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1.
STAR Protoc ; 2(4): 100943, 2021 12 17.
Article in English | MEDLINE | ID: covidwho-1510407

ABSTRACT

During the COVID-19 pandemic, US states developed Crisis Standards of Care (CSC) algorithms to triage allocation of scarce resources to maximize population-wide benefit. While CSC algorithms were developed by ethical debate, this protocol guides their quantitative assessment. For CSC algorithms, this protocol addresses (1) adapting algorithms for empirical study, (2) quantifying predictive accuracy, and (3) simulating clinical decision-making. This protocol provides a framework for healthcare systems and governments to test the performance of CSC algorithms to ensure they meet their stated ethical goals. For complete details on the use and execution of this protocol, please refer to Jezmir et al. (2021).


Subject(s)
COVID-19/therapy , Critical Care/standards , Health Care Rationing/standards , Practice Guidelines as Topic/standards , Standard of Care/ethics , Triage/standards , COVID-19/virology , Critical Care/ethics , Health Care Rationing/ethics , Humans , SARS-CoV-2/isolation & purification , Triage/ethics , Triage/methods
2.
J Med Ethics ; 46(8): 495-498, 2020 08.
Article in English | MEDLINE | ID: covidwho-1467727

ABSTRACT

Key ethical challenges for healthcare workers arising from the COVID-19 pandemic are identified: isolation and social distancing, duty of care and fair access to treatment. The paper argues for a relational approach to ethics which includes solidarity, relational autonomy, duty, equity, trust and reciprocity as core values. The needs of the poor and socially disadvantaged are highlighted. Relational autonomy and solidarity are explored in relation to isolation and social distancing. Reciprocity is discussed with reference to healthcare workers' duty of care and its limits. Priority setting and access to treatment raise ethical issues of utility and equity. Difficult ethical dilemmas around triage, do not resuscitate decisions, and withholding and withdrawing treatment are discussed in the light of recently published guidelines. The paper concludes with the hope for a wider discussion of relational ethics and a glimpse of a future after the pandemic has subsided.


Subject(s)
Decision Making/ethics , Ethics, Clinical , Health Care Rationing/ethics , Health Equity/ethics , Health Personnel/ethics , Pandemics/ethics , Betacoronavirus , COVID-19 , Coronavirus Infections/virology , Disaster Planning , Humans , Moral Obligations , Pneumonia, Viral/virology , Poverty , Practice Guidelines as Topic , Professional-Patient Relations , Resuscitation Orders , SARS-CoV-2 , Social Values , Triage/ethics , Vulnerable Populations , Withholding Treatment/ethics
3.
Chest ; 161(2): 504-513, 2022 02.
Article in English | MEDLINE | ID: covidwho-1401308

ABSTRACT

BACKGROUND: Faced with possible shortages due to COVID-19, many states updated or rapidly developed crisis standards of care (CSCs) and other pandemic preparedness plans (PPPs) for rationing resources, particularly ventilators. RESEARCH QUESTION: How have US states incorporated the controversial standard of rationing by age and/or life-years into their pandemic preparedness plans? STUDY DESIGN AND METHODS: This was an investigator-initiated, textual analysis conducted from April to June 2020, querying online resources and in-state contacts to identify PPPs published by each of the 50 states and for Washington, DC. Analysis included the most recent versions of CSC documents and official state PPPs containing triage guidance as of June 2020. Plans were categorized as rationing by (A) short-term survival (≤ 1 year), (B) 1 to 5 expected life-years, (C) total life-years, (D) "fair innings," that is, specific age cutoffs, or (O) other. The primary measure was any use of age and/or life-years. Plans were further categorized on the basis of whether age/life-years was a primary consideration. RESULTS: Thirty-five states promulgated PPPs addressing the rationing of critical care resources. Seven states considered short-term prognosis, seven considered whether a patient had 1 to 5 expected life-years, 13 rationed by total life-years, and one used the fair innings principle. Seven states provided only general ethical considerations. Seventeen of the 21 plans considering age/life-years made it a primary consideration. Several plans borrowed heavily from a few common sources, although use of terminology was inconsistent. Many documents were modified in light of controversy. INTERPRETATION: Guidance with respect to rationing by age and/or life-years varied widely. More than one-half of PPPs, many following a few common models, included age/life-years as an explicit rationing criterion; the majority of these made it a primary consideration. Terminology was often vague, and many plans evolved in response to pushback. These findings have ethical implications for the care of older adults and other vulnerable populations during a pandemic.


Subject(s)
COVID-19 , Civil Defense/standards , Crew Resource Management, Healthcare , Critical Care , Health Care Rationing/standards , Standard of Care/organization & administration , Triage , Aged , COVID-19/epidemiology , COVID-19/therapy , Crew Resource Management, Healthcare/ethics , Crew Resource Management, Healthcare/methods , Crew Resource Management, Healthcare/organization & administration , Critical Care/ethics , Critical Care/organization & administration , Critical Care/standards , Humans , SARS-CoV-2 , Surge Capacity/standards , Triage/ethics , Triage/organization & administration , Triage/standards , United States/epidemiology , Vulnerable Populations
4.
Hist Philos Life Sci ; 43(3): 91, 2021 Jul 13.
Article in English | MEDLINE | ID: covidwho-1309115

ABSTRACT

Ageism has unfortunately become a salient phenomenon during the COVID-19 pandemic. In particular, triage decisions based on age have been hotly discussed. In this article, I first defend that, although there are ethical reasons (founded on the principles of benefit and fairness) to consider the age of patients in triage dilemmas, using age as a categorical exclusion is an unjustifiable ageist practice. Then, I argue that ageism during the pandemic has been fueled by media narratives and unfair assumptions which have led to an ethically problematic group homogenization of the older population. Finally, I conclude that an intersectional perspective can shed light on further controversies on ageism and triage in the post-pandemic future.


Subject(s)
Ageism/ethics , COVID-19/therapy , Triage/ethics , Ageism/prevention & control , Ageism/psychology , Ageism/statistics & numerical data , Humans , SARS-CoV-2/physiology , Triage/statistics & numerical data
5.
BMC Fam Pract ; 22(1): 146, 2021 07 03.
Article in English | MEDLINE | ID: covidwho-1295439

ABSTRACT

BACKGROUND: Early in the COVID-19 pandemic, general practices were asked to expand triage and to reduce unnecessary face-to-face contact by prioritizing other consultation modes, e.g., online messaging, video, or telephone. The current study explores the potential barriers and facilitators general practitioners experienced to expanding triage systems and their attitudes towards triage during the COVID-19 pandemic. METHOD: A mixed-method study design was used in which a quantitative online survey was conducted along with qualitative interviews to gain a more nuanced appreciation for practitioners' experiences in the United Kingdom. The survey items were informed by the Theoretical Domains Framework so they would capture 14 behavioral factors that may influence whether practitioners use triage systems. Items were responded to using seven-point Likert scales. A median score was calculated for each item. The responses of participants identifying as part-owners and non-owners (i.e., "partner" vs. "non-partner" practitioners) were compared. The semi-structured interviews were conducted remotely and examined using Braun and Clark's thematic analysis. RESULTS: The survey was completed by 204 participants (66% Female). Most participants (83%) reported triaging patients. The items with the highest median scores captured the 'Knowledge,' 'Skills,' 'Social/Professional role and identity,' and 'Beliefs about capabilities' domains. The items with the lowest median scores captured the 'Beliefs about consequences,' 'Goals,' and 'Emotions' domains. For 14 of the 17 items, partner scores were higher than non-partner scores. All the qualitative interview participants relied on a phone triage system. Six broad themes were discovered: patient accessibility, confusions around what triage is, uncertainty and risk, relationships between service providers, job satisfaction, and the potential for total digital triage. Suggestions arose to optimize triage, such as ensuring there is sufficient time to conduct triage accurately and providing practical training to use triage efficiently. CONCLUSIONS: Many general practitioners are engaging with expanded triage systems, though more support is needed to achieve total triage across practices. Non-partner practitioners likely require more support to use the triage systems that practices take up. Additionally, practical support should be made available to help all practitioners manage the new risks and uncertainties they are likely to experience during non-face-to-face consultations.


Subject(s)
COVID-19 , General Practice , General Practitioners , Remote Consultation , Triage , Attitude of Health Personnel , COVID-19/epidemiology , COVID-19/prevention & control , COVID-19/therapy , Clinical Competence , England/epidemiology , Female , General Practice/organization & administration , General Practice/standards , General Practice/trends , General Practitioners/psychology , General Practitioners/standards , Health Knowledge, Attitudes, Practice , Humans , Infection Control/methods , Infection Control/standards , Male , Practice Patterns, Physicians'/ethics , Practice Patterns, Physicians'/trends , Remote Consultation/ethics , Remote Consultation/methods , Risk Management/trends , SARS-CoV-2 , Triage/ethics , Triage/methods , Triage/organization & administration , Triage/standards
6.
Br Med Bull ; 138(1): 5-15, 2021 06 10.
Article in English | MEDLINE | ID: covidwho-1246698

ABSTRACT

INTRODUCTION: The coronavirus disease 2019 pandemic has placed intensive care units (ICU) triage at the center of bioethical discussions. National and international triage guidelines emerged from professional and governmental bodies and have led to controversial discussions about which criteria-e.g. medical prognosis, age, life-expectancy or quality of life-are ethically acceptable. The paper presents the main points of agreement and disagreement in triage protocols and reviews the ethical debate surrounding them. SOURCES OF DATA: Published articles, news articles, book chapters, ICU triage guidelines set out by professional societies and health authorities. AREAS OF AGREEMENT: Points of agreement in the guidelines that are widely supported by ethical arguments are (i) to avoid using a first come, first served policy or quality-adjusted life-years and (ii) to rely on medical prognosis, maximizing lives saved, justice as fairness and non-discrimination. AREAS OF CONTROVERSY: Points of disagreement in existing guidelines and the ethics literature more broadly regard the use of exclusion criteria, the role of life expectancy, the prioritization of healthcare workers and the reassessment of triage decisions. GROWING POINTS: Improve outcome predictions, possibly aided by Artificial intelligence (AI); develop participatory approaches to drafting, assessing and revising triaging protocols; learn from experiences with implementation of guidelines with a view to continuously improve decision-making. AREAS TIMELY FOR DEVELOPING RESEARCH: Examine the universality vs. context-dependence of triaging principles and criteria; empirically test the appropriateness of triaging guidelines, including impact on vulnerable groups and risk of discrimination; study the potential and challenges of AI for outcome and preference prediction and decision-support.


Subject(s)
COVID-19/therapy , Critical Care/ethics , Triage/ethics , COVID-19/epidemiology , COVID-19/transmission , Clinical Protocols , Humans
7.
New Bioeth ; 27(2): 127-132, 2021 Jun.
Article in English | MEDLINE | ID: covidwho-1207208

ABSTRACT

The current coronavirus pandemic presents the greatest healthcare crisis in living memory. Hospitals across the world have faced unprecedented pressure. In the face of this tidal wave of demand for limited healthcare resources, how are clinicians to identify patients most likely to benefit? Should age or frailty be discriminators? This paper seeks to analyse the current evidence-base, seeking a nuanced approach to pandemic decision-making, such as admission to critical care.


Subject(s)
COVID-19/epidemiology , Critical Care/ethics , Frailty/epidemiology , Health Care Rationing/ethics , Triage/ethics , Age Factors , Aged , Aged, 80 and over , Clinical Decision-Making , Comorbidity , Humans , Middle Aged , SARS-CoV-2
8.
Camb Q Healthc Ethics ; 30(2): 390-402, 2021 04.
Article in English | MEDLINE | ID: covidwho-1149670

ABSTRACT

The coronavirus disease (COVID-19) crisis provoked an organizational ethics dilemma: how to develop ethical pandemic policy while upholding our organizational mission to deliver relationship- and patient-centered care. Tasked with producing a recommendation about whether healthcare workers and essential personnel should receive priority access to limited medical resources during the pandemic, the bioethics department and survey and interview methodologists at our institution implemented a deliberative approach that included the perspectives of healthcare professionals and patient stakeholders in the policy development process. Involving the community more, not less, during a crisis required balancing the need to act quickly to garner stakeholder perspectives, uncertainty about the extent and duration of the pandemic, and disagreement among ethicists about the most ethically supportable way to allocate scarce resources. This article explains the process undertaken to garner stakeholder input as it relates to organizational ethics, recounts the stakeholder perspectives shared and how they informed the triage policy developed, and offers suggestions for how other organizations may integrate stakeholder involvement in ethical decision-making as well as directions for future research and public health work.


Subject(s)
COVID-19 , Ethics, Institutional , Health Personnel , Patient Participation , Policy Making , Resource Allocation/ethics , Attitude of Health Personnel , Health Care Rationing/ethics , Humans , Organizational Policy , Triage/ethics
9.
BMC Med Ethics ; 22(1): 28, 2021 03 22.
Article in English | MEDLINE | ID: covidwho-1147083

ABSTRACT

BACKGROUND: The worsening COVID-19 pandemic in South Africa poses multiple challenges for clinical decision making in the context of already-scarce ICU resources. Data from national government and the last published national audit of ICU resources indicate gross shortages. While the Critical Care Society of Southern Africa (CCSSA) guidelines provide a comprehensive guideline for triage in the face of overwhelmed ICU resources, such decisions present massive ethical and moral dilemmas for triage teams. It is therefore important for the health system to provide clinicians and critical care facilities with as much support and resources as possible in the face of impending pandemic demand. Following a discussion of the ethical considerations and potential challenges in applying the CCSSA guidelines, the authors propose a framework for regional triage committees adapted to the South African context. DISCUSSION: Beyond the national CCSSA guidelines, the clinician has many additional ethical and clinical considerations. No single ethical approach to decision-making is sufficient, instead one which considers multiple contextual factors is necessary. Scores such as the Clinical Frailty Score and Sequential Organ Failure Assessment are of limited use in patients with COVID-19. Furthermore, the clinician is fully justified in withdrawing ICU care based on medical futility decisions and to reallocate this resource to a patient with a better prognosis. However, these decisions bear heavy emotional and moral burden compounded by the volume of clinical work and a fear of litigation. CONCLUSION: We propose the formation of Provincial multi-disciplinary Critical Care Triage Committees to alleviate the emotional, moral and legal burden on individual ICU teams and co-ordinate inter-facility collaboration using an adapted framework. The committee would provide an impartial, broader and ethically-sound viewpoint which has time to consider broader contextual factors such as adjusting rationing criteria according to different levels of pandemic demand and the latest clinical evidence. Their functioning will be strengthened by direct feedback to national level and accountability to a national monitoring committee. The potential applications of these committees are far-reaching and have the potential to enable a more effective COVID-19 health systems response in South Africa.


Subject(s)
COVID-19 , Critical Care/ethics , Decision Making/ethics , Health Care Rationing/ethics , Intensive Care Units , Pandemics , Triage/methods , Cooperative Behavior , Emotions , Ethics, Medical , Health Resources , Humans , Medical Futility , Prognosis , SARS-CoV-2 , South Africa , Triage/ethics
10.
HEC Forum ; 33(1-2): 1-6, 2021 Jun.
Article in English | MEDLINE | ID: covidwho-1146775

ABSTRACT

The essays in this special issue of HEC Forum provide reflections that make explicit the implicit anthropology that our current pandemic has brought but which in the medical ethics literature around COVID-19 has to a great extent ignored. Three of the essays are clearly "journalistic" as a literary genre: one by a hospital chaplain, one by a medical student in her pre-clinical years, and one by a fourth-year medical student who reports her experience as she completed her undergraduate clerkships and applied for positions in graduate medical education. Other essays explore the pandemic from historical, sociological, and economic perspectives, particularly how triage policies have been found to be largely blind to structural healthcare disparities, while simultaneously unable to appropriately address those disparities. Central issues that need to be addressed in triage are not just whether a utilitarian response is the most just response, but what exactly is the greatest good for the greatest number? Together, the essays in this special issue of HEC Forum create a call for a more anthropological approach to understanding health and healthcare. The narrow approach of viewing health as resulting primarily from healthcare will continue to hinder advances and perpetuate disparities. Health outcomes result from a complex interaction of various social, economic, cultural, historical, and political factors. Advancing healthcare requires contextualizing the health of populations amongst these factors. The COVID-19 pandemic has made us keenly aware of how interdependent our health as a society can be.


Subject(s)
COVID-19/epidemiology , Pandemics/ethics , Triage/ethics , Humans , Politics , SARS-CoV-2 , Social Responsibility , Social Values
11.
BMC Med ; 18(1): 404, 2020 12 18.
Article in English | MEDLINE | ID: covidwho-979471

ABSTRACT

BACKGROUND: The COVID-19 pandemic has placed sustained demand on health systems globally, and the capacity to provide critical care has been overwhelmed in some jurisdictions. It is unknown which triage criteria for allocation of resources perform best to inform health system decision-making. We sought to summarize and describe existing triage tools and ethical frameworks to aid healthcare decision-making during infectious disease outbreaks. METHODS: We conducted a rapid review of triage criteria and ethical frameworks for the allocation of critical care resources during epidemics and pandemics. We searched Medline, EMBASE, and SCOPUS from inception to November 3, 2020. Full-text screening and data abstraction were conducted independently and in duplicate by three reviewers. Articles were included if they were primary research, an adult critical care setting, and the framework described was related to an infectious disease outbreak. We summarized each triage tool and ethical guidelines or framework including their elements and operating characteristics using descriptive statistics. We assessed the quality of each article with applicable checklists tailored to each study design. RESULTS: From 11,539 unique citations, 697 full-text articles were reviewed and 83 articles were included. Fifty-nine described critical care triage protocols and 25 described ethical frameworks. Of these, four articles described both a protocol and ethical framework. Sixty articles described 52 unique triage criteria (29 algorithm-based, 23 point-based). Few algorithmic- or point-based triage protocols were good predictors of mortality with AUCs ranging from 0.51 (PMEWS) to 0.85 (admitting SOFA > 11). Most published triage protocols included the substantive values of duty to provide care, equity, stewardship and trust, and the procedural value of reason. CONCLUSIONS: This review summarizes available triage protocols and ethical guidelines to provide decision-makers with data to help select and tailor triage tools. Given the uncertainty about how the COVID-19 pandemic will progress and any future pandemics, jurisdictions should prepare by selecting and adapting a triage tool that works best for their circumstances.


Subject(s)
COVID-19 , Critical Care , Health Care Rationing/ethics , Health Care Rationing/methods , Triage/methods , Disease Outbreaks , Humans , SARS-CoV-2 , Triage/ethics
12.
J Med Ethics ; 47(2): 108-112, 2021 02.
Article in English | MEDLINE | ID: covidwho-985734

ABSTRACT

One prominent view in recent literature on resource allocation is Persad, Emanuel and Wertheimer's complete lives framework for the rationing of lifesaving healthcare interventions (CLF). CLF states that we should prioritise the needs of individuals who have had less opportunity to experience the events that characterise a complete life. Persad et al argue that their system is the product of a successful process of reflective equilibrium-a philosophical methodology whereby theories, principles and considered judgements are balanced with each other and revised until we achieve an acceptable coherence between our various beliefs. Yet I argue that many of the principles and intuitions underpinning CLF conflict with each other, and that Persad et al have failed to achieve an acceptable coherence between them. I focus on three tensions in particular: the conflict between the youngest first principle and Persad et al's investment refinement; the conflict between current medical need and a concern for lifetime equality; and the tension between adopting an objective measure of complete lives and accommodating for differences in life narratives.


Subject(s)
Decision Making/ethics , Ethics, Clinical , Health Care Rationing/ethics , Health Equity/ethics , Social Justice , Triage/ethics , Delivery of Health Care/ethics , Ethical Analysis , Health Priorities/ethics , Health Status , Humans , Morals
14.
Bioethics ; 35(4): 356-365, 2021 05.
Article in English | MEDLINE | ID: covidwho-1120413

ABSTRACT

Most ethics guidelines for distributing scarce medical resources during the coronavirus pandemic seek to save the most lives and the most life-years. A patient's prognosis is determined using a SOFA or MSOFA score to measure likelihood of survival to discharge, as well as a consideration of relevant comorbidities and their effects on likelihood of survival up to one or five years. Although some guidelines use age as a tiebreaker when two patients' prognoses are identical, others refuse to consider age for fear of discriminating against the elderly. In this paper, I argue that age is directly relevant for maximizing health benefits, so current ethics guidelines are wrongly excluding or deemphasizing life-stage in their triage algorithms. Research on COVID-19 has shown that age is a risk factor in adverse outcomes, independent of comorbidities. And limiting a consideration of life-years to only one or five years past discharge does not maximize health benefits. Therefore, based on their own stated values, triage algorithms for coronavirus patients ought to include life-stage as a primary consideration, along with the SOFA score and comorbidities, rather than excluding it or using it merely as a tiebreaker. This is not discriminatory because patients ought to have equal opportunity to experience life-stages. The equitable enforcement of that right justifies unequal treatment based on age in cases when there is a scarcity of life-saving resources. A consideration of life-stage would thus allow healthcare workers to responsibly steward public resources in order to maximize lives and life-years saved.


Subject(s)
Age Factors , COVID-19 , Health Care Rationing/ethics , Triage/ethics , Ethical Theory , Humans , Life Expectancy , Organ Dysfunction Scores , Prognosis , Risk Factors , SARS-CoV-2
16.
J Diabetes Sci Technol ; 15(5): 1005-1009, 2021 09.
Article in English | MEDLINE | ID: covidwho-1085175

ABSTRACT

The COVID-19 pandemic raised distinct challenges in the field of scarce resource allocation, a long-standing area of inquiry in the field of bioethics. Policymakers and states developed crisis guidelines for ventilator triage that incorporated such factors as immediate prognosis, long-term life expectancy, and current stage of life. Often these depend upon existing risk factors for severe illness, including diabetes. However, these algorithms generally failed to account for the underlying structural biases, including systematic racism and economic disparity, that rendered some patients more vulnerable to these conditions. This paper discusses this unique ethical challenge in resource allocation through the lens of care for patients with severe COVID-19 and diabetes.


Subject(s)
COVID-19/therapy , Diabetes Complications/therapy , Diabetes Mellitus/therapy , Resource Allocation , COVID-19/complications , COVID-19/epidemiology , Diabetes Complications/economics , Diabetes Complications/epidemiology , Diabetes Mellitus/economics , Diabetes Mellitus/epidemiology , Health Services Accessibility/economics , Health Services Accessibility/ethics , Health Services Accessibility/standards , Health Services Accessibility/statistics & numerical data , Health Status Disparities , Healthcare Disparities/economics , Healthcare Disparities/ethics , Healthcare Disparities/organization & administration , Healthcare Disparities/statistics & numerical data , Humans , Pandemics , Racism/ethics , Racism/statistics & numerical data , Resource Allocation/economics , Resource Allocation/ethics , Resource Allocation/organization & administration , Resource Allocation/statistics & numerical data , Triage/economics , Triage/ethics , United States/epidemiology , Ventilators, Mechanical/economics , Ventilators, Mechanical/statistics & numerical data , Ventilators, Mechanical/supply & distribution
17.
HEC Forum ; 33(1-2): 73-90, 2021 Jun.
Article in English | MEDLINE | ID: covidwho-1083437

ABSTRACT

The Covid-19 pandemic has presented major challenges to society, exposing preexisting ethical weaknesses in the modern social fabric's ability to respond. Distrust in government and a lessened authority of science to determine facts have both been exacerbated by the polarization and disinformation enhanced by social media. These have impaired society's willingness to comply with and persevere with social distancing, which has been the most powerful initial response to mitigate the pandemic. These preexisting weaknesses also threaten the future acceptance of vaccination and contact tracing, two other tools needed to combat epidemics. Medical ethicists might best help in this situation by promoting truth-telling, encouraging the rational adjudication of facts, providing transparent decision-making and advocating the virtue of cooperation to maximize the common good. Those interventions should be aimed at the social level. The same elements of emphasizing cooperation and beneficence also apply to the design of triage protocols for when resources are overwhelmed. A life-stages approach increases beneficence and reduces harms. Triage should be kept as simple and straightforward as reasonably possible to avoid unwieldly application during a pandemic.


Subject(s)
COVID-19/prevention & control , Ethicists , Pandemics/prevention & control , Physical Distancing , Professional Role , Cooperative Behavior , Decision Making/ethics , Humans , Resource Allocation/ethics , SARS-CoV-2 , Triage/ethics , Truth Disclosure/ethics
18.
Med Decis Making ; 41(4): 393-407, 2021 05.
Article in English | MEDLINE | ID: covidwho-1072866

ABSTRACT

BACKGROUND: During the COVID-19 pandemic, many intensive care units have been overwhelmed by unprecedented levels of demand. Notwithstanding ethical considerations, the prioritization of patients with better prognoses may support a more effective use of available capacity in maximizing aggregate outcomes. This has prompted various proposed triage criteria, although in none of these has an objective assessment been made in terms of impact on number of lives and life-years saved. DESIGN: An open-source computer simulation model was constructed for approximating the intensive care admission and discharge dynamics under triage. The model was calibrated from observational data for 9505 patient admissions to UK intensive care units. To explore triage efficacy under various conditions, scenario analysis was performed using a range of demand trajectories corresponding to differing nonpharmaceutical interventions. RESULTS: Triaging patients at the point of expressed demand had negligible effect on deaths but reduces life-years lost by up to 8.4% (95% confidence interval: 2.6% to 18.7%). Greater value may be possible through "reverse triage", that is, promptly discharging any patient not meeting the criteria if admission cannot otherwise be guaranteed for one who does. Under such policy, life-years lost can be reduced by 11.7% (2.8% to 25.8%), which represents 23.0% (5.4% to 50.1%) of what is operationally feasible with no limit on capacity and in the absence of improved clinical treatments. CONCLUSIONS: The effect of simple triage is limited by a tradeoff between reduced deaths within intensive care (due to improved outcomes) and increased deaths resulting from declined admission (due to lower throughput given the longer lengths of stay of survivors). Improvements can be found through reverse triage, at the expense of potentially complex ethical considerations.


Subject(s)
COVID-19/therapy , Critical Care , Health Care Rationing , Hospitalization , Intensive Care Units , Pandemics , Triage , Adolescent , Adult , Aged , Aged, 80 and over , COVID-19/mortality , Computer Simulation , Critical Care/ethics , Ethics, Clinical , Female , Health Care Rationing/ethics , Health Care Rationing/methods , Humans , Intensive Care Units/ethics , Male , Middle Aged , Pandemics/ethics , Prognosis , SARS-CoV-2 , Triage/ethics , Triage/methods , United Kingdom , Young Adult
19.
BMJ Support Palliat Care ; 11(2): 133-137, 2021 Jun.
Article in English | MEDLINE | ID: covidwho-1066896

ABSTRACT

The COVID-19 pandemic has made unprecedented global demands on healthcare in general and especially the intensive care unit (ICU). the virus is spreading out of control. To this day, there is no clear, published directive for doctors regarding the allocation of ICU beds in times of scarcity. This means that many doctors do not feel supported by their government and are afraid of the medicolegal consequences of the choices they have to make. Consequently, there has been no transparent discussion among professionals and the public. The thought of being at the mercy of absolute arbitrariness leads to fear among the population, especially the vulnerable groups.


Subject(s)
COVID-19/therapy , Intensive Care Units/ethics , Pandemics/ethics , Triage/ethics , Triage/methods , COVID-19/diagnosis , Humans , SARS-CoV-2
20.
Bioethics ; 35(2): 125-134, 2021 02.
Article in English | MEDLINE | ID: covidwho-1066621

ABSTRACT

In March 2020, the rapid increase in severe COVID-19 cases overwhelmed the healthcare systems in several European countries. The capacities for artificial ventilation in intensive care units were too scarce to care for patients with acute respiratory disorder connected to the disease. Several professional associations published COVID-19 triage recommendations in an extremely short time: in 21 days between March 6 and March 27. In this article, we compare recommendations from five European countries, which combine medical and ethical reflections on this situation in some detail. Our aim is to provide a detailed overview on the ethical elements of the recommendations, the differences between them and their coherence. In more general terms we want to identify shortcomings in regard to a common European response to the current situation.


Subject(s)
COVID-19/therapy , Health Care Rationing , Standard of Care/ethics , Triage/ethics , Age Factors , COVID-19/epidemiology , Europe/epidemiology , Health Personnel/ethics , Health Personnel/psychology , Health Priorities , Hospitalization , Human Rights , Humans , Intensive Care Units/ethics , Practice Guidelines as Topic , SARS-CoV-2/physiology , Treatment Outcome , Ventilators, Mechanical/supply & distribution , Withholding Treatment/ethics
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