The practical ethics of medication shortages: Understanding patient preferences for allocation, decision making, and disclosure through narrative inquiry.

Abstract

e18323 Background: Hospital medication shortages (HMS) are pervasive throughout the U.S. healthcare system. Current management mechanisms are heterogeneous but routinely include the use of alternatives and the rationing of medications between patients. Little is known about oncology patient preferences for decision-makers, ethical allocation systems, or thresholds for disclosure during HMS. Methods: Oncology patients previously hospitalized for inpatient care within the last 24 months underwent qualitative interviews supplemented with validated instruments measuring: trust (Trust in Oncologist Scale), therapeutic alliance (Human Connection Scale), and shared decision-making (Shared Decision-Making Questionnaire). Qualitative data underwent Framework Analysis for thematic identification. Results: To date, 16 patients have been interviewed: median age 61y (31-77); 44% female; 56% married; 56% > college education; median number of treatment regimens 2 (1-6), days in hospital 18 (3-66), number of hospitalizations 2(1-8). All patients (100%) reported extremely high levels of trust, therapeutic alliance, and shared decision-making with their oncologist. Two patients (13%) reported personal experiences with HMS, 43% reported knowledge of HMS within the U.S., and no patients reported knowledge of local hospital HMS. Framework Analysis revealed that virtually all patients preferred that their oncologist act as the primary decision-maker during allocation/rationing and favored pharmacist and ethicist involvement. Most patients preferred allocation systems that prioritized efficacy, age, and degree of illness. No patients desired the use of a lottery or reciprocity-based decisions. Virtually all patients favored disclosure of shortages if alternatives were used, independent of the level of difference in efficacy/toxicity, and in the case of both chemotherapeutics and supportive medications. Conclusions: Despite ubiquitous HMS in oncology, patients are generally unaware of local HMS and prefer: multi-disciplinary decision-makers during HMS allocation, prioritized allocation schemes, and more frequent HMS disclosure than presently occurs. Study recruitment is ongoing.