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Doctors advise on how to decide who to treat, who not to treat during flu pandemic
HELEN BRANSWELL
TORONTO (CP) - A team of critical care doctors has come up with a tool their colleagues would hope never to have to use - a guide on how to make the harrowing decisions about who not to treat during a flu pandemic.
The triage protocol, as it is called, suggests a scoring system that would see treatment withheld from people with the least chance of surviving in favour of helping those deemed to be more likely to pull through if they get care.
The protocol, published Monday in the Canadian Medical Association Journal, doesn't suggest scoring the elderly more harshly based on age alone. But the authors admit advanced age could be a count against care in a future version of their decision tool.
"We received strong and consistent feedback from both expert and stakeholder consultations that an age criterion should be included," they wrote.
"This remains one of the areas requiring further research and community input."
The tool the authors devised would grade patients in need of intensive care based on how many of their organs are in failure with the goal of "doing the most for the most with the limited resources available."
Those who had the lowest chance of surviving - those with end-stage heart disease, for instance - wouldn't get intensive care treatment. Patients would be reassessed at prescribed intervals.
One of the authors said the difficulties around whether to use age as a factor in the triaging of emergency care underscores how important it is to have a public debate on the tough choices health-care would have to make during a severe pandemic.
"I have a lot of trouble with solely using age," admitted Dr. Randy Wax, a critical care physician at Toronto's Mount Sinai Hospital.
"Having said that, there are many people - and I don't mean health-care workers, I mean members of the public - who would argue that . . . those who are younger may be able in the aftermath of a horrible tragedy like a pandemic . . . to make a different kind of contribution back to to society."
"I don't have the answer to that. And I think that's why it's important to get this out in the public so that we can get some public discussion and feedback."
It is expected a severe flu pandemic would swamp health-care systems worldwide, putting health-care workers in a situation where they essentially have to play God by deciding to withhold treatment they would give in normal times with normal caseloads.
Ethicists and health-care experts concerned about the kinds of decisions a pandemic would force on society have been calling for some time for a public debate. They feel public input is critical to shape policies on things like who should get first crack at vaccine and antiviral drugs in times of shortage and who should get health care when the system can't help all.
"We're crying for public input across the board on these issues," said Dr. Ross Upshur, director of the University of Toronto's Joint Centre on Bioethics.
But Upshur is pessimistic that governments will initiate public discussion of such difficult issues before a crisis hits.
"Am I optimistic that we'll have the necessary conversation before the time? My answer to that is no," he said. "I am concerned that the clock is ticking."
Wax said these are discussions that even health-care workers are loathe to have.
"It's difficult. None of us wants to ever have to make that sort of decision. But it's probably much more dangerous to put our heads in the sand and assume that it won't happen than it is to be prepared in case it does happen and have a plan that's made in advance that we've had lots of time to discuss and try to make as fair and ethical as possible."
The authors suggest hospitals would need a triage officer who would be the ultimate authority. Those people would have to be educated well in advance and would need legal protection to shelter them from the possibility aggrieved relatives might take punative legal action later, Wax said.
The protocol was written at the behest of the Ontario government. But Wax said the authors think it could serve as a model for other parts of Canada and other countries as well.
HELEN BRANSWELL
TORONTO (CP) - A team of critical care doctors has come up with a tool their colleagues would hope never to have to use - a guide on how to make the harrowing decisions about who not to treat during a flu pandemic.
The triage protocol, as it is called, suggests a scoring system that would see treatment withheld from people with the least chance of surviving in favour of helping those deemed to be more likely to pull through if they get care.
The protocol, published Monday in the Canadian Medical Association Journal, doesn't suggest scoring the elderly more harshly based on age alone. But the authors admit advanced age could be a count against care in a future version of their decision tool.
"We received strong and consistent feedback from both expert and stakeholder consultations that an age criterion should be included," they wrote.
"This remains one of the areas requiring further research and community input."
The tool the authors devised would grade patients in need of intensive care based on how many of their organs are in failure with the goal of "doing the most for the most with the limited resources available."
Those who had the lowest chance of surviving - those with end-stage heart disease, for instance - wouldn't get intensive care treatment. Patients would be reassessed at prescribed intervals.
One of the authors said the difficulties around whether to use age as a factor in the triaging of emergency care underscores how important it is to have a public debate on the tough choices health-care would have to make during a severe pandemic.
"I have a lot of trouble with solely using age," admitted Dr. Randy Wax, a critical care physician at Toronto's Mount Sinai Hospital.
"Having said that, there are many people - and I don't mean health-care workers, I mean members of the public - who would argue that . . . those who are younger may be able in the aftermath of a horrible tragedy like a pandemic . . . to make a different kind of contribution back to to society."
"I don't have the answer to that. And I think that's why it's important to get this out in the public so that we can get some public discussion and feedback."
It is expected a severe flu pandemic would swamp health-care systems worldwide, putting health-care workers in a situation where they essentially have to play God by deciding to withhold treatment they would give in normal times with normal caseloads.
Ethicists and health-care experts concerned about the kinds of decisions a pandemic would force on society have been calling for some time for a public debate. They feel public input is critical to shape policies on things like who should get first crack at vaccine and antiviral drugs in times of shortage and who should get health care when the system can't help all.
"We're crying for public input across the board on these issues," said Dr. Ross Upshur, director of the University of Toronto's Joint Centre on Bioethics.
But Upshur is pessimistic that governments will initiate public discussion of such difficult issues before a crisis hits.
"Am I optimistic that we'll have the necessary conversation before the time? My answer to that is no," he said. "I am concerned that the clock is ticking."
Wax said these are discussions that even health-care workers are loathe to have.
"It's difficult. None of us wants to ever have to make that sort of decision. But it's probably much more dangerous to put our heads in the sand and assume that it won't happen than it is to be prepared in case it does happen and have a plan that's made in advance that we've had lots of time to discuss and try to make as fair and ethical as possible."
The authors suggest hospitals would need a triage officer who would be the ultimate authority. Those people would have to be educated well in advance and would need legal protection to shelter them from the possibility aggrieved relatives might take punative legal action later, Wax said.
The protocol was written at the behest of the Ontario government. But Wax said the authors think it could serve as a model for other parts of Canada and other countries as well.