TABLE 1.

Summary of Scenarios and Stakeholder Reactions

Scenario 1: Allocation of Scarce Resources
Context:  Your community is in the midst of influenza pandemic, and oseltamivir phosphate (ie, Tamiflu) is the only drug that may effectively reduce mortality of ill patients and limit infection of exposed people. Issue:  Supplies of Tamiflu are limited, and hospitals across the country are independently making decisions to govern allocation of antiviral medications. The 4 major hospitals in a given geographic area have recently established different protocols regarding prioritization of antivirals:   Hospital A: Prophylaxis of staff who are exposed while caring for influenza patients.   Hospital B: Treatment of the sickest influenza patients.   Hospital C: Treatment of the patients most likely to benefit, namely those who present within 48 h of symptom onset.   Hospital D: Prophylaxis of exposed staff and treatment of all probable and confirmed cases, regardless of severity.	Stakeholder Reactions:  Consumers supported the approach of reserving antiviral medications for those most likely to benefit.  Providers did not reach consensus in support of a particular approach, but strongly advocated for the protection of health care providers and first responders as a top priority.  Both groups agreed that decisions governing the prioritization of scarce resources must be unified at the state level.  Both groups agreed that, for this strategy to be effective, it must be accompanied by aggressive risk communication to health care providers and the public.
Scenario 2: Prioritization of Critical Care
Context:  You are 6 wk into the pandemic, and the health care system has been taxed beyond capacity, with every hospital bed full, every ventilator in use, and all health care providers working extended shifts. To increase the number of available beds to accommodate the surge of influenza patients, all scheduled operations have been postponed for the past 2 wk. Issue:  The postponed procedures include diagnostic and palliative operations for patients with pancreatic cancer, ovarian cancer, and malignant brain tumors, among other diseases. For many of these patients, their expected survival is <6 mo, but without immediate operations, they will likely die within 2 wk. As a result of the pandemic, medical resources are scarce, and the usual critical care that would follow those operations cannot be provided to all in need. Hospitals across the country are independently making decisions to govern how to modify standards of critical care to provide limited but high-yield critical care interventions and processes for many additional patients.   Hospital A: Providing critical care according to usual standards on a first-come, first-served basis.   Hospital B: Providing key critical care interventions only to those patients with an expected survival of >6 mo.	Stakeholder Reactions:  Both consumers and providers strongly opposed the approach of maximizing life-years saved by only providing key critical care interventions to patients with an expected survival of >6 mo.  Providers felt that triage on a case-by-case basis would be more realistic and ethically sound, whereas consumers were strongly and emotionally opposed to any model of limiting critical care interventions.  Providers also favored individual hospitals having ultimate authority over such decisions, using an institutional review board model, and identifying a small committee to which these decisions could be referred.
Scenario 3: Government Control of Private Institutions
Context:  You are 2 mo into the pandemic, and all health care facilities are challenged by continuing to provide care with increasingly limited resources. The large medical centers have managed to cope, but many community hospitals have been struggling to continue providing care. Issue:  An effective community response to the pandemic requires that all health care facilities be mobilized to their fullest potential, but these community hospitals require outside logistical support and supplies to continue operating. Anticipating these problems, states across the country are establishing laws to govern seizure of private assets.   State A: After trying without success to persuade the large medical centers to provide some of their ventilators and expert staff to community hospitals, state A seized and redistributed ventilators.   State B: Fearing that it would create a disincentive for preparedness among hospitals in the future, state B did not seize hospital resources. As a result, several of the smaller community hospitals in state B are no longer able to staff available beds due to shortages of personnel and resources.	Stakeholder Reactions:  Both consumers and providers opposed state seizure and redistribution of hospital-owned ventilators.  Providers felt that it would be more practical to transfer patients to hospitals with available resources rather than to move ventilators and other resources.  Consumers were concerned that seizure and redistribution of resources would be a disincentive to hospital preparedness.  Both groups were strongly in favor of state tracking of ventilators and other health care resources.
Scenario 4: Provider Safety vs Duty to Care
Context:  Dr Smith is a surgeon at hospital B. Ever since his hospital’s cache of N-95 respirators was depleted last week, a number of Dr Smith’s colleagues have contracted influenza. Issue:  Dr Smith fears for his own safety in the absence of appropriate personal protective equipment, and is also concerned about exposing his wife and 2 young children to influenza. His wife insists that he stay home from work rather than risking exposure, but Dr Smith has a deep commitment to his profession and feels a strong duty to care for his patients. In light of his concerns, Dr Smith is torn between his personal desire to protect himself and his family and his professional mission to use his skills and expertise to help the patients who need him.	Stakeholder Reactions:  Both consumers and providers believed that Dr Smith should continue to work, despite his concerns about his personal safety.  Providers emphasized the importance of the ethical code governing physician duty to care, and noted that failing to care for patients may result in legal and/or licensing issues.  Both groups strongly supported prospective action on behalf of hospitals to protect their staff and families of staff so that issues such as this do not arise, for example, stockpiling personal protective equipment, promoting personal/family emergency preparedness, and providing emergency accommodations for staff who do not want to go home and risk infecting their families.
Scenario 5: Prioritization of Critical Care—The Provider’s Perspective
Context:  As a surgeon, Dr Smith deeply opposes hospital B’s decision to provide key critical care interventions only to those patients with an expected survival of >6 mo. Issue:  This new rule requires that Dr Smith cancel a bowel obstruction surgery scheduled for later this week. Without surgery, his patient—a 36-y-old mother of 3 with ovarian cancer—will die within 2 wk. Dr Smith is considering performing the operation in violation of hospital rules, potentially risking his career. In light of his disagreement with recent hospital policies, Dr Smith is torn between his professional mission to use his skills and expertise to help the patients who need him, and his obligation to observe the rules of his institution.	Stakeholder Reactions:  Although both groups expressed the importance of health care providers serving as advocates for their patients, providers particularly opposed Dr Smith violating hospital policy.  Providers acknowledged that a surgeon’s decision to violate hospital rules would implicate a number of others in the process.  Providers identified the need for improved systems within hospitals to support physicians in the event that rules governing the allocation of critical care interventions are introduced, for example, liability protection, mental health support.