See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/343240509

A Call for Dialysis-Specific Resource Allocation Guidelines During COVID-19

Article  in  The American Journal of Bioethics · July 2020

DOI: 10.1080/15265161.2020.1777346

CITATIONS READS

0 16

2 authors:

Jordan A Parsons Dominique E. Martin

University of Bristol Deakin University
10 PUBLICATIONS   9 CITATIONS    92 PUBLICATIONS   524 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Ethics of End Stage Kidney Disease View project

Nephrology Ethics View project

All content following this page was uploaded by Dominique E. Martin on 27 July 2020.

The user has requested enhancement of the downloaded file.

 The American Journal of Bioethics

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/uajb20

A Call for Dialysis-Specific Resource Allocation

Guidelines During COVID-19

Jordan A. Parsons & Dominique E. Martin

To cite this article: Jordan A. Parsons & Dominique E. Martin (2020) A Call for Dialysis-Specific
Resource Allocation Guidelines During COVID-19, The American Journal of Bioethics, 20:7,
199-201, DOI: 10.1080/15265161.2020.1777346

To link to this article: https://doi.org/10.1080/15265161.2020.1777346

Published online: 27 Jul 2020.

Submit your article to this journal

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=uajb20

THE AMERICAN JOURNAL OF BIOETHICS
2020, VOL. 20, NO. 7, 199–201
https://doi.org/10.1080/15265161.2020.1777346
OPEN PEER COMMENTARIES
A Call for Dialysis-Specific Resource Allocation Guidelines During COVID-19
Jordan A. Parsonsa,b and Dominique E. Martinc
a
University of Bristol; bMartin-Luther-University Halle-Wittenberg; cDeakin University
INTRODUCTION
In their article, “Ethical Challenges Arising in the
COVID-19 Pandemic: An Overview from the
Association of Bioethics Program Directors (ABPD)
Task Force,” McGuire and colleagues (2020) provide a
valuable discussion of several ethical issues raised by
the COVID-19 pandemic. Notably absent, however, is
consideration of ethical issues in the provision of care
for people with end-stage kidney disease (ESKD) dur-
ing the pandemic. More than two million people
worldwide receive kidney replacement therapy (KRT)
annually in the form of dialysis or transplantation,
including almost half a million in North America
(Liyanage et al. 2015). This population not only has a
markedly higher risk of complications and mortality
from COVID-19 infection but may also face increased
barriers to accessing KRT during the pandemic.
Furthermore, demand for dialysis has increased as a
result of acute kidney injuries among those with
severe COVID-19 infection, necessitating rationing of
this life sustaining resource (Goldfarb et al. 2020).
These factors highlight the importance of ethical ana-
lysis and guidance for the management of ESKD care
during the pandemic.
INCREASED DEMAND FOR DIALYSIS SERVICES
An early pressure on dialysis resources in the pan-
demic setting is the suspension or restriction of kid-
ney transplants in many centers. Like the cancellation
of other “elective” surgeries, limitation of transplant
services is part of efforts to protect capacity within
health systems, including staff availability and inten-
sive care services, as well as concerns about infection
CONTACT Jordan A. Parsons jordan.parsons@bristol.ac.uk
2PL, United Kingdom.
ß 2020 Taylor & Francis Group, LLC
THE AMERICAN JOURNAL OF BIOETHICS 199
risks for new transplant recipients. Although other
transplants—primarily heart, lung, and liver—have
continued for patients who may otherwise face death,
those needing kidney transplantation usually have the
option of dialysis. In the short-term, this increases
demand for dialysis. Of note, when kidney transplants
resume there will be a backlog of candidates for
deceased donor kidneys that will exacerbate existing
organ shortages.
Acute demand for in-hospital hemodialysis may be
most affected by surges in COVID-19 infections. An
estimated 20–40% of patients admitted to intensive
care as a result of the virus develop acute kidney
injury and require KRT for a median of 15 days
(Ronco et al. 2020). At the same time, the ability to
provide dialysis may be undermined by damaged sup-
ply chains of healthcare resources needed for dialysis
delivery and staff shortages (Goldfarb et al. 2020).
Burgner and colleagues (2020) have outlined strategies
to manage dialysis resources during peak demand.
Their suggestions include “permissive underdialysis,”
such as shortening the treatment time for inpatient
dialysis, decreasing the dialysate flow rate, or reducing
the frequency of dialysis treatment for ESKD patients
from three times to twice a week. However, such
underdialysis is likely to negatively affect patients; the
more frequently dialysis is performed, the lower the
rate of complications (Rivara et al. 2016). Clinicians
may be faced with a choice between providing
“underdialysis” for a large group of patients or stand-
ard care dialysis for a smaller group.
Additional efforts to reduce pressure on in-hospital
dialysis services include changing treatment modalities
for patients. Patients receiving care at in-hospital
Centre for Ethics in Medicine, Bristol Medical School, University of Bristol, Bristol BS8
200 OPEN PEER COMMENTARIES
dialysis units or independent dialysis centers may be
encouraged to switch to at-home options if possible.
However, whilst this may reduce the risks of COVID-
19 infection associated with regular attendance at a
hospital or dialysis center, changing modalities may
increase burdens or risk of complications for patients.
It may be difficult to provide customary standards of
training and support for patients commencing at-
home dialysis due to staff shortages and social dis-
tancing measures, which may leave some patients and
their carers ill prepared or reluctant to seek help,
thereby increasing the risk of errors and potential com-
plications resulting from self-treatment. The use of tele-
medicine for the support of at-home dialysis patients
has been implemented in light of the pandemic and it
seems to be successful for patients who were previously
undergoing dialysis at home (Srivatana et al. 2020).
However, there remain challenges in the use of tele-
medicine during the initial training period when com-
mencing at-home dialysis and visits to dialysis centers
are likely to be necessary for some patients (Srivatana
et al. 2020). It is important that any widespread shift in
treatment modalities (e.g., hemodialysis to peritoneal
dialysis) or the location of dialysis provision (in-center
to at-home with telemedicine support) takes into con-
sideration the impact on individual patients, not all of
whom may be able to adapt to such changes. Some
patients may feel obligated to agree to proposed
changes despite having a strong preference for in-per-
son support from clinicians.
GUIDELINES FOR ALLOCATION OF DIALYSIS
RESOURCES ARE NEEDED
Despite measures to reduce demand, nephrologists may
be required to restrict access to in-hospital hemodialysis.
Many nephrologists in high-income countries may be
unaccustomed to rationing dialysis and may lack access
to guidelines for decision-making if rationing becomes
necessary. Most discussions of resource allocation in the
context of COVID-19 have thus far focused on access
to and guidelines for the management of ventilators.
Such guidelines may be unsuitable for use in the alloca-
tion of dialysis. Although mechanical ventilation and
dialysis are both life sustaining interventions, there are
key differences between them which have significant
implications for resource allocation.
The lives of several people may be sustained by use
of a single hemodialysis machine over a week, ena-
bling greater flexibility in decision-making about
resource allocation in response to the dynamics of
demand. The decision to cease dialysis in one patient
may, for example, be overturned within a few days
with limited impact on patient health. In contrast, a
ventilator is generally used for only one person
(although recent innovations have trialed multi-person
use (McGuire et al. 2020)), and the decision not to
provide access or to withdraw access to the machine
from a patient with severe respiratory failure may lead
rapidly to death.
If the principle of maximizing the number of lives
saved is used to guide the allocation of treatment, as
proposed by Emanuel and colleagues (2020), this
means that individuals with acute respiratory failure
competing for ventilators are on a largely even foot-
ing, with the ventilator given to the individual most
likely to survive the acute illness—whether COVID-19
related or not. In contrast, patients requiring dialysis
on a likely short-term basis as a result of acute kidney
injury secondary to COVID-19 may be advantaged
over those with ESKD for whom dialysis represents a
chronic treatment. Several more lives might—in the-
ory—be saved over a period of time if a dialysis
machine is dedicated to meeting the short-term needs
of a series of COVID-19 patients rather than the
ongoing needs of a finite number of patients with
ESKD. Uncertainty regarding the longer-term out-
comes for COVID-19 patients with acute kidney inju-
ries and the poor survival rates of those with severe
infection may of course shift the balance of utility
gains in favor of patients with ESKD.
Emanuel and colleagues (2020) suggest that it
might be permissible to withdraw life sustaining treat-
ment from a patient if it may offer another patient a
greater survival benefit. This possibility is likely to
cause physicians considerable emotional and moral
distress as it appears to entail violating their duty of
fidelity—breaching the commitment to continue pro-
viding care to an individual patient once a therapeutic
relationship has been established. Ordinarily, treat-
ment of a patient on long-term dialysis ought only to
be ceased at the patient’s request, or, if the patient
lacks capacity, if it is determined to be in the patient’s
best interests to cease treatment. Although rationing
of healthcare resources sometimes entails difficult
decisions to withhold treatment from particular
patients, the possibility of revoking an allocation or
taking back a resource once treatment has been initi-
ated for the purpose of reallocating the resource to
another patient is rarely considered. However, accord-
ing to the equivalence thesis, “[o]ther things being
equal, it is permissible to withdraw a medical treat-
ment that a patient is receiving if it would have been
permissible to withhold the same treatment (not

already provided), and vice versa” (Wilkinson and
Savulescu 2014). If there is no morally relevant differ-
ence between withholding and withdrawing, it would
be appropriate to withdraw dialysis from the long-
term patient who, in present circumstances, would
not be prioritized to receive treatment, thereby creat-
ing capacity for those requiring only short-term care
(though this would depend on the nature of allocation
guidelines at the time). Whilst the equivalence thesis
is generally discussed in relation to intensive care, it
may take on a wider relevance in pandemic circum-
stances, and in dialysis provision may disadvantage
patients with ESKD.
CONCLUSION
The ethical literature concerning the first wave of the
COVID-19 pandemic has understandably been
focused on the intensive care setting and allocation of
essential health resources that were expected to be in
highest demand. As our knowledge of the disease and
the broader impact of the pandemic on people and
health systems evolves, it is important that other
adversely affected areas of health care provision are
not overlooked. Emerging evidence indicates that
equity of access to KRTs may be a critical issue at
times of peak COVID-19 infections, and the longer-
term impact of the pandemic on dialysis provision in
particular may require significant adjustments for
patients and care providers with respect to decision-
making about treatment modalities and standards of
care. Ethical analyses of the issues that arise in kidney
health care and guidelines to support patients, clini-
cians, and policy makers in managing these are
urgently needed.
ORCID
Jordan A. Parsons http://orcid.org/0000-0002-1050-6051
View publication stats
THE AMERICAN JOURNAL OF BIOETHICS 201
Dominique E. Martin http://orcid.org/0000-0001-
9363-0770
REFERENCES
Burgner, A., T. A. Ikizler, and J. P. Dwyer. 2020. COVID-
19 and the inpatient dialysis unit: Managing resources
during contingency planning pre-crisis. Clinical Journal
of the American Society of Nephrology: CJASN 15(5):
720–722. doi: 10.2215/CJN.03750320.
Emanuel, E. J., G. Persad, R. Upshur, et al.. 2020. Fair allo-
cation of scarce medical resources in the time of
COVID-19. The New England Journal of Medicine
382(21): 2049–2055. doi: 10.1056/NEJMsb2005114.
Goldfarb, D. S., J. A. Benstein, O. Zhdanova, et al.. 2020.
Impending shortages of kidney replacement therapy for
COVID-19 patients. Clinical Journal of the American
Society of Nephrology. doi: 10.2215/CJN.05180420.
Liyanage, T., T. Ninomiya, V. Jha, et al. 2015. Worldwide
access to treatment for end-stage kidney disease: A sys-
tematic review. The Lancet 385(9981): 1975–1982. doi:
10.1016/S0140-6736(14)61601-9.
McGuire, A. L., M. P. Aulisio, F. D. Davis, et al. 2020.
Ethical challenges arising in the COVID-19 pandemic: An
overview from the Association of Bioethics Program
Directors (ABPD) Task Force. American Journal of Bioethics
20(7): 15–27. doi:10.1080/15265161.2020.1764138.
Rivara, M. B., S. V. Adams, S. Kuttykrishnan, et al. 2016.
Extended-hours hemodialysis is associated with lower
mortality risk in patients with end-stage renal disease.
Kidney International 90(6): 1312–1320. doi: 10.1016/j.
kint.2016.06.028.
Ronco, C., T. Reis, and F. Husain-Syed. 2020. Management
of acute kidney injury in patients with COVID-19. The
Lancet Respiratory Medicine. doi: 10.1016/S2213-
2600(20)30229-0.
Srivatana, V., F. Liu, D. M. Levine, and S. D. Kalloo. 2020.
Early use of telehealth in home dialysis during the
COVID-19 pandemic in New York City. Kidney 360. doi:
10.34067/KID.0001662020.
Wilkinson, D., and J. Savulescu. 2014. A costly separation
between withdrawing and withholding treatment in
intensive care. Bioethics 28 (3): 127–137. doi: 10.1111/j.
1467-8519.2012.01981.x.