DEATH PAN­ELS OR LIFE SAVERS?

Triage teams may have to make tough calls

The Province - - PANDEMIC NEWS - DOU­GLAS TODD

Did you get a good chance at life?

That’s the kind of ques­tion ethi­cists be­gin ask­ing if masses of strug­gling hu­mans be­gin plead­ing for med­i­cal help when life-sav­ing re­sources are scarce.

The broad life-eval­u­a­tion ques­tion con­nects to triage, which pri­or­i­tizes bat­tle­field ca­su­al­ties in war and pa­tients in emer­gency wards. It points to the moral con­cerns that flooded the minds and hearts of doc­tors and nurses in Italy when peo­ple suf­fer­ing dire breath­ing prob­lems from the COVID-19 virus were over­whelm­ing the sup­ply of ven­ti­la­tors.

It’s a ques­tion at the cen­tre of the dilemma with which Dr. Michael Kenyon, head of the in­ten­sive care unit at Nanaimo Re­gional Gen­eral Hos­pi­tal, re­cently con­fronted B.C.’s provin­cial health of­fi­cer, Dr. Bon­nie Henry. Kenyon pub­licly com­plained that, should his hos­pi­tal’s 14 ven­ti­la­tors all be in use, he would fol­low the lead of some Ital­ian health of­fi­cials and start tak­ing 70-year-olds off the ven­ti­la­tors, fol­lowed by 60-year-olds, and so on. Kenyon warned he would be ready to give pre­cious ven­ti­la­tors mainly to 30-year-olds with three chil­dren. Fam­i­lies that had not had a full chance at life.

Henry, in her news brief­ings, re­sponded that Kenyon had raised ag­o­niz­ing is­sues that re­flect “what we’re see­ing around the world, which puts us in moral dis­tress.” She later clar­i­fied that a team of med­i­cal ethi­cists, spe­cial­iz­ing in nurs­ing, is fine-tun­ing a provincewi­de eth­i­cal pro­to­col for ven­ti­la­tor ra­tioning, which will be posted on­line.

Should the COVID-19 cri­sis spin out of con­trol in Canada — and it is im­por­tant to re­mem­ber it has not — many heart­break­ing ques­tions will have to be an­swered, the over­all one be­ing: Which pa­tients should get prece­dence for the coun­try’s lim­ited sup­ply of ven­ti­la­tors?

A re­cent na­tional study es­ti­mated the to­tal num­ber of ven­ti­la­tors in Canada at about 5,000. On Tues­day, Ot­tawa or­dered 1,700 more, and said it’s con­sid­er­ing seek­ing 4,000 ex­tra. B.C. Health Min­is­ter Adrian Dix says there are 1,372 in this prov­ince.

The ur­gency is un­der­stand­able. Pa­tients who need their breath­ing as­sisted af­ter be­ing in­tu­bated by a tube linked to a ven­ti­la­tor can die within min­utes of be­ing de­tached from the air pumps. At the peak of Italy’s cri­sis, doc­tors made head­lines when some were said to be weep­ing in the hall­ways about the prospect of be­ing forced to make life-and­death de­ci­sions about which strug­gling pa­tients the com­put­er­ized tech­nol­ogy would ben­e­fit the most.

It’s not hard to make pro­jec­tions that can scare the pub­lic. Canada so far has more than 12,000 con­firmed and prob­a­ble cases of COVID19, with more than 1,100 in B.C. There have been 183 deaths na­tion­ally, with 35 deaths in B.C. as of Fri­day, me­dian age 85.

Dr. Theresa Tam, Canada’s top pub­lic health of­fi­cial, says seven per cent of cases have re­quired hos­pi­tal­iza­tion, with three per cent of those pa­tients need­ing to be hooked up to ven­ti­la­tors. If the num­ber of in­fected peo­ple sky­rock­ets, de­mand for ven­ti­la­tors could ex­ceed sup­ply.

A B.C. Health Min­istry spokeswoma­n, Laura Stovel, would not pro­vide any­one to in­ter­view on the sub­ject of the gov­ern­ment’s eth­i­cal pro­to­col for ac­cess to ven­ti­la­tors, say­ing only she will send “the link once they have been posted on­line.”

How­ever, the min­istry re­leased a gen­eral doc­u­ment on March 28 called COVID-19 Eth­i­cal De­ci­sion-Mak­ing Frame­work, which at­tempts to lay out broad guide­lines for al­lo­cat­ing scarce med­i­cal re­sources. It doesn’t men­tion ven­ti­la­tors.

“The needs of the com­mu­nity may out­weigh the needs of in­di­vid­u­als in such crises; per­sonal rights and free­doms must some­times be con­strained,” says the frame­work. Some of the key prin­ci­ples to be bal­anced in ra­tioning re­sources in­clude re­spect, rea­son­able­ness, eq­uity, ef­fi­ciency and fair­ness.

“Those who most need and can de­rive the great­est ben­e­fit from re­sources ought to be of­fered re­sources pref­er­en­tially. Re­sources ought be to dis­trib­uted such that the max­i­mum ben­e­fits to the great­est num­ber will be achieved,” the B.C. frame­work says.

At the peak of the Ital­ian surge, health providers did not want to dis­cuss the cri­te­ria for so-called pulling the plug, telling in­ves­ti­ga­tors such as Dr. Lisa Rosen­baum that “you will just scare a lot of peo­ple.” Some, how­ever, told Rosen­baum, for her ar­ti­cle in the New Eng­land Jour­nal of Medicine, “The cit­i­zens won’t ac­cept the re­stric­tions un­less you tell them the truth.”

Along with most med­i­cal ethi­cists, Henry has said the judg­ment calls about who gets ven­ti­la­tors would be made by a triage com­mit­tee, sep­a­rate from front-line physi­cians and nurses, who ad­vo­cate for each pa­tient. Henry made that point, which is cru­cial to ethi­cists, af­ter the head of Nanaimo’s ICU unit sug­gested he per­son­ally would de­ter­mine who should con­tinue to be in­tu­bated to as­sist their breath­ing.

It’s only through a clear, trans­par­ent process, sug­gest ethi­cists and the health min­istry, that the pub­lic will buy in to the eth­i­cal val­ues that go into the ex­cru­ci­at­ing de­ci­sions over which or­der pa­tients should be of­fered me­chan­i­cal breath­ing.

TRIAGE AC­CORD­ING TO AN AT-RISK ETHI­CIST

For Michael Mc­Don­ald, for­mer head of the Univer­sity of B.C.’s Cen­tre for Ap­plied Ethics, the ques­tion of whether one had a de­cent chance at life is more than hy­po­thet­i­cal.

At age 77, with a heart con­di­tion, Mc­Don­ald says he feels he has “a tar­get on my back” in re­gards to the pos­si­bly low pri­or­ity he and his wife, who is in a wheel­chair, would be given should they re­quire a ven­ti­la­tor dur­ing a mass-care surge.

Nev­er­the­less, Mc­Don­ald said the sup­ply of ven­ti­la­tors will never be in­fi­nite. “Have you had fair in­nings?” That’s how the late Daniel Cal­laghan, founder of the in­flu­en­tial Hast­ings Cen­ter for bioethics re­search, talked about who should get med­i­cal treat­ment in a time of ra­tioning, Mc­Don­ald said.

“Have you had a good chance at life? He was talk­ing about this in terms of the larger con­text, like peo­ple in my age group, se­niors. He asks how much re­sources should we spend on se­niors, how much in gen­eral in our health-care sys­tem?”

Mc­Don­ald, who has served on hos­pi­tal ethics boards and taught many stu­dents who now spe­cial­ize in bioethics, fully rec­og­nizes that deter­min­ing whether some­one has had “fair in­nings” is not pre­cise. And never will be.

And he is not sug­gest­ing, like Texas Lt.-Gov. Dan Pa­trick did on March 24, that 69-yearold grand­par­ents like Pa­trick him­self should be will­ing to risk con­tract­ing COVID-19 so the U.S. could end the lock­down that is crip­pling the econ­omy.

Yet Mc­Don­ald sup­ports peo­ple learn­ing more about the spe­cific fac­tors and val­ues to con­sider should a pan­demic lead to a short­age of ven­ti­la­tors.

When On­tario was bat­tered by a SARS epi­demic in 2004, the Univer­sity of Toronto’s bioethics com­mit­tee put out a pub­li­ca­tion called Stand On Guard for Thee. It main­tained that med­i­cal triage should bal­ance prin­ci­ples such as duty to pro­vide care, equal­ity, trust, sol­i­dar­ity, in­di­vid­ual lib­erty and open­ness.

Eas­ier to say than do. But at least the Stand on Guard state­ment makes clear which value should not be para­mount when ra­tioning ven­ti­la­tors.

Triage is not based on the mar­ket­place value of first­come, first-served, like be­ing the first to plonk down your blan­ket in front of the stage at a folk fes­ti­val. In a pan­demic, as B.C.’s Health Min­istry ethics frame­work sug­gests, it is the needs of the broader com­mu­nity that mat­ter.

The most spe­cific fact-based ques­tion med­i­cal staff will ask dur­ing a surge of de­mand, ac­cord­ing to a pro­to­col called The New York Guide­lines, is: “How can we save the most lives, as de­fined by the

Those who most need and can de­rive the great­est ben­e­fit from re­sources ought to be of­fered re­sources pref­er­en­tially.”

B.C. Health Min­istry frame­work

pa­tient’s short-term like­li­hood of sur­viv­ing the acute med­i­cal episode?”

Pa­tient rank­ing should pro­ceed in three steps, ac­cord­ing to The Tough­est Triage — Al­lo­cat­ing Ven­ti­la­tors in a Pan­demic, a March 25 es­say in The New Eng­land Jour­nal of Medicine writ­ten by Dr. Robert Truog and two other physi­cians.

The first is to check whether the pa­tient has had “ir­re­versible shock” that ren­ders ven­ti­la­tor treat­ment fu­tile.

The sec­ond step is to assess each pa­tient’s risk of mor­tal­ity via a scor­ing sys­tem called the Se­quen­tial Or­gan Fail­ure As­sess­ment. Com­mon to ICU de­part­ments, it uses a score to rank a pa­tient’s like­li­hood of sur­vival based on the con­di­tion of their blood, heart, lung, liver and ner­vous sys­tems.

The third step, say Truog and his co-authors, in­volves con­tin­u­ally as­sess­ing a pa­tient’s progress, such that those “whose con­di­tion is not im­prov­ing are re­moved from the ven­ti­la­tor to make it avail­able for an­other pa­tient.”

‘SOFT UTIL­I­TAR­I­AN­ISM’ CAN GUIDE US

Triage ethics have been shaped by a philo­soph­i­cal school some de­scribe as “soft util­i­tar­i­an­ism.”

And in a cri­sis sit­u­a­tion, it’s not bad to seek what one early Stoic thinker called “the con­so­la­tion of phi­los­o­phy.” There was a time, less than 50 years ago, when “physi­cians ar­gued that with­draw­ing a ven­ti­la­tor was an act of killing, pro­hib­ited by both law and ethics,” say Truog and his co-authors.

In re­cent years, the main cause of fa­tal­i­ties in ICU units has been vol­un­tary ven­ti­la­tor with­drawal at the re­quest of a pa­tient or pa­tient rep­re­sen­ta­tive. Some ju­ris­dic­tions have been lean­ing to­ward util­i­tar­i­an­ism by also al­low­ing physi­cians to uni­lat­er­ally re­move life sup­port when treat­ment is deemed fu­tile.

Util­i­tar­i­an­ism is of­ten as­so­ci­ated with Bri­tish po­lit­i­cal philoso­pher John Stu­art Mill, who taught the ul­ti­mate aim of ethics should be “the great­est good for the great­est num­ber.” B.C.’s Health Min­istry bor­rows an ex­plicit util­i­tar­ian view when it says it will dis­trib­ute med­i­cal re­sources so “the max­i­mum ben­e­fits to the great­est num­ber will be achieved.”

Util­i­tar­i­an­ism is not a per­fect guide­line to life and death, how­ever. As Univer­sity of Min­nesota emer­gency physi­cian Dr. Daniel O’Laugh­lin says, it is hard for so­ci­ety to de­fine “the great­est good.”

Does it re­fer, for in­stance, to to­tal lives saved, to­tal po­ten­tial years of life saved or some­thing else? Util­i­tar­i­an­ism can also threaten what many be­lieve is ev­ery in­di­vid­ual’s right to care.

Yet O’Laugh­lin ac­knowl­edges that in a time of med­i­cal scarcity physi­cians’ Hip­po­cratic Oath — “do no harm” to any in­di­vid­ual — does not stand up. Those forced to ra­tion ven­ti­la­tors will need to cause harm to one pa­tient whose prog­no­sis is bad for “the greater good” of a sec­ond or third pa­tient who has a bet­ter chance.

An­other key value to bal­ance with the “great­est good” is equal­ity, of­ten as­so­ci­ated with philoso­pher John Rawls. Some ob­vi­ous ways to be un­equal, or un­fair, would be to deny peo­ple ac­cess to a ven­ti­la­tor based on their eth­nic­ity, their poverty or be­cause they are ad­dicted to drugs, Mc­Don­ald says.

Equal­ity is a value the B.C. Health Min­istry shares, since its frame­work says, “re­source al­lo­ca­tion de­ci­sions must be made with con­sis­tency” re­gard­less of “hu­man con­di­tion,” in­clud­ing dis­abil­ity, abil­ity to pay or “so­cial worth.”

Still, no mat­ter how many eth­i­cal prin­ci­ples one brings into weigh­ing who should get ac­cess to a ven­ti­la­tor, some sit­u­a­tions present true dilem­mas, with no clear right or wrong. As Rosen­baum asks rhetor­i­cally: “Would you pref­er­en­tially in­tu­bate a healthy 55-year-old over a young mother with breast can­cer whose prog­no­sis is un­known?”

Ethics is of­ten an im­per­fect process. Yet Mc­Don­ald, who feels he’s had a full life even though he’s part of a vul­ner­a­ble se­niors pop­u­la­tion with ex­ist­ing health con­di­tions, says some­times hu­mans must weigh their own self-in­ter­est against larger prin­ci­ples.

“The great English util­i­tar­ian Henry Sidg­wick talked about ‘the point of view of the uni­verse’ as the right per­spec­tive. That is to take se­ri­ously the wel­fare of all those whom we af­fect in our ac­tions and not be par­tial to our­selves. John Rawls asks us to think of con­struct­ing a moral or­der that we could en­dorse from the point of view of the least well off,” Mc­Don­ald says.

“I try to see the world from a more uni­ver­sal per­spec­tive, but I can’t help but think about what my judg­ments mean for me. So in a way I am happy to say that, yes, I am 77 with pre-ex­ist­ing health con­di­tions. Peo­ple can then ask do I ex­hibit the req­ui­site im­par­tial­ity.”

LIFE-AND-DEATH CHOICES

Some peo­ple re­fer to the com­mit­tees that would make eth­i­cal de­ci­sions about who re­ceives ven­ti­la­tor treat­ment as “death pan­els.” But de­fend­ers say they’re the op­po­site: They save lives.

A po­ten­tial ven­ti­la­tor short­age dur­ing the COVID-19 pan­demic is not the first time health of­fi­cers will have faced triage. It first came to the fore in the 1800s, in a for­mal way, un­der Napoleon, when bat­tle sur­geon Do­minique Jean Lar­rey sorted wounded sol­diers into num­bered cat­e­gories for the pur­pose of giv­ing im­me­di­ate care to those most likely to ben­e­fit.

Hos­pi­tal emer­gency wards also do triage. Faced with floods of peo­ple with dif­fer­ent de­grees of wounds, panic at­tacks and fevers, emer­gency-room doc­tors and nurses are con­stantly fol­low­ing risk pro­to­cols that help them de­cide who gets treat­ment first and who has to wait for hours, if not longer.

Ex­tra­or­di­nary med­i­cal treat­ments are also not al­ways pro­vided to pa­tients, even when re­sources are avail­able. When he was on the ethics board of a ma­jor B.C. hos­pi­tal, Mc­Don­ald and his team found physi­cians just out of med­i­cal school in­cor­rectly thought they were legally com­pelled to re­sus­ci­tate pa­tients who had suf­fered cat­a­strophic car­diac ar­rest.

The des­per­ate re­sus­ci­ta­tions were al­most en­tirely un­suc­cess­ful. Worse yet, they caused ex­treme dis­tress for fam­i­lies and pa­tients who had to wit­ness them. The hos­pi­tal had to put out no­tices re­mind­ing doc­tors and nurses that they weren’t ac­tors in an imag­i­nary TV med­i­cal show, where dra­matic re­sus­ci­ta­tions al­most al­ways mag­i­cally saved the pa­tient.

Ven­ti­la­tor triage is as much about the com­plex facts of each pa­tient’s case as it is about eth­i­cal val­ues, says Mc­Don­ald. It’s also about be­ing hon­est, with pa­tients and their loved ones. Health pro­fes­sion­als who de­ter­mine they must pull a pa­tient off a ven­ti­la­tor must not tell white lies to try to make peo­ple feel bet­ter.

“Clin­i­cians may be mo­ti­vated to try to com­fort the fam­ily by telling them that me­chan­i­cal ven­ti­la­tion is not be­ing pro­vided be­cause it would be fu­tile and by re­as­sur­ing them that ev­ery­thing has been done,” says the New Eng­land Jour­nal of Medicine.

In a triage sit­u­a­tion, with a short­age of ven­ti­la­tors, some­times the plug could be pulled sim­ply be­cause some­one else could prob­a­bly ben­e­fit from it more.

“Though well-in­ten­tioned,” says the jour­nal, “in­ac­cu­rate rep­re­sen­ta­tions could ul­ti­mately un­der­mine pub­lic trust and con­fi­dence.”

It’s cru­cial to avoid giv­ing the im­pres­sion triage de­ci­sions will ever be flaw­less.

De­spite the won­ders of mod­ern medicine, it’s still a sphere that con­tains un­cer­tainty and even mystery. Just as it is hard to an­swer the ques­tion of whether some­one has had a good chance at life.

Hu­mans are called upon to mud­dle with in­tegrity through even life-and-death choices. At the best of times be­ing alive re­quires some sto­icism and a larger per­spec­tive, a will­ing­ness to pa­tiently face the worst with for­bear­ance.

— GETTY IMAGES

Doc­tors treat a coro­n­avirus pa­tient in an in­ten­sive care unit at the Covid 3 Hos­pi­tal (Isti­tuto clin­ico Casal­Palocco) last week in Rome.

FRaN­CIs Ge­OR­GIaN/PNG

UBC ethics pro­fes­sor emer­i­tus Michael Mc­Don­ald is 77 and knows he’s com­pro­mised med­i­cally should there ever be a triage sit­u­a­tion. But he thinks age is par­tially rel­e­vant should there be ven­ti­la­tor ra­tioning.

— REUTERS

An em­ployee works at Ven­tec Life Sys­tems in March. The ven­ti­la­tor man­u­fac­turer in Bothell, Wash., has seen an in­crease in de­mand for its prod­uct since the COVID-19 out­break be­gan.

— GETTY IMAGES

Doc­tors stand at the en­trance of the No­men­tana hos­pi­tal out­side of Rome on Thurs­day.

— GETTY IMAGES

A nurse checks a pa­tient in a COVID-19 ward at Cre­mona Hos­pi­tal on Thurs­day in Cre­mona, Italy.

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