Image: Djibouti: refugees new and old Ali Addeh refugee camp, Djibouti. ©European Union/ECHO 2016
Author: Dr. Kathryn Richardson, PallCHASE Exec Member
During the past 4 years, I’ve been providing palliative care technical support to humanitarian healthcare workers in different countries throughout Africa, the middle east, central and South Asia and South America. A challenge that teams sometimes face is clarifying the ethical frameworks that are guiding decision making and this can be problematic when decisions about resource allocation are confused with decision making in palliative care.
Resource allocation decisions are necessary in most healthcare systems, and particularly so in humanitarian contexts. Budgets are limited, and decisions need to be made about which services will be provided and which patients will be referred for higher level treatment (which often implies an obligation to cover associated costs, if referral is even possible).
The COVID-19 pandemic highlighted the challenge of limited resources, whether this was access to ICU beds and ventilators in middle and high-income countries, or availability of oxygen in lower resourced settings. Similarly, in protracted humanitarian crises, humanitarian medical organizations need to make decisions on where to place resources. Health facilities may not have the capacity to provide extended and intensive medical interventions for patients with a low chance of survival. An example is prolonged life-saving interventions for extremely low birth weight babies with very low chance of survival. Hard decisions sometimes need to be made to prioritize intensive care for newborns with a good or reasonable chance of survival.
These decisions are difficult for healthcare staff. Teams need support to take these decisions with clear guidance concerning the care which can be provided in their setting, support tools for decision-making, and clearly defined referral criteria. These decisions also need to be taken collaboratively, to reduce the burden on individual clinicians. As far as possible, these decisions should be made at a project level, rather than at the level of the individual patient.
What should not happen is to confuse resource allocation decisions aimed at maximizing benefit for the greatest number of patients with decision-making in palliative care. Decision-making in palliative care is not deciding which patients ‘to put in palliative care’ or ‘put on the palliative care pathway’, as I hear too often. Rather decision-making in palliative care is always focused on the best interests of the patient and takes into consideration the patients and family’s priorities.
Where there is confusion about resource allocation and palliative care decision-making, teams are understandably suspicious about the motives for providing palliative care. Where health care professionals doubt if they are acting in the patients’ best interests when providing palliative care, they should stop and check the rationale for the care being provided. Resource allocation decisions are a part of acute care decision making in humanitarian settings, and palliative care is provided alongside this or starts after these tough decisions have been made.
