The most recent issue of the Canadian Medical Association Journal (CMAJ) includes an articleoutlining a triage protocol to determine who will be admitted to ICU during a flu pandemic.
The idea is that the surge in demand for ICU beds, particularly ventilatory support or mechanical ventilation, will outstrip the available resources and we will need some system that has already widely approved to make the tough decisions.
The triage protocol will be applied to every patient who is being considered for an ICU bed, not just those with the flu, because the resource of ICU beds is the same for flu and non-flu patients.
I think it is wise to work on a triage protocol before we find ourselves in the pandemic situation so that the experts can take the time to determine what factors to consider in determining who should and who shouldn't receive life-saving therapy. In modern healthcare, we are not used to or prepared to deny a patient critical care unless the patient or family has expressed that they do not want it so we could quickly find ourselves in the situation of having an ICU full of patients with a poor chance of survival, while new patients keep rolling in the door.
Four components make up the triage protocol: inclusion criteria, exclusion criteria, minimum qualifications for survival and a prioritization tool.
The inclusion criteria are easy: the patient must be sick enough to need ICU either to help with breathing or other resuscitation efforts that can't be done in a non-ICU setting.
The exclusion criteria start to set some limits on who will and will not receive critical care during a public health emergency. I should make the point that these folks will receive other forms of care like antibiotics and analgesics. Conditions such as severe burns, severe trauma or advanced cancer will preclude patients from going to ICU because their chance of survival is already low. The protocol sets an age limit of less than 85 years for admission to ICU but I could see that limit being lowered if the pandemic were affecting a large proportion of the population.
Minimum qualifications for survival means looking at some physiologic criteria such as certain blood tests and levels of brain function, as well as reassessing the patient at 2 and 5 days to determine that the patient still has a decent chance of survival. The idea here is to avoid allocating a lot of resources to an individual who has gotten so sick that he is unlikely to survive without medical care that is far above the average in terms of duration or special treatments.
Let me give an example of what minimum qualifications for survival means. In my hospital we had a case a few years ago of a healthy 17 year old who developed respiratory failure very suddenly. It wasn't clear why this had happened but he was very sick and kept getting sicker. It got to the point that we couldn't get enough oxygen into him using our regular ventilators and everyone was afraid that he was going to die despite our best efforts. Our ICU doctors had to try some techniques that were experimental at the time, and it took a few days, but slowly this patient started to recover and he eventually made it out of hospital.
According to this triage protocol, even though this patient was only 17 and previously healthy, once he got so sick that he wasn't responding to conventional therapies, the ICU would have to desist from trying experimental therapies so he would probably die. It seems harsh but if it frees up the ICU bed to treat several more patients then it may be the best decision in the grand scheme of things.
The prioritization tool helps to identify which patients are most likely to respond, and respond quickly to ICU treatment. The idea is that if you have 50 patients in the emergency room who all fit the inclusion and exclusion criteria and the minimum qualifications for survival but can only treat 30 of them, who do you take to the ICU.
As I said before, I think it is a good idea to develop a protocol like this before we ever need it. As the authors of the protocol said:
This triage protocol is a tool aimed at maximizing benefits for the largest number of patients presenting to an overwhelmed critical care system. The ethical values that inform this protocol were derived from the work of the Joint Centre for Bioethics, in the document Stand on Guard for Thee. The authors identify 10 substantive values (individual liberty, protection of the public from harm, proportionality, privacy, duty to provide care, reciprocity, equity, trust, solidarity and stewardship) and 5 procedural values (reasonable, open and transparent, inclusive, responsive and accountable).
Under normal circumstances, all patients should have an equal claim to receive the health care they need. Unfortunately, during a pandemic it will not be possible for all patients to receive intensive care due to finite resources. A triage protocol will assist in distributing the available resources fairly by triaging patients who will not benefit from treatment to noncritical care management, thereby conserving critical care resources for patients who are more likely to benefit. Although it may be unfortunate that some patients do not receive all that they could possibly "use," this does not by default make it unfair. Any restrictions placed on treatment must, however, adhere to the value of proportionality, which requires that restrictions to individual liberties not exceed what is necessary to address the essential needs of the community.
This protocol only addresses one aspect of healthcare during a pandemic situation. We still need to discuss as a society important issues like triaging vaccines and antiviral treatments during a pandemic, and how we will manage law and order and maintain basic necessities, like a food supply.