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.
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