Disaster Ethics in Critical Care: Sara Gray
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The document discusses disaster triage and who receives scarce medical resources. It outlines three key aspects: guiding principles, inclusion and exclusion criteria, and a defined triage process. The guiding principles are to mitigate harm, follow utilitarian ethics of saving the most lives, have clear activation triggers for triage, and ensure a fair process with broad buy-in. The inclusion and exclusion criteria specify medical conditions that would qualify or disqualify patients from receiving certain critical interventions like ventilation or vasopressors. A dedicated triage team would apply these principles and criteria during a defined triage process to allocate scarce resources in a disaster.
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Disaster Ethics in Critical Care: Sara Gray
- 1. Disaster Triage: who gets what? Sara Gray
- 27. 1. Mechanical ventilation 2. Vasopressors
- 28. 1. Cardiac arrest 2. Severe trauma 3. Severe burns 4. Metastatic malignancy 5. DNR 6. Severe end organ failure
- 29. End organ failure = excluded? • NYHA III/IV • FEV1 < 25% • MELD > 20 • Severe dementia • Severe irreversible neuro condition • Severe irreversible immunocompromise
- 39. Triage of Scarce Resources Mitigate Utilitarian ethics Clear activation triggers Broad buy-in and engagement Dedicated team Fair process This discussion is worth it, if it saves more lives.
Editor's Notes
- Imagine with me, that you are working your normal Saturday evening shift. Picture it. The administrators have all gone home. And you’re busy, but not swamped. Just a typical 10pm scenario.
- Out there nearby, there’s a huge rock concert going on, at a stadium close to you. And you’re expecting that by the end of the evening, your hospital will see a fair number of intoxicated patients SMILE) after the concert ends. But then your twitter feed goes crazy, and you find out that two bombs just detonated, at the stadium. With an estimated 40,000 people in attendance. And that every ambulance in town is headed your way. At first, this is goes pretty well. Your team is well trained, all hands on deck are called in to help. But the patients just keep coming, and coming, and coming.
- I know we routinely are overcrowded, and running out of resources? Who here is ever short of a bed for a patient? Everyday, right? Me too. But this talk is about what we do when our normal lack of resources is amplified by an order of magnitude.
- And you start to get low on precious resources. Until you ask someone to get a ventilator, and they say “there are no more vents”.
- This is a pivotal moment. Because if you are the person responding to this disaster, your decisions and actions over the next few hours will have an enormous impact. You want to get this right. How do we decide who gets what, when there is not enough for everyone?
- At my place, I am the medical director for emergency preparedness, and one of my jobs, is to dream up disasters, and then work out plans for managing them. We have nice plans for the vast majority of calamities, but this one in fact, I need your help on…. For this one, I am looking for your ideas, your feedback, your input. My goal here, is to start a global, social media conversation on this topic, and see what we can all learn from each other. I have no financial stake in this. But I have a serious academic interest, I am looking for the best available solution to this problem.
- Now to be clear, I am not talking about START triage tags, or their equivalents. I like these systems. These systems, which are pretty well sorted out tell you which patient to manage first in a crisis. In general, your immediate priority are going to be the red patients, the unstable ones. See the reds first.
- This is no problem when you have one red patient and at least one bed available. But say that you have only one bed, and you have three red patients.
- Or five.
- Or twenty. How do you choose who gets that one precious bed? They are all there in front of you, how are you going to choose? And perhaps your scarce resource is a bed, but it could equally be a ventilator, or a transfusion or an OR. This concept of triage of scarce resources is scalable to any you are running short of, and that’s what we’re talking about here. This is where is starts to get serious., and where having criteria to guide these decisions can make all the difference.
- Who has a plan for this? Who has a plan, with clear criteria, telling them which patient gets the bed, and which patient does not? Yeah, me neither. SMILE and shrug. And to be fair, very few places have this type of plan in place. If you’re not sure, here‘s your homework. Go home and check your code orange plan, or your mass casualty plan. And if you have a triage plan with nice clear criteria, please send it out to all of us so we can learn from it! SMILE
- Because at this stage, it’s probably better to not just wing it. I think we all agree here, that at this moment, when it is up to you, late in the evening, we would all love to have a decent plan to follow for triaging scarce resources.
- Even when we look to the published literature, there are very few detailed plans out there. Most papers on this topic conclude that it’s a great idea to have a plan like this, and say that we need to develop plans. As in, somebody else should work on this. SMILE Why does this happen? (14 papers include an actual triage process for this)
- Because this is a terrifying topic, that no one wants to mention out loud. We hate talking about the possibility of this issue. Because in this scenario, someone does NOT get a bed, or a ventilator, or an OR. We are afraid to even discuss the concept of patients getting palliation rather than ICU. We are afraid of the legal issues. Of the backlash from the public. Of the guilt that comes with not being able to save everyone during terrible circumstances.
- So we duck and hope it never happens. Or that if it happens, that we are not the ones working at the time.
- But imagine what it would be like if you had this type of plan, with clear criteria, signed off by your chiefs. Signed off by your health region. Imagine if triage plans like this were accepted by governments? Plans that could help keep us safe as health care workers, and much more importantly, plans that could save as many lives as possible.
- So you’re standing there in your unit, and patients are pouring in, and your team is working like crazy, but your reasonable evening is descending into chaos. And let’s assume, for the sake of the argument that you start to run out of ICU beds. Let’s assume that this is our resource that is now scarce.
- Now we need our plan. From the literature, we can clearly identify important elements that need to be included in a triage plan.
- You need some guiding principles You need inclusion and exclusions criteria for your scarce resource And you need a clear, and well-defined process for doing this Let’s start with guiding principles The over-arching principle for this type of plan is that you never want to actually use it. So step one is mitigation.
- Mitigation also happens to be steps 2, 3 and 4. I think we can all agree that we should never triage or ration our resources without exhausting every other possible option. We must share resources with our partner hospitals, we must use alternatives, we must urgently get shipments in of whatever we need. But there is always that slim possibility, particularly in resource poo environments, that we run out. That there is not enough. That we need to make difficult choices.
- So let’s look at the ethics of this. Because if mitigation is the first guiding principle, remaining ethical needs to be the second principle. Our normal philosophy, is that all patients are equal, and all patients should have the same expectation of the best care available. We are trained to do this, to do our best for every patient we see. In a disaster, where resources are scarce, we need to make a mental, and ethical shift. The literature recommends to move to the utilitarian philosophy, of trying to save the greatest number.
- What does this mean? This means that we know that not everyone will survive, but knowing that, we still try to achieve the best outcomes for the greatest number of people. This means that not everyone gets everything. This sounds OK, but this is a very tough psychological switch to make. THIS concept is a big part of why this discussion makes people feel uncomfortable.
- The third, and vital guiding principle, is that developing this type of plan needs to be done in a transparent manner. We need to get this discussion out of the closet. Ideal plans include consulting and incorporating members of the public, and making the plan public. This can not be done well in a covert manner. This is not something you want to spring on your community in a hurry, you want them engaged and involved in the process of making these difficult decisions.
- Then you get to the nitty gritty. The inclusions and exclusions. Who gets offered a scarce resource? If you patient meets the inclusion criteria, and does not meet any exclusions, then they become a candidate for the ICU bed. These criteria are taken from the published literature, there are 8 papers or protocols out there, that I can find, that discuss inclusion and exclusion criteria. Most of these were developed in response to SARS or the various influenza scares that we have had. So you are there , in your hospital, with one ICU bed, and 10 patients really need that bed.
- The literature shoes significant consensus about the inclusion criteria. Almost everyone agrees with using these. To qualify for an ICU bed, either the patient needs a vent, OR the patient has fluid-refractory shock requiring vasopressors. And I actually think that in a real disaster, we would just run the pressors on the regular wards, and try to keep all the ventilated patients in the ICU. The inclusions are easy, it’s the exclusions that are tough.
- These are collated from the available literature. Describe criteria
- Insert end organ failure criteria here/ If patients have any of the following exclusions, they are not a candidate for an ICU bed. With the goal of saving as many lives as possible, under a scenario where mitigation has failed, and there are not enough beds to go around.
- Next, the process for this must be explicit.
- We need clear activation triggers on when to declare a crisis, and when to activate this type of plan. These triggers should be agreed upon by hospitals and health regions and governments. Including governments in the discussion is vital, because ideally governments would offer legal protection for health care workers during crisis standards of care.
- Next, you need a team to do this. A multidisciplinary team of people who are not doing bedside care, to make decisions based on the criteria. The team should include a consultant intensivist, a nurse or respiratory therapist, an ethicist or a member of the community. They should make decisions based on anonymized patient data. And this team needs to be supported by dedicated psychological support, because this would be a very stressful and difficult team to work on.
- It is recommended to have a retrospective review board overseeing this, to ensure that the triage team is implementing the protocol fairly and ethically.
- General medical care or palliative care options must be available for patients who do not meet your critical care criteria. Patients who are denied an ICU bed must still get the best care that we are able to deliver at that stage.
- And then you need a clear process for how you re-assess patients. This includes both patients in the ICU, and also patients who remain on the waiting list for the ICU. Yes, I said that out loud. Most of the published protocols include assessing your current ICU patients, to ensure that they meet criteria. This is a very controversial and divisive issue. The general consensus from the literature is that ALL patients should be re-assessed roughly every 48 hours, for ongoing requirement for a bed, and re-triaged as needed at that time.
- How are you feeling? Usually by now, people feel somewhat overwhelmed. This is normal. Some days I just want to duck and cover and hope it never happens. But then I think about what it would be like to be working, and having to make those choices. And it seems clear to me that it is better to have the difficult conversation now. In the broad light of day. To figure out the best criteria and process now, Before the crisis strikes.
- Because plans like this are difficult to talk about, and horrifying to consider, but also quite possibly life-saving. We need to get this conversation going. And SMACC is the perfect place SMILE to start a debate. Tweet me your thoughts. Or if you need more characters, leave a comment on my website, which has the full details of the policy. We need to debate my criteria and develop better ones. We need to reach consensus and start writing these policies.
- Policies that we hope we will never never use. But policies that are there, in the background, just in case the unthinkable happens.
- Let’s sum up.
- So I’d prefer to be ready. To be prepared. To develop skills and tools that I hope never to use. For the safety of us all. And best possible outcomes for all of our patients.
- Tweet me feedback SMILE, let me know what you think, and thank you for your attention.