A, Existing paradigmatic approach to health care resource limitation based on the Institute of Medicine’s Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response.4 B, Description of response to resource limitation based on our analysis of clinician experience during the coronavirus disease 2019 pandemic. Multiple other factors that compounded the association of resource limitation with quality of care during the pandemic included the need to limit contact between clinicians and restrict visitors, the rapid pace of change, and the lack of scientific evidence.
eTable 1. Consolidated Criteria for Reporting Qualitative Research Guidelines (COREQ) Checklist
eTable 2. Sample Semistructured Interview Guide
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Butler CR, Wong SPY, Wightman AG, O’Hare AM. US Clinicians’ Experiences and Perspectives on Resource Limitation and Patient Care During the COVID-19 Pandemic. JAMA Netw Open. 2020;3(11):e2027315. doi:10.1001/jamanetworkopen.2020.27315
How have US clinicians planned for and responded to resource limitation during the coronavirus disease 2019 pandemic?
This qualitative study included interviews with 61 clinicians across the United States. While institutions planned for an explicit and systematic approach to resource allocation in crisis settings, this approach did not address many challenges encountered by frontline clinicians, leaving them to struggle with what constituted acceptable standards of care and to make difficult allocation decisions.
The findings of this study suggest that expanding the scope of institutional planning to address a broader spectrum of resource limitation may help to support clinicians, promote equity, and optimize care during the pandemic.
Little is known about how US clinicians have responded to resource limitation during the coronavirus disease 2019 (COVID-19) pandemic.
To describe the perspectives and experiences of clinicians involved in institutional planning for resource limitation and/or patient care during the pandemic.
Design, Setting, and Participants
This qualitative study used inductive thematic analysis of semistructured interviews conducted in April and May 2020 with a national group of clinicians (eg, intensivists, nephrologists, nurses) involved in institutional planning and/or clinical care during the COVID-19 pandemic across the United States.
Main Outcomes and Measures
Emergent themes describing clinicians’ experience providing care in settings of resource limitation.
The 61 participants (mean [SD] age, 46  years; 38 [63%] women) included in this study were practicing in 15 US states and were more heavily sampled from areas with the highest rates of COVID-19 infection at the time of interviews (ie, Seattle, New York City, New Orleans). Most participants were White individuals (39 [65%]), were attending physicians (45 [75%]), and were practicing in large academic centers (≥300 beds, 51 [85%]; academic centers, 46 [77%]). Three overlapping and interrelated themes emerged from qualitative analysis, as follows: (1) planning for crisis capacity, (2) adapting to resource limitation, and (3) multiple unprecedented barriers to care delivery. Clinician leaders worked within their institutions to plan a systematic approach for fair allocation of limited resources in crisis settings so that frontline clinicians would not have to make rationing decisions at the bedside. However, even before a declaration of crisis capacity, clinicians encountered varied and sometimes unanticipated forms of resource limitation that could compromise care, require that they make difficult allocation decisions, and contribute to moral distress. Furthermore, unprecedented challenges to caring for patients during the pandemic, including the need to limit in-person interactions, the rapid pace of change, and the dearth of scientific evidence, added to the challenges of caring for patients and communicating with families.
Conclusions and Relevance
The findings of this qualitative study highlighted the complexity of providing high-quality care for patients during the COVID-19 pandemic. Expanding the scope of institutional planning to address resource limitation challenges that can arise long before declarations of crisis capacity may help to support frontline clinicians, promote equity, and optimize care as the pandemic evolves.
Since the first US case of coronavirus disease 2019 (COVID-19) was diagnosed in mid-January 2020,1 the pandemic has completely transformed health care delivery in this country. Early reports from frontline clinicians in global epicenters describing extreme shortages and bedside rationing of ventilators and intensive care unit (ICU) beds2 prompted a national conversation about how to respond to similar challenges in the United States.3 Hospitals and health care systems drew on frameworks developed by the Institute of Medicine (IOM) and other national organizations to guide care in resource-limited emergency settings.4-7
Under the IOM’s framework, resource allocation is intentionally siloed from other aspects of clinical care to ensure a fair process and spare frontline clinicians from the responsibility of having to ration scarce resources at the bedside. The IOM recommends a phased adaptation to resource limitation. Institutions first shift from conventional to contingency capacity, in which resources are adapted, optimized, and redistributed to maintain a standard of care that is functionally equivalent to usual care. If resources become so limited that a functionally equivalent standard of care can no longer be sustained, institutions then shift to crisis capacity, and care is redirected to provide the greatest aggregate benefit to the population.8 Under crisis standards of care, a specialized triage team becomes responsible for rationing scarce resources and making decisions about which patients will and will not receive potentially life-saving treatments.
Although the IOM framework reflects lessons learned during earlier pandemics9,10 and has been iteratively refined through ethical analysis8 and community deliberation,11,12 there have been few opportunities to test the framework in real-world clinical settings. Reports from past pandemics13,14 and from early global epicenters of the COVID-19 pandemic,15 press reports,16,17 and perspectives published in the scientific literature18,19 describe some of the challenges faced by frontline clinicians. However, there is little empirical work describing the experiences and perspectives of US clinicians pertaining to resource limitation and clinical care during the COVID-19 pandemic.20,21 To address this knowledge gap, we conducted a qualitative analysis of interviews with US clinicians during the pandemic.
We recruited clinicians from across the United States who had cared for patients during the COVID-19 pandemic and/or had been involved in planning institutional responses to resource limitation. We used purposive sampling to select a group of participants with a variety of roles who were practicing in a range of different settings. We began by recruiting clinicians with direct experience planning for and/or practicing in settings of resource limitation (intensivists, nephrologists, and triage team members) at our own institution (the University of Washington). We then expanded recruitment to include other groups of clinicians (eg, trainees, palliative care specialists, nurse care coordinators) and those practicing in other parts of the country. We used a snowballing recruitment strategy in which we asked participants to identify colleagues with relevant experience who might be interested in participating in the study. We did not exclude participants who had collegiate relationships with members of the research team. Interviews were conducted between April 9, 2020, and May 26, 2020. The University of Washington institutional review board approved this study and authorized verbal in lieu of written consent. Verbal consent was obtained from all participants. We report details of our methods using the Consolidated Criteria for Reporting Qualitative Research (COREQ) reporting guideline (eTable 1 in the Supplement).22
Participating clinicians completed one 30-minute to 60-minute audio-recorded interview with 1 of us (C.R.B., a White, female senior nephrology fellow trained in qualitative methodology and clinical bioethics). All but 1 interview, which included 2 participants at their request, were conducted 1-on-1, and 2 interviews were spread over 2 sittings. A semistructured interview guide (eTable 2 in the Supplement) was developed by 3 of us (C.R.B., A.M.O., and S.P.Y.W; A.M.O. and S.P.Y.W. are academic nephrologists and physician scientists with experience in qualitative methodology, geriatric nephrology, and palliative care) and included open-ended questions to elicit clinicians’ perspectives and experiences pertaining to clinical care, institutional policies, and resource limitation during the pandemic. The interview guide was iteratively refined by 1 of us (C.R.B.) with input from 2 of us (A.M.O. and S.P.Y.W.) to allow for elaboration of emerging themes. Interviews were recorded and transcribed verbatim. To protect confidentiality, participants were offered the opportunity to review their written transcripts to confirm accuracy and identify passages that they did not want published, but they were not invited to review draft or final versions of the article. Participants also completed an online survey with questions about their demographic characteristics and practice experience. The size of participants’ home hospital (or the hospital at which they volunteered, if that was the focus of the interview) was ascertained by online search.
We conducted an inductive thematic analysis23 of interview transcripts with the goal of discovering emergent themes describing clinicians’ perspectives, experiences, and practices pertaining to resource limitation during the COVID-19 pandemic. Two of us (C.R.B. and A.M.O.) independently reviewed and openly coded transcripts until reaching thematic saturation (ie, the point at which no new concepts were identified),24,25 which occurred after reviewing 30 interview transcripts. One of us (C.R.B.) coded all remaining transcripts for concurrence. Throughout the analysis, the 2 investigators iteratively reviewed codes, collapsed codes into groups with related meanings and relationships, and developed larger thematic categories, returning frequently to the transcripts to ensure that emergent themes were well-grounded in the data.23,25 All coauthors (including A.G.W., a pediatric nephrologist, physician scientist, and bioethicist) reviewed example quotations and themes and together developed the final thematic schema. We used Atlas.ti version 8 (Scientific Software Development GmbH) to organize and store text and codes.
We approached a total of 97 clinicians by email, of whom 75 (77%) agreed to participate and 22 (23%) declined or did not respond to our inquiry. Among those who agreed to participate, we purposively sampled 61 clinicians to participate in interviews from April 9, 2020, to May 26, 2020 (Table 1).26 All but 1 participant completed the online survey. The mean (SD) age of participants was 46 (11) years, and most were White (39 [65%]), were attending physicians (45 [75%]), and were practicing in large academic hospitals (≥300 beds, 51 [85%]; academic, 46 [77%]). Participants were practicing in 15 states across the United States and had primary affiliations with 29 different hospitals or clinics, with greater sampling of clinicians practicing in states with the highest rates of COVID-19 infection at the time of the study (eg, Seattle, New York City, New Orleans).
Three overlapping and interrelated themes pertaining to resource limitation and clinical care during the COVID-19 pandemic emerged from qualitative analysis, as follows: (1) planning for crisis capacity, (2) adapting to resource limitation, and (3) multiple unprecedented barriers to care delivery. Exemplar quotations are referenced in parenthesis and listed in Table 2, Table 3, and Table 4.
Institutional leaders who participated in planning for crisis capacity described the challenges of adapting and operationalizing existing guidelines as well as the substantial moral weight of the task. They were relieved when it became clear that these processes would likely not be needed at their institutions (Table 2).
Clinicians who were involved in institutional planning described strong institutional support for their work to develop protocols to guide care should their region reach crisis capacity (quotation 1). They believed that establishing protocols in advance would allow for a more carefully considered approach (quotation 2) and would be reassuring to staff (quotation 3).
Their work involved developing actionable triage algorithms based on existing frameworks (quotation 4). Group deliberation focused on both big picture ethical questions (quotation 5) as well as more granular operational details (quotation 6). Several clinicians with whom we spoke were not formally involved in institutional planning efforts but had offered input and/or developed their own protocols when they identified gaps in planning or disagreed with institutional policies (quotations 7 and 8).
To support fairness and avoid bias, the plan was for triage team members to receive very limited information about individual patients when making selection decisions (quotation 9). Some clinicians involved in planning were skeptical about the feasibility of making triage decisions in the absence of detailed clinical information (quotation 10). Others expressed uncertainty about whether and how triage protocols would address more ambiguous or dynamic types of resource limitation (eg, ICU bed shortages vs staff or supply shortages) (quotation 11). Clinicians could also be mindful of how their work might be viewed by other clinicians and the public (quotation 12) and were wary of sharing details about committee deliberations (quotation 13), plans (quotation 14), or team membership (quotation 15) with their colleagues and/or during the research interview.
Clinicians who had been appointed to triage teams were usually respected leaders in intensive care, palliative care, or bioethics who were recognized for their ability to collaborate and communicate (quotation 16). Some of the intensivists and ethicists with whom we spoke saw the work of the triage team as an extension of their usual work (quotations 17 and 18), but many clinicians saw this experience as entirely new (quotation 19). Clinicians described being motivated to participate in the triage team out of a sense of duty and desire to contribute (quotation 20) but were also cognizant of the moral weight and emotional burden of the task before them (quotation 21).
Clinicians involved in triage planning understood the processes they were developing to be intended exclusively for crisis settings (quotations 22 and 23) and saw the importance of optimizing resources under contingency capacity to avoid having to resort to crisis standards of care (quotation 24). While several clinicians described a period of intense planning early in the pandemic, by the time of our interviews, many were relieved to report that crisis standards of care were unlikely to be invoked at their institutions, and some had paused or disengaged from triage planning (quotations 25 and 26).
Clinicians working during the pandemic were forced to grapple with multiple expected and unexpected forms of resource limitation that did not rise to the level of triggering crisis capacity. Nevertheless, these limitations could compromise care, require that they make difficult allocation decisions, and engender moral distress (Table 3).
Although none of the clinicians with whom we spoke reported a shift to crisis capacity at their institutions, they nevertheless described being faced with a range of expected and unexpected forms of resource limitation (eg, dialysis machines, staff, routine supplies) (quotation 27) that could arise in a haphazard manner with little warning (quotation 28). Some expressed frustration that resource shortages they were seeing in practice were not acknowledged as such by hospital or regional leadership (quotations 29 and 30) or felt unsupported by colleagues at neighboring medical centers (quotation 31). When not available from their institutions, some clinicians resorted to obtaining health care equipment through personal contacts or even fabricated it themselves (quotations 32 and 33).
Clinicians were strongly motivated to avoid situations in which they would have to categorically deny needed treatment to any patient (quotation 34) and went to great lengths to develop alternative treatment options (quotation 35). This might involve using unorthodox therapies or nontraditional approaches to care delivery that could be suboptimal or potentially harmful (quotations 36 and 37). For example, some nephrologists described triaging patients for hemodialysis based on immediate need (quotations 38 and 39), delaying dialysis until there was an emergent indication (quotation 40), and/or prescribing shorter treatment times. As 1 clinician explained, “everyone gets a little bit of bad care” (quotation 41). Rarely, clinicians were able to draw a clear line between acceptable and unacceptable care (quotation 42), but most focused on doing the best they could under the circumstances (quotation 43).
The notion of rationing generally had negative connotations (quotation 44), and some clinicians even described erring on the side of providing more intensive interventions to avoid the appearance of rationing (quotation 45). With rare exceptions (quotation 46), clinicians did not explicitly speak of having had to ration health care resources (quotation 47). Nonetheless, some clinicians did describe situations in which they had to make difficult choices about which patients would and would not receive life-saving therapies, typically on the basis of age and/or comorbidity. This was often seen as part of the spectrum of normal clinical decision-making (quotations 48 and 49) and within their scope of practice (quotation 50). Some clinicians did describe struggling to understand what constituted acceptable practice vs rationing (quotations 51 and 52) and expressed misgivings about the approach to selecting patients for life-saving treatments during the pandemic (quotations 53 and 54).
Many clinicians were fearful of having to ration resources (quotation 55). Even in lower acuity and outpatient settings, some struggled with whether it was acceptable to provide suboptimal care (quotation 56) and worried about the potential harms of disrupted care practices (quotation 57). A sense of responsibility for poor outcomes could take a substantial emotional toll (quotation 58). Some clinicians felt that explicit guidelines would be helpful in limiting this moral distress (quotation 59), while others felt personally responsible for poor outcomes regardless of whether they were adhering to institutional recommendations or requirements (quotation 60).
Clinicians described multiple barriers to care delivery during the pandemic. These challenges compounded and were difficult to disentangle from the effects of resource limitation (Table 4).
Policies and practices were modified to limit physical interaction between staff, patients, and family members with the dual goals of reducing viral spread and conserving personal protective equipment. While necessary, policies to limit contact with patients were seen as being detrimental to care and to the experiences of both patients and clinicians (quotations 61 and 62). Decisions about something as routine as whether to perform a physical examination could expose tensions around the conflicting goals of conserving scarce resources, protecting oneself, and caring for patients (quotations 63 and 64). Visitor restrictions could complicate and disrupt the process of engaging family members in decision-making (quotations 65 and 66).
The rapid pace of change and limited scientific understanding of COVID-19 (quotations 67 and 68) led to substantial uncertainty in day-to-day practice. A sense of desperation and a desire to do everything possible to save lives might lead to more aggressive treatment practices and/or greater willingness to try unproven therapies (quotation 69), reluctance to engage palliative care specialists (quotation 70), and delays in end-of-life decision-making (quotation 71).
Many clinicians commented that families and patients were often quite understanding of care disruption (quotation 72), and that they were surprised at how accepting some families could be when care was compromised by the need to conserve resources and/or protect clinicians (quotations 73 and 74). However, some clinicians did describe contentious interactions with family members (quotation 75) and patients (quotation 76) who felt that care was being inappropriately withheld. Other clinicians described deliberately avoiding mention of resource limitation when talking with families (quotation 77).
Our thematic analysis of interviews with US clinicians who were directly involved in patient care and/or strategic planning during the COVID-19 pandemic highlights the real-world complexity of adaptation to resource limitation. Clinicians described patterns of institutional planning that mirrored the IOM’s phased approach, which assumes a common understanding about what constitutes usual standards of care with a plan for a coordinated regional response when these become untenable. However, consistent with prior anecdotal reports,27-30 the clinicians we interviewed described how, even in the absence of formal declarations of crisis capacity, a variety of expected and unexpected forms of resource limitations severely compromised care and required that they make difficult allocation decisions at the bedside.
Clinicians and clinical teams went to great lengths to develop alternative treatment options and to stretch existing resources to provide at least some care to all in need and avoid having to categorically deny treatment to any patient. However, this approach could mean providing care that fell far short of the IOM standard of functional equivalence to usual care. When substituting lower-quality or delayed treatments, clinicians and clinical teams were left to grapple with what constituted an acceptable standard of care, which could be a source of self-doubt and moral distress. While most clinicians did not feel that they had been in the position of having to ration scarce resources, some nevertheless described practices, such as selection by age or comorbidity, that may be subject to implicit biases31 and may not be supported by societal priorities for fairness in resource allocation.32-35
Existing frameworks guiding institutional approaches to resource allocation in crisis settings4-7 represent an important step toward promoting fairness through transparent allocation processes.36 However, our results suggest that a narrow focus on crisis capacity may fail to address the full spectrum and complexity of challenges to providing high-quality care encountered by frontline clinicians during the COVID-19 pandemic (Figure). Insights gained from our study suggest several strategies to better support clinicians and guide clinical care as the pandemic evolves. First, regional authorities and institutions could prepare guidelines, protocols, and defined standards of care in advance to address the myriad types of resource limitation and challenges to providing high-quality care that arise long before declaration of crisis capacity. Second, in addition to their narrow role in allocating scarce resources under crisis capacity, triage team members could collaborate and/or consult with frontline clinicians to address challenges related to more nuanced forms of resource limitation.37,38 Finally, as the community moves beyond the current crisis and plans for the future, training in bioethics may help to support clinical teams in navigating the value conflicts that can arise when resources are limited in both pandemic and usual care settings.39,40
This study has limitations. Our results may not capture the experiences and perspectives of clinicians practicing in other parts of the world, in regions of the United States not represented in our study, or in specialties not represented by our participants (eg, pediatrics).41 We also did not collect information about the COVID-19 caseload at each participant’s institution at the time of the interview, which may have shaped participants’ experiences and perspectives. Because resource allocation can be a sensitive topic, participants may have felt limited in discussing some aspects of their experiences. Furthermore, the dynamic nature of the pandemic makes it likely that new challenges not identified in our study will arise over time and practices may evolve in response to early experience.
In this qualitative study, many clinicians described institutional planning for crisis capacity, but this did not always address real-world challenges to providing care when resources were limited. Expanding the scope of institutional planning beyond crisis capacity may be helpful in supporting clinicians and addressing moral distress, promoting equity, and optimizing care as the pandemic evolves.
Accepted for Publication: October 3, 2020.
Published: November 6, 2020. doi:10.1001/jamanetworkopen.2020.27315
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Butler CR et al. JAMA Network Open.
Corresponding Author: Catherine R. Butler, MD, MA, Division of Nephrology, Department of Medicine, University of Washington, 1959 NE Pacific St, Campus Box 356521, Seattle, WA 98195 (email@example.com).
Author Contributions: Drs Butler and O’Hare had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Butler, Wong, O’Hare.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Butler, Wong.
Critical revision of the manuscript for important intellectual content: Butler, Wightman, O’Hare.
Statistical analysis: Butler.
Obtained funding: Wong.
Administrative, technical, or material support: Butler, Wong, O’Hare.
Supervision: All authors.
Conflict of Interest Disclosures: Dr O’Hare reported receiving grants from US Department of Veterans Affairs Health Services Research and Development, the National Institute of Diabetes and Digestive and Kidney Diseases, and the US Centers for Disease Control and Prevention; participating in an operation project with the US Department of Veterans Affairs National Center for Ethics in Health Care; and receiving personal fees from UpToDate, the Coalition for the Supportive Care of Kidney Patients, Hammersmith Hospital, the University of Alabama, Birmingham, the University of Pennsylvania, the New York Society of Nephrology, the University of California, San Francisco, Fresenius Medical Care, Dialysis Clinic, Inc, the Devenir Foundation, the Japanese Society of Dialysis Therapy, Chugai Pharmaceuticals, and the American Society of Nephrology outside the submitted work. No other disclosures were reported.
Funding/Support: This work was supported by the National Institute of Health National Institute of Diabetes and Digestive and Kidney Diseases (grant No. 5T32DK007467-33 to Dr Butler and grant No. 1K23DK107799-01A1 to Dr Wong), a COVID-19 Research Award from the University of Washington Institute of Translational Health Sciences (to Dr. Butler), and the Division of Nephrology, University of Washington (faculty funds to Dr O’Hare).
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health or National Institute of Diabetes and Digestive and Kidney Diseases.
Additional Contributions: We are truly grateful for the generosity of clinician participants who volunteered their time during a period of unprecedented demands on their energy. We would also like to thank Mark Tonelli, MD (Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington), for his help facilitating recruitment and thoughtful input on an early draft of the manuscript and Ross Burnside for his help with transcription. They were not compensated for their time.