Monday, March 16, 2020

COVID19 and the ethics of hospital triage decision-making

There is a lot of talk these days about the predicted coming wave of COVID19 patients needing ICU beds and ventilators in particular, and the inevitable need to prioritise in terms of access. Based on what I'm reading I am somewhat reassured that the right decision criteria will be deployed. Medicine, as always when it comes to the crunch, moves speedily from publicly professed deontological values and handwaving right to consequentialist, if not outright utilitarian, decision-making. That is a good thing. You want to use your limited available resource to maximise the number of life-years preserved. It'll mean, among many other things, that you need to prioritize looking after infected health care workers first (incidentally, that doesn't include clinical ethicists :). It'll also mean to remove people who would need long-term intensive care from beds that could otherwise be utilised by a larger number of patients with better odds of faster recovery. This will be a big challenge for health care professionals who put much store in the acts and omissions doctrine, thinking mistakenly that they're less responsible for the death of someone they omitted to admit to an ICU bed, even though they could have chosen to move a patient with worse odds out of that bed. You are responsible for the choices you make, an act of omission is still an act that you are morally responsible for. 

What makes this less straightforward in practice than it looks like is that what 'the odds' are will inevitably change over time, as health care professionals begin gathering information about what does and doesn't work. This is something we saw during the Ebola virus outbreak of 2014/15. Death rates were staggeringly high and went down considerably as a result of the experience and knowledge gained by the attending health care workers. A case in point, the limited currently available evidence suggests that the vast majority of people who get on ventilators die anyway (the two papers that I have seen peg the mortality rate between 86%-97%), so the current debate about lack of ventilators might be a lot of noise about nothing. I wouldn't be surprised, however, if that changed over time, so this is something that makes allocation decisions more difficult, as the decision-making needs to be continuously updated, based on the rapidly accumulating evidence. Now, while this may well lead to different practical decisions, the normative criteria used to evaluate that evidence should remain pretty stable.

The really important bit though is that hospitals, by now, should have transparent resource allocation decision frameworks in place. They should have communicated those to their staff and made clear that to them that those criteria are binding on everyone. They should also communicate those criteria to the public. Nothing breeds suspicion, conspiracy theories and panic better than non-transparent decision-making procedures in a time of crisis. People need to understand that there is not one rule for them and another one for others who are better connected, as it were. We are all in the same boat, really. 

Which takes me to my last point. This all strikes me as obvious. So I went (16 March 2020) to the COVID19 bits of the website of our local Kingston Health Science Centre (the new name for KGH/Hotel Dieu), to find out what their policies look like, and, to my surprise, there is no relevant information. There's invariably important information about restrictions, like how many visitors will be admitted, and it's all eminently sensible. However, the hospital communicates nothing about what will substantively drive its triage nurses' and clinicians' decision-making should the predicted wave of COVID19 hit the hospital, and you're unfortunate enough to end up there, as a patient. That is unacceptable. Patients and their loved ones have a right to know how life-and-death triage decisions will be made at the hospital where they or their loved ones will be admitted. Incidentally, if everyone knows the basis on which decisions will be made, patient expectations would be realistic from the outset, which can only help in such circumstances. 

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