Triage & Resource Allocation
What were the ethical justifications behind the COVID-19 guidelines?
The COVID-19 pandemic has been overwhelming public health-care systems around the world. With demand exceeding the availability of medical resources in several regions, hospitals have been forced to invoke triage. To ensure that this difficult task proceeds in a fair and organised manner, governments scrambled experts to draft triage guidelines under enormous time pressure. Although there are similarities between the documents, they vary considerably in how much weight their respective authors place on the different criteria that they propose. Since most of the recommendations do not come with ethical justifications, analysing them requires that one traces back these criteria to their underlying theories of distributive justice. In the literature, COVID-19 triage has been portrayed as a value conflict solely between utilitarian and egalitarian elements. While these two accounts are indeed the main antipodes, I shall show that in fact all four classic theories of distributive justice are involved: utilitarianism, egalitarianism, libertarianism, and communitarianism. Detecting these in the documents and classifying the suggested criteria accordingly enables one to understand the balancing between the different approaches to distributive justice—which is crucial for both managing the current pandemic and in preparation for the next global health crisis.
Simulating Pandemic Prioritisation in intensive Care
Objectives: Simulation and evaluation of a prioritization protocol at a German university hospital using a convergent parallel mixed methods design.
Design: Prospective single-center cohort study with a quantitative analysis of ICU patients and qualitative content analysis of two focus groups with intensivists.
Setting: Five ICUs of internal medicine and anesthesiology at a German university hospital.
Patients: Adult critically ill ICU patients ( n = 53).
Interventions: After training the attending senior ICU physicians ( n = 13) in rationing, an impending ICU congestion was simulated. All ICU patients were rated according to their likelihood to survive their acute illness (good-moderate-unfavorable). From each ICU, the two patients with the most unfavorable prognosis ( n = 10) were evaluated by five prioritization teams for triage.
Measurements and main results: Patients nominated for prioritization visit ( n = 10) had higher Sequential Organ Failure Assessment scores and already a longer stay at the hospital and on the ICU compared with the other patients. The order within this worst prognosis group was not congruent between the five teams. However, an in-hospital mortality of 80% confirmed the reasonable match with the lowest predicted probability of survival. Qualitative data highlighted the tremendous burden of triage and the need for a team-based consensus-oriented decision-making approach to ensure best possible care and to support professionals. Transparent communication within the teams, the hospital, and to the public was seen as essential for prioritization implementation.
Conclusions: To mitigate potential bias and to reduce the emotional burden of triage, a consensus-oriented, interdisciplinary, and collaborative approach should be implemented. Prognostic comparative assessment by intensivists is feasible. The combination of long-term ICU stay and consistently high Sequential Organ Failure Assessment scores resulted in a greater risk for triage in patients. It remains challenging to reliably differentiate between patients with very low chances to survive and requires further conceptual and empirical research.
Was there a hidden form of Triage in the Pandemic?
Background: With the sudden onset of the COVID-19 pandemic, countries rushed to devise and implement guidelines for triage. In Germany, academic discourse had focused on criteria for triage, while often neglecting their translation into clinically applicable protocols in intensive care units (ICUs).
Research question: How did intensivists in German ICUs experience the institutional implementation of a national triage guideline and how did they respond to the resource constraints during the initial phases of the COVID-19 pandemic?
Study Design and Methods: For this qualitative study, we conducted semi-structured expert interviews with fourteen intensivists from various German hospitals between November 2021 and April 2022. The inclusion criteria were (I) being a senior ICU physician, (II) having worked in intensive care during the pandemic, and (III) being involved in institutional triage preparation. Transcripts were analysed using qualitative content analysis.
Results: Participants addressed triage preparation, implementation of triage protocols, and the allocation of critical care resources. They stressed legal uncertainty as a major barrier to implementing said protocols. We identified the potentially harmful phenomenon of what we term ‘covert triage’: pre-emptive, non-transparent, and improvised rationing to avoid the exhaustion of capacity, which would have triggered official triage. To keep ICU beds free for patients with more promising prognoses, intensivists resorted to two main strategies: raising informal Crisis Standards of Care (Covert Triage Type I) and manipulating consultations to dissuade patients and relatives from seeking intensive care treatment (Covert Triage Type II).
Is Treating Permanently Unconscious Patients Futile?
Under which conditions may physicians who are requested to treat permanently unconscious patients refuse to do so? Wasserman et al. (2023) maintain that refusals on the basis of supposed futility are unethical as they amount to passing off personal value judgments as medical expertise. Instead, unwillingness to carry out an intervention should be framed as conscientious objection. I argue that referring to futility with regard to a patient’s presumed quality of life is appropriate if – and only if – a total and irreversible loss of consciousness has been diagnosed with adequate certainty. The diagnosis turns a graded notion into a binary affair: conscious awareness is a necessary condition of any degree of quality of life to be meaningfully ascribed to an organism. Consequently, the complete absence of consciousness precludes such an ascription; further treatment is then indeed futile from a quality-of-life standpoint.
Should Patients Who Arrive First be Treated First?
Queuing to receive a desired good is a method of allocation deeply entrenched into our lives – be it waiting for housing, to become a member of certain clubs, or to receive promotion. We therefore often take it for granted that, other things being equal, those who have been waiting the longest enjoy priority. But should this always be so? In this comment, we respond to the suggestion of replacing waiting lists in medical settings with a last-come-first-served approach. Drawing parallels with the allocation of donor organs, we argue that both medical utility and equity would be diminished by policies that simply prioritise the most recent referral.
How Do triage protocols translate abstract theories into concrete criteria for rationing?
During the COVID-19 pandemic, national triage guidelines were developed to address the anticipated shortage of life-saving resources. Rationing and triage imply that, in addition to individual patient interests, population health must also be considered. The paper analyses how triage protocols can translate abstract theories of distributive justice into concrete material and procedural criteria for rationing intensive-care resources. We reconstruct the development and implementation of a rationing protocol at a German university hospital, describing the ethical challenge of triage, clarifying the aspirational norms, and summarising specific norms of fair triage and allocation for developing and implementing an institutional policy and practice model. We reflect on how critical topics are seen by clinicians and which interventions helped to manage the perceived burdens of triage dilemmas. The article seeks to inform the debate about triage concepts and policies to ensure the best possible treatment and fair allocation of resources as well as to help protect both patients and professionals in worst-case scenarios.