Discussing Triage Ethics in the Time of a Pandemic

As the COVID-19 crisis continues, health care providers are being challenged by a lack of resources that force difficult ethical choices. On March 25, the Adventist Bioethics Consortium gathered on a Zoom call for a discussion of triage ethics. The call drew 149 participants from the five Adventist health care systems and their sub-systems, plus students and faculty at Andrews University, AdventHealth University, Loma Linda University, and the North American Division.

Triage, the presenters noted, is something that is an everyday reality in medicine as decisions are made in emergency departments, on hemodialysis units, and regarding various organ replacements. Normally, the triage process is called upon to differentiate between patients whose needs are minor, and those where treatment can be delayed, from those who must receive immediate treatment, and those described as expectant, or beyond the point where treatment can save them. Hospital protocols guide this decision-making process. Multi-disciplinary teams are used for the most difficult decisions to allow front line physicians to remain patient advocates rather than the ultimate deciders of a patient’s fate.

Grace Oei, clinical director of the LLU Bioethics Center, shared materials from The Hastings Center’s March 16, 2020 document “Guidelines for Institutional Ethics Services Responding to the Coronavirus Pandemic.” Oei was one of the 14 authors of the document that is guiding hospitals around the country in putting into place protocols for COVID-19 decision making. Dr. Oei emphasized the importance of a plan in managing uncertainty. Policies and guidelines provide a safeguard for vulnerable populations with the intentional steps that are outlined ahead of time. She noted that the current situation puts the clinical ethics that focuses on the individual patient in contention with public health ethics that seeks the greater good for the community. She suggested that care must be taken to combine the two. There must be a duty to care as well as a duty to equality and equity.

With COVID-19, triage decisions include resource rationing. What happens as three key resources become scarce: stuff (masks, gowns, ventilators), space, and staff. How are decisions on rationing made? Explicit rationing (decisions made by an administrative body to specify allocation of treatments or services) contrasts with implicit rationing (decisions to limit treatment in an ad-hoc fashion). “In a crisis,” Dr. Oei said, “we should seek to limit implicit rationing in favor of explicit rationing.”

Gina Mohr, chair of the Loma Linda University Health Ethics Committee, emphasized the importance of communication in the ethics process. In addition to planning ahead and creating a framework for decisions that safeguard patients, she said medical personnel and hospitals need to be open and transparent in their decision making and in communicating information both within the hospital and with the general public.

Before the session was opened up for questions, key points from the New York Ventilator Allocation Guidelines were shared. Saving the most lives is the goal of the guidelines, and they require hospitals to have a separate triage committee for decision-making rather than expecting the frontline physician to be making allocation decisions. Decisions about resources are to be based on clinical factors only. Separate triage algorithms are required for neonatal, pediatrics, and adult patients. Oversight of the guidelines is required. As is transparency with the option of appealing decisions.

Participants were directed to the Adventist Bioethics Consortium website for a variety of resources, including the Hastings Center Document and the New York Ventilator Guidelines.

Gerald Winslow, director of the LLU Bioethics Center served as the moderator of the event, and read the questions that were sent in by participants.

With the fear that exists among the staff and in the community, should hospitals report the number of COVID-19 cases that they have? Absolutely, was the answer. Staff need to know about the cases. Dr. Oei said that knowing about cases actually calms staff spirits and makes it easier to handle the situation. In communicating with the community, Dr. Mohr recommended being as transparent as possible.

Are there specific algorithms for making decisions about rationing? Yes, was the answer. Almost too many. There are so many algorithms, it can be difficult to know which ones are best. The bioethics consortium website contains a repository of algorithms, the group was told. They were also reminded that it is important to make sure that patients get treated equally, if they have different diseases. Equality is also important for patients who come from disadvantaged communities where discrimination has already created health disadvantages for them, so that they arrive at the hospital with compromised health.

The advice given was that when rationing decisions are being made, they should not be made by comparing individuals but conditions — a protocol for determining whether the patient is improving or not. SOFA scores, the rating system used by Intensive Care Units to track a patient’s six organ systems, for instance, were pointed to as an example of information upon which to make decisions.

Sharing resources — large hospitals with small ones, within and among systems, sharing information with staff within a hospital, with patients, families, communities. Sharing the burden of decision making. Sharing was the key in the conversation to addressing the current pandemic in which not sharing the virus itself has been asked of the general public as they are told to stay home.

Watch the “Triage Ethics During a Pandemic” webinar below or on YouTube:

View the PowerPoint presentation here.

Bonnie Dwyer is editor of Spectrum.

Main photo by Fusion Medical Animation on Unsplash. In-line screenshots from the PowerPoint presentation, courtesy of the Adventist Bioethics Consortium.

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This is a companion discussion topic for the original entry at http://spectrummagazine.org/node/10316

DNR – Do Not Resuscitate is usually made by an Ethics Committee
in the hospital. Families are included in this. Even when there are
Advanced Directives brought with the patient.
It is not something that is taken lightly by the hospital community.

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You are correct Steve. As a family we went through this about a year and half ago with my mom. She had been in and out of LL hospital for two years and for probably six of those visits we got talked out of the DNR. She was suffering and finally I said if you don’t let her ( us ) have a DNR I will have to take you to court.

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I had to make the same decision for my mother who did not have a DNR.
At 80 she was still working as an LPN. She developed a brain bleed from
an undiagnosed brain aneurysm. Apparently on the floor some time.
CT showed not repairable. So we put her on IV fluids to keep her hydrated
and pain medication as determined by the nursing staff.
I calculated that sometime in 2 weeks she would go to her rest. And she
did so. She appeared to go peacefully.

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How does one’s insurance coverage factor in with regard to rationing? Whether or not they are on Medicare Dis-Advantage Plan?

Hospitals are required to anyone who shows up for Services.
As long there is FAMILY the hospital is required to treat appropriately.
This is for Insurance and Non-Insured persons.
IF there is no Family person that can be found, the Hospital CAN
ask the Court to appoint an Advocate for the patient and the Advocate
has certain guidelines they HAVE to follow.

It is my understanding that all hospitals must treat patients who show up for emergency treatment until that condition is stablized, but private hospitals may turn away patients in a non-emergency. There are different rules for privately-owned and public hospitals. I am speaking about U.S. hospitals. I’m not aware of laws guiding hospitals outside of the U.S.

@niteguy2
During the Ebola epidemic in W. Africa our SDA mission hospital in Liberia followed a strict policy of screening and allowing only non-Ebola infected patients for treatment. This time, in relation to the Covid 19 pandemic, with the exception of the U. S. Navy, can you imagine a hospital Ethics Committee in this country recommending a similar policy?

It would be difficult, wouldn’t it? The need for stringent isolation precautions in a epidemic would necessitate altering previously agreed upon priorities. Transparency in revealing a hospital’s motivation for making new policies that would appear to some to be discriminatory would be necessary as would provision to care for the infected patients, whether those provisions were provided by the hospital or by other hospitals in the community. In a crisis like the present one that could kill up to 250,000 Americans, I think I am beginning to think I could imagine it, but those decisions would involve many more entities than a lone hospital Ethics Committee.

Just imagine the agony of those millions of people losing their jobs AND healthcare insurance. And the President just blocked them from being allowed to get ObamaCare because it’s not the right time of the cycle… How can that be???

And still worse, Trump is battling right now in the Courts aiming to eliminate ObamaCare, thus making millions of people to lose their healthcare insurance. What baffles me though is that many of those victims will end up blaming the Democrats for their loss and will end up voting for Trump again. What is it that mesmerizes them so effectively?

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My experience with private hospital is that they are required to
Triage all who apply through the E.R.
However, if they desire to transfer one to a PUBLIC Hospital,
there are certain protocols and procedures that have to be
followed for safe transfer.

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The Washington Post published an article today saying that the reason why Trump has 47% of approval is because of his attacks on the media.

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