Triage Protocol for Critical Care in PanFlu

[sharon sanders]

From our friends at the Bellagio Group:

Development of a Triage Protocol for Critical Care During an Influenza Pandemic

http://www.cmaj.ca/cgi/reprint/175/11/1377

Bellagio Commentary:

Triage Protocol

The November 21 issue of the Canadian Medical Association Journal featured a pair of articles on developing a triage protocol for critical care (ventilators etc.) during a pandemic. An article by Christian & colleagues describes the protocol and how it was developed (it was commissioned specifically for the province of Ontario, but one would expect it might be adopted, in whole or in part, by other Canadian provinces, and perhaps outside Canada). In brief, the protocol has 4 components:

1. Inclusion criteria: dictate the presence of one or more conditions indicating a patient might benefit from ICU care
2. Exclusion criteria: exclude patients who have an especially poor prognosis, those with medical needs that couldn't be provided during a pandemic, and those with underlying illnesses with a high likelihood of death (e.g., metastatic cancer, severe organ failure).
3. Minimum qualifications for survival: call for reassessment at 48 and 120 hours to identify and exclude those who aren't improving significantly (i.e., even if a patient initially qualifies for critical care placement, he/she may not stay indefinitely)
4. Prioritization scheme: picks out patients who are sick enough to require ICU admission, but are in otherwise good enough condition that they have a decent chance of recovery when care is provided. Those are are likely to die even with intensive care receive palliative or curative care, but not in the ICU. Those who in less serious condition can be admitted to the ICU if space is available.

The stated goal of the plan is "maximizing benefits for the largest number of patients presenting to an overwhelmed critical care system. They cite a number of substantive and procedural ethical values described in the report Stand on Guard for Thee [PDF], although it's not clear where many of these values (individual liberty, protection from harm, privacy, reciprocity, equity) fit into the protocol. It seems that the overarching principle is rather that of utility ("maximizing benefits"). This is not a meant as a criticism. This protocol really just one facet of a broader pandemic plan, and as such, it probably needn't reflect the full array of ethical values (which, I think, are more clearly applicable to public health responses in the face of a pandemic, e.g., social distancing measures)
In an accompanying commentary, Melnychuk and Kenny point out some of the remaining ethical "loose ends" in the triage protocol, and in pandemic planning more broadly:

...their article is missing a crucial element: they provide a robust scientific discussion of triage, stating that a set of substantive and procedural values informed their triage protocol, but they do not tell us exactly how that occurred. There is an urgent need for a national ethical framework that makes explicit the values and principles that will guide pandemic influenza planning. The development of such a framework entails real work in the formulation of policy and its implementation; we must be clear why certain values are privileged and others not. This paper contributes to the project, but there is much tough work yet to be done. Three key interconnected values that are identified in Stand on Guard for Thee appropriately focus on the common good and thus are highly relevant to pandemic planning: equity (we need to maintain equity and not increase inequity in the face of fear and uncertainty), trust (we need to have trust in both fair processes and fair treatments) and solidarity (we are all in this together, and protecting the public and hence ourselves will require society-wide collaborations). By maintaining equity, building trust and promoting solidarity, the common good can be more effectively promoted and protected.

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