Pandemic strikes — Who receives no treatment?
Journal recs raise ethical concerns
ED managers are well aware of the need for triage protocols during a disaster and have incorporated them into their disaster response plans. However, plans vary among facilities and within regions. In an attempt to standardize, the American College of Chest Physicians (ACCP) convened a task force representing leading universities, medical groups, the military, and government agencies.
Their recommendations, which were published in the May Chest,1 have raised ethical concerns among some practitioners and medical organizations. They include the following list of patients who should not be treated during a disaster:
- patients older than 85 years of age;
- seriously hurt trauma victims;
- severely burned patients;
- patients with severe dementia;
- patients with a severe chronic disease
"This sounds like a very, very naive approach, the recommendations of people who have never had to do critical triage of many, many people," asserts Kenneth V. Iserson, MD, MBA, professor of emergency medicine at The University of Arizona, Tucson, and director of the Arizona Bioethics Program. The university, with the University of New Mexico and New Mexico State University, has created the Critical Response and Emergency Systems Training (CREST) program through a cooperative agreement with the U.S. Office of the Assistant Secretary of Preparedness and Response.
"Our videos talk about the real way to do it," says Iserson. "You train people who are going to do the triage and follow general guidelines, but every case or group of cases will be specific."
One of the problems with such broad guidelines, says Iserson, is that there always are exceptions, and some, he argues, should not even be included.
"Extensive third-degree burns, give me a break!" he says. "In any really extensive triage situation where there are multiple casualties, the extensive third-degree burns are way on the bottom of the list."
As for the very elderly, he continues, the key issue is not their age but whether they are survivable. "I've seen 85-year-olds who are much more active than 40-year-olds," Iserson points out.
In addition, he says, the nature of the disaster also might dictate the triage response. "From flu, to war, to hurricanes, the situation varies, the responses of people vary, and the resources available vary with the situation and change over time," he explains. "Your cadre of triage officers has to be flexible."
The pandemic guidelines at the University of Utah Hospital, Salt Lake City, use a sliding scale for triage, reports Colleen Connelly, RN, BSN, emergency preparedness manager. They use a modified Sequential Organ Failure Assessment (SOFA) score, she says, "And the scale slides depending on the level of pandemic. The list of patients that don't receive a ventilator or who are turned away [from active treatment] to palliative care are more clearly done in our plan."
Nonetheless, says Connelly, she recognizes the need for such guidelines. "I've been working with my hospital and my state [on disaster preparedness] for several years, so I know that when we talk about projecting the number of people who will be ill or require a ventilator, just in my county alone, it's something like five times the number we have in the entire state," she says.
So when Connelly considers those statistics along with federal projections that there will be a 40% decrease in the health care work force during a mass casualty disaster, "Then [the Chest plan] makes more sense to me. If I have a 68- or 70-year-old person with 90% full thickness burns and a 16-year-old in the same condition, who gets the ventilator? Who gets care?"
When all possible beds are filled, all alternative sites are overwhelmed, and when staffing is unavailable, "that's when that piece of the triage guidelines gets initiated, and I regard that as a good thing," she says. Making such decisions is very difficult, "and it's hard to put them all on the health care provider," she says.
Still, Connelly says, Iserson is correct to point out that each case must be considered individually. For elderly patients, for example, considerations should include more than age, such as whether they can perform activities of daily living, whether they have family to assist with care after discharge, and so on. "It's not just a case of whether they are old," she says.
The other side of the coin, however, is that the urge to "save everybody" must be tempered with a dose of realism. "A pandemic, for example, is so big that we owe it to our health care providers to at least be able to give them some guidelines," Connelly says. "It's not fair not to talk about it just because it makes someone uncomfortable."
Reference
- Devereaux AV, Dichter JR, Christian MD, et al. Definitive care for the critically ill during a disaster: A framework for allocation of scarce resources in mass critical care: From a task force for mass critical care summit meeting. Chicago; Jan. 26-27, 2007. Chest 2008; 51S-66S. DOI 10.1378/chest.07-2693.
Sources/Resource
For more information on triage during a disaster, contact:
- Colleen Connelly, RN, BSN, Emergency Preparedness Manager, University of Utah Hospital, Salt Lake City. Phone: (801) 585-3134. E-mail: [email protected].
- Kenneth V. Iserson, MD, MBA, Professor of Emergency Medicine, Director, Arizona Bioethics Program, The University of Arizona, Tucson. Phone: (520) 626-2398. Fax: (520) 626-2480.
To view a copy of the Critical Response and Emergency Systems Training (CREST) video, go to www.crestaznm.org. Then, go to: "Looking for The Most Difficult Healthcare Decisions video? Click here."
ED managers are well aware of the need for triage protocols during a disaster and have incorporated them into their disaster response plans. However, plans vary among facilities and within regions.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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