Under Strain Of Limited Resources, The Ethics And Emotional Impact Of Triage Decisions
In the last month, videos and stories of doctors in hospitals around the world flooded with COVID-19 patients have circulated across social media platforms. The grief and distress of having to decide who gets treatment with ventilators and other critical equipment in short supply is almost unimaginable.
While professionals on the front lines in Georgia have not yet had to face those wrenching decisions, recent models predict that infections will peak in the first week of May. Meanwhile, bioethicists are preparing healthcare professionals with guidance on making split-second triage decisions.
On Second Thought learned more about how these decisions are made with both Kathy Kinlaw, associate director for the Emory University Center for Ethics and director of the center’s program in Health Sciences and Ethics, and Brendan Parent, assistant professor of bioethics at New York University’s Langone Health.
In the absence of federal triage guidelines for coronavirus, decisions on how to triage patients are typically made on an institution by institution basis. One of the guiding questions is patient’s chance of getting successfully discharged after using a ventilator.
“It’s very important that these ethics guidance plans are based on clinical criteria,” Kinlaw said. “There is no exclusion of groups of individuals. We’re very concerned about that, because we know it would be discriminatory.”
However, Parent noted that it’s often impossible to consider those clinical criteria outside of a broader sociological context. “Such criteria is sometimes a byproduct, or indirectly related to, preexisting conditions,” he said. “If you take two individuals, one of which has a worse SOFA [Sequential Organ Failure Assessment] score than the other, it’s quite possible that score is the product of living in poverty, [or] living in a food desert.”
Both Kinlaw and Parent spoke to the emotional toll that making these decisions places on medical personnel. However, they say that so far, the staff they’ve worked with has remained resilient.
“I think it is an extraordinary combination of compassion for humanity, as well as rational thinking, that draws people to the healthcare profession,” Parent reflected. “All of these people have seen death and have dealt with the most traumatic, extreme situations. And while this is a new level, I don’t think that people will become inured to the experience of trauma.”
Both he and Kinlaw underscored the need to support the emotional and mental health of medical workers right now. They also noted the role that bioethicists play in supporting clinicians during this resource-strapped time.
“As a person who works as a clinical ethicist at the bedside and treasures the opportunity to be with patients and families, even in making hard decisions, I very much have the faces and the voices of [those] people in my mind,” Kinlaw reflected. “I also have the faces and voices of all my healthcare colleagues in mind, who are going through this incredibly difficult process.”
Parent agreed. “It is this incredibly onerous job,” he shared. “While it should hit us in our hearts, we can feel as though our work and what we have been known for, which is thinking, can actually have practical effect[s] in implementing a just system of protecting people.”
On the ethics of triage decisions versus discriminatory practices
Parent: I think it's an important comparison to be aware of, especially when frameworks allow something like pre-existing intellectual developmental disabilities to creep into the decision making process.
But, I do think that it is incredibly difficult, as Kathy mentions, to be able to focus exclusively on medical criteria when such criteria is sometimes a byproduct or indirectly related to preexisting conditions.
So, for example, the New York Task Force on Life and the Law produced pandemic ventilator triage guidelines specifically focused on the sequential organ failure assessment score, which is the score that actually quantifies the likelihood of survival with optimal medical care based on six organ systems.
But if you take two individuals, one of whom who has a worse SOFA [Sequential Organ Failure Assessment] score than the other, it's quite possible that that score is the product of living in poverty, living in a food desert. And while this might be unavoidable and of course, our goal, we need to focus on providing effective care that saves the most lives when we have limited resources. It points to these kinds of social inequities that hopefully we can focus more attention on.
On the preparedness of healthcare systems to make triage decisions
Kinlaw: It's powerful to know that there was work that was done on pandemic influenza about a decade ago, and some creation of CDC guidelines, for example, that helped a lot of clinicians and other people in health care systems prepare for what would need to go into effect and how we might best do that. And then things kind of went quiet for a while.
And so, we are not prepared, I think, adequately in most health care systems, or have not been to this point, for physicians and other health care providers to be a part of this process. I think much good training is beginning to occur, or has occurred, so that if these difficult decisions need to be made, people will be better equipped.
But it is going to be hard. It's going to be very difficult for anyone participating in this process — patients, families and health care professionals — and it will cause a tremendous amount of moral distress for our physicians and nurses and health care providers.
On the responsibility bioethicists feel in creating policy
Parent: If bioethicists are trying to create these policies that in some ways determines who lives and who dies, it's important for us not to become inured to the fact that this actually has an impact on individuals.
And so to be able to create the policy so that these decisions can be made, whereas we could imagine if they didn't exist, some number of clinicians just throwing their hands up and saying, “I don't want to be responsible for this, I'm going to get out of town, or I don't have the capacity to do it.”
You know, it is this incredibly onerous job. And if we can work together to make this possible, while it should hit us in our hearts, we can feel as though our work and what we have been known for, which is thinking, can actually have practical effect[s] in implementing a just system of protecting people.
On humanizing patients treated under triage decisions
Kinlaw: I would say as a person who works as a clinical ethicist at the bedside, and treasures the opportunity to be with patients and families even in making hard decisions, that I very much have the faces and the voices of people in my mind in thinking about the processes that we're creating.
I also have the faces and voices of all of my health care colleagues in mind who are going through this incredibly difficult process. I think that we must, so that we don't lose sight of the people affected as we're developing this guidance. And by the way, bioethicists, of course, are developing this in close collaboration with all of our clinical colleagues. I think there is some grace and some strength in our having the chance to do that with others.
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