The CRISMA Program on Ethics and Decision Making in Critical Illness (EDM) conducts scholarly work to understand and improve how medical decisions are made for critically ill patients who are unable to make decisions for themselves. Bringing together health services researchers, decision scientists, philosophers, bioethicists, and clinicians, EDM investigators design interventions that go beyond the standard 'informed decision making' paradigm. These interventions help clinicians address the convergence of several of the most difficult aspects of modern medicine: dying patients, expensive technological care, and uncertainty about how best to deliver care consistent with patients' values and preferences.
Policies available for download:
"Allocation of Scarce Critical Care Resources During a Public Health Emergency”
To assist hospitals and health systems to implement a fair and transparent approach to allocating scarce critical care resources during the COVID-19 pandemic, we have created a model hospital policy that hospitals can download and adapt for their needs. In light of the large disparities in COVID-19 outcomes among disadvantaged groups, the policy was revised on April 9, 2021 to contain two additional strategies to promote equity. For more detail on the ethics and rationale for the policy, see Dr. White's paper "Mitigating Inequities and Saving Lives with ICU Triage during the COVID-19 Pandemic" in the American Journal of Respiratory and Critical Care Medicine.
“Model Hospital Policy for Fair Allocation of Medications to Treat COVID-19”
Purpose
The purpose of this model policy is to provide health systems and public health officials with a fair method to allocate medications to treat COVID-19 when the supply is insufficient to treat all eligible patients. The policy document describes 1) the ethical justification for the use of a weighted lottery, as well as for the specific weighting factors in the lottery; 2) instructions for how to deploy a weighted lottery; and 3) recommendations for the use of an allocation team to oversee the conduct of the lottery process.
The weighted lottery was successfully implemented at hospitals across the UPMC health system during periods of remdesivir shortage in 2020. It is currently being used to allocate Tixagevimab Plus Cilgavimab (Evusheld) for Pre-Exposure Prophylaxis for SARS-CoV-2 among patients at high risk of severe COVID disease.
Hospitals and health systems are welcome to adapt the policy for their specific needs.
Policy Consortium
The model policy was developed by a multi-institution consortium whose members had expertise in bioethics, economics, health disparities, health law, medicine, pharmacy, and hospital operations. The main contributors were:
University of Pittsburgh School of Medicine/UPMC Health System
Douglas B. White, MD, MAS; Vice Chair and Professor of Critical Care Medicine
Ryan Bariola, MD; Associate Professor of Medicine, (Infectious Diseases)
Jessica Daley, Pharm.D.; Vice President HC Pharmacy and Supply Chain Commercial Services
Naudia N. Jonassaint, MD, MHS; Vice Chair for Diversity and Inclusion, Department of Medicine
Erin McCreary, Pharm.D., BCPS, BCIDP; UPMC Presbyterian Hospital, Department of Pharmacy
Rachel Sackrowitz, MD, MBA; Chief Medical Officer, UPMC ICU Service Center
Mark Schmidhofer MD, MS; Professor of Medicine (Cardiology)
Graham M. Snyder, MD, MS; Associate Professor of Medicine (Infectious Diseases)
Donald M. Yealy, MD; Chair, Department of Emergency Medicine
Boston College
Tayfun Sonmez, PhD; Professor of Economics
M. Utku Unver, PhD; Professor of Economics
Harvard University
Robert Truog, MD, MA; Director, Harvard Center for Bioethics, Frances Glessner Lee Professor of Legal Medicine
Massachusetts Institute of Technology
Parag Pathak, PhD; Professor of Economics
University of Denver
Govind Persad, JD, PhD; Assistant Professor of Law
- Program Members
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PRIMARY FACULTY
- Deepika Mohan, MD, MPH
- Douglas White, MD, MAS
AFFILIATED FACULTY
- Marie K. Norman, PhD, Division of General Internal Medicine
- Jennifer Seaman, PhD, RN, School of Nursing
- Yael Schenker, MD, Division of General Internal Medicine
PROGRAM STAFF
- Rachel Butler, MHA, MPH, Program Manager
- Elke Brown, MD, Senior Project Coordinator
- Sana Khalid, MBBS, Research Assistant
- Dave Maloney, BS, Research Coordinator
- Mary Beth Ryabik, RN, BSN, MBA, Research Project Manager
- Grace Vincent, BA, Research Coordinator
- Chelsea Yang, BS, Research Assistant
CURRENT TRAINEES
- Sarah Andersen, MD, T32 Postdoctoral Fellow
- William Gautier, MS, Medical Student
- Stephana Julia Moss, PhD, Postdoctoral Fellow
- Vlad Razskazovskiy, Medical Student
- Kathryn Vessel, Medical Student
ALUMNI
- Alexandra Bursic, MD
- Mary Callahan, MD
- Tracy Campbell, MD
- Brett Curtis, Medical Student
- Ravi Doobay, MD
- Natalie Ernecoff, PhD
- Taylor Lincoln, MD
- Kate Petty, MD
- Bailey Sparks, MD
- Alexis Steinberg, MD
- Angela Suen, MD
- Recent and Ongoing Research Projects
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Online PARTNER Training Pilot Study
The goal of this study is to pilot test a low-cost, scalable platform to train clinicians in the serious illness communication skills needed to achieve goal-concordant care for incapacitated patients, including those with Alzheimer’s disease and related dementias. Funding: NIH/NINR 3R01NR014663-05S1 (PI: White)Randomized Trial of a Scalable, Interactive Tool to Support Surrogate Decision-makers of Critically Ill Older Adults
The goal of this study is to test the efficacy of the Family Support Tool, an interactive, web-based tool to help family members of older incapacitated patients navigate the emotional, psychological, and cognitive complexities of being a surrogate, on the patient-centeredness of care, surrogates’ psychological symptom burden, and patients’ healthcare utilization. We will conduct a mixed methods qualitative study in parallel with the RCT to better understand factors that influenced the efficacy of the intervention. Funding: NIH/NIA R01AG066731 (PI: White)Randomized Trial of Specialty Palliative Care Integrated with Critical Care for Critically Ill Older Adults at High Risk of Death or Severe Disability
The goal of this study is to determine the effect of specialty palliative care integrated with critical care on patient and family outcomes. We will conduct a mixed methods qualitative study in parallel with the RCT to better understand factors that influenced the efficacy of the intervention. Funding: NIH/NIA R01AG068567 (MPIs: White, Schenker)Mentored Patient Oriented Research in Improving Surrogate Decision Making for Patients with Advanced Respiratory Failure
This study leverages insights from organizational behavior, social psychology, and decision science to: characterize the attitudes and actual practices of clinicians toward providing interprofessional team-based decision support to surrogate decision-makers; conduct exploratory analyses examining associations between team functioning and outcomes of patients with advanced respiratory failure; and determine whether and how clinicians elicit values and preferences of incapacitated patients from surrogates. Funding: NIH/NHLBI K24HL148314 (PI: White)Prediction of Functional Outcomes from Chronic Critical Illness
This is the first multicenter prospective cohort study that measures risk factors for long-term physical and cognitive dysfunction in chronical critical illness (CCI). The goal is to construct a multi-outcome prognostic model to facilitate shared decision-making and resource planning. Funding NIH/NINR R01NR016489 (PI: Carson, UNC) - Contact
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For information on program activities or to inquire about collaborations and training opportunities, please contact Douglas White, MD, MAS.