Ethical Framework for Nutrition Support Resource Allocation During Shortages: Lessons From COVID‐19

Abstract

The coronavirus disease 2019 (COVID‐19) pandemic has impacted all aspects of our population. The “Troubling Trichotomy” of what can be done technologically, what should be done ethically, and what must be done legally is a reality during these unusual circumstances. Recent ethical considerations regarding allocation of scarce resources, such as mechanical ventilators, have been proposed. These can apply to other disciplines such as nutrition support, although decisions regarding nutrition support have a diminished potential for devastating outcomes. The principal values and goals leading to an ethical framework for a uniform, fair, and objective approach are reviewed in this article, with a focus on nutrition support. Some historical aspects of shortages in nutrition supplies and products during normal circumstances, as well as others during national crises, are outlined. The development and implementation of protocols using a scoring system seems best addressed by multidisciplinary ethics and triage committees with synergistic but disparate functions. Triage committees should alleviate the burdens of unilateral decisions by the healthcare team caring for patients. The treating team should make every attempt to have patients and the public at large update or execute/develop advance directives. Legal considerations, as the third component of the Troubling Trichotomy, are of some concern when rationing care. The likelihood that criminal or civil charges could be brought against individual healthcare professionals or institutions can be minimized, if fair protocols are uniformly applied and deliberations well documented.

Challenges of Maintaining Optimal Nutrition Status in COVID‐19 Patients in Intensive Care Settings

“…9 Additional battles include product shortages and staffing shortages due to hospital census decreasing, though on the front line, the acuity of these patients has skyrocketed. 11 The acuity is higher than any patient population previously seen. As these patients are labile with medical status changing daily, it is imperative that the RDNs provide intensive follow-up daily as well.…”

“…Barrocas et al recently discussed the strategies that could be implemented for allocation of the nutrition resources during the COVID-19 crisis, keeping ethical factors into consideration. 11 In current scenarios, when at many times it might not be possible to provide the ideal nutrition care to all the patients in need, the nutrition support professionals could help the treating team and respective RDNs in collective, informed decision making by using the standardized prognostic and survival parameters. 11 Nutrition support professionals can provide essential input with regards to the type of feed, route of delivery, volume, etc.…”

“…11 In current scenarios, when at many times it might not be possible to provide the ideal nutrition care to all the patients in need, the nutrition support professionals could help the treating team and respective RDNs in collective, informed decision making by using the standardized prognostic and survival parameters. 11 Nutrition support professionals can provide essential input with regards to the type of feed, route of delivery, volume, etc. When scarcity of resources is a major concern, they can triage and evaluate which patients could benefit the most.…”

Advancing Nutrition and Dietetics Practice: Dealing With Ethical Issues of Nutrition and Hydration

“…The COVID-19 pandemic resulted in increased demand and some instances of a shortage of personal protective equipment, hospital beds, intensive care unit (ICU) beds and supplies, and ventilators, along with the availability of the medical workforce, which became ill or quarantined. 22 Emanuel (3) If a feeding strategy is started in one site, it may have to be stopped when the individual is transferred to another site within the same facility or to another facility. This can lead to a sense of abandonment for the person.…”

“…The COVID-19 pandemic resulted in increased demand and some instances of a shortage of personal protective equipment, hospital beds, intensive care unit (ICU) beds and supplies, and ventilators, along with the availability of the medical workforce, which became ill or quarantined. 22 Emanuel et al 23 proposed 4 ethical values in a pandemic: maximizing the benefits achieved with limited resources, treating people equally, promoting and rewarding instrumental value (giving priority to those who can save others or to those who have saved others in the past), and giving priority to the worst off. These 4 proposed ethical values may be a matter of intense ethical debate.…”