Table 1.

Allocation strategies and considerations in the COVID-19 pandemic.

Allocation strategy	Definition	COVID-19 pandemic application
Utilitarian	Prioritizing based on likelihood of survival. Saving the most lives.	-Favoring VV-ECMO allocation to patients with lower RESP score or based on another risk calculator. -Ignores other morally relevant considerations
Life stages or QALYs preserved	Saving the most life years QALY.	-No appropriate validated risk tool available. -Introduces subjectivity, consider multidisciplinary approach.
Likelihood of death	Prioritizing individuals of the greatest acuity.	-The sickest patients will naturally have lower survival resulting in worsened outcomes. -Significant resources may be spent in medically inappropriate cases.
Societal value	Prioritizing individuals with particular instrumental or social value.	-Who should be prioritized, to what degree? (Politicians, religious figures, health care workers, military personnel) -May invite controversy.
First come, first served	Prioritizing patients currently on VV-ECMO	-Accounts for no clinically or socially relevant factors. -Significant resources may be spent in medically inappropriate cases. -Disparately impacts those communities with least access to ECMO centers.
Lottery	Prioritizing patients based on random chance.	-Accounts for no clinically or socially relevant factors.
Self-sacrifice	Allowing individuals or surrogate decision makers acting on their behalf to disavow their right to VV-ECMO.	-Potentially coercive or impacted by distressed emotional state in time of crisis. -Potential for conflict.
Combination	Prioritizing patients based on more than one rationing strategy.	-May inform institutional scoring rubric established a priori. -Consider multidisciplinary approach, evolving needs.

Abbreviations: QALY, quality adjusted life years; VV-ECMO, veno-venous extracorporeal membrane oxygenation, RESP, Respiratory ECMO Survival Prediction.