventilators those patients who are not improving, to make way for others who may have better chances of surviving, even if family members do not agree. It says ethical guidance is particularly timely because shortages of mechanical ventilators could arise in the coming months if the H1N1 or "swine flu" virus becomes more widespread or severe.
    According to a CDC spokesman, the guidelines were "developed independently" by an "independent group of experts on ethical principles" and are not CDC recommendations -- even though CDC employees made up two-thirds of the 18-member group that drafted the document. Fewer than half of the group's members had substantial backgrounds in bioethics. Some helped write the allocation schemes analyzed in the document, putting them in the potentially uncomfortable position of assessing their own work.
    The document, which makes few specific recommendations, offers what it terms an "ethical framework" for policymakers who are deciding who should receive ventilators:
    • New York, Utah, Florida and other states and groups of medical professionals have drafted pandemic triage guidelines that call for patients with certain pre-existing conditions (such as the elderly or those with advanced cancer, severe heart disease or severe neurological deficits) to be categorically excluded from access to ventilators or hospital admission in a severe pandemic. The panel suggested a different approach: All patients should be given a priority score calculated to reflect a variety of factors, such as the likelihood they would survive if given a ventilator, the number of years they are expected to live, or age. Guidelines should be based on evidence and revised on the basis of research, and no one should be summarily excluded.
    • The panel questioned whether it would be fair for policymakers to require certain people who have a comparatively lower but still reasonable chance of survival to give up ventilators to others with a better chance at survival, in an effort to increase the number of lives saved across a population. The document suggests that the goal of maximizing the "health of the public" in a disaster be weighed against giving all patients "a fair chance at survival."
    • The group advised against factoring an individual's perceived contributions to society into allocation decisions, writing: "In our morally pluralistic society, there has been widespread rejection of the idea that one individual is intrinsically more worthy of saving than another."
    • However, the committee accepted another controversial idea -- that mechanical ventilators could be disconnected from patients "whose prognosis has significantly worsened," regardless of their wishes, and provide those ventilators to "patients with a better prognosis." Patients, it said, "should be notified this will occur, given a chance to say good-byes and complete religious rituals, and provided compassionate palliative care."
    Some doctors have questioned that last concept. The U.S. Supreme Court's acceptance of withdrawing life support hinges on the 14th Amendment's guarantees of a right to liberty. A patient or the patient's legal surrogate has a right to refuse treatment (or in rare cases a doctor can deem a treatment "futile" or not beneficial to the patient). Many of the states' triage plans for pandemics do not envision seeking consent before ventilators are withdrawn. Decisions would be made by clinicians using a clinical scoring system or exclusion criteria.
    The draft document advises policymakers to include the public in "frank dialogue and genuine deliberation" about the various tradeoffs among the principles. "Most importantly," the report said, "the values and priorities of community members who will be impacted by decisions about allocation of scarce life-saving resources must be considered in the development of triage plans."
    Thus far, the public has been little engaged. The ethics group spent two years drafting the document, and did not, as part of its deliberations, specifically reach out to the broader community.

    ** Link to draft-version (near-final text):