Perspectives of Triage Team Members Participating in Statewide Triage Simulations for Scarce Resource Allocation During the COVID-19 Pandemic in Washington State.

Importance: The COVID-19 pandemic prompted health care institutions worldwide to develop plans for allocation of scarce resources in crisis capacity settings. These plans frequently rely on rapid deployment of institutional triage teams that would be responsible for prioritizing patients to receive scarce resources; however, little is known about how these teams function or how to support team members participating in this unique task. Objective: To identify themes illuminating triage team members' perspectives and experiences pertaining to the triage process. Design, Setting, and Participants: This qualitative study was conducted using inductive thematic analysis of observations of Washington state triage team simulations and semistructured interviews with participants during the COVID-19 pandemic from December 2020 to February 2021. Participants included clinician and ethicist triage team members. Data were analyzed from December 2020 through November 2021. Main Outcomes and Measures: Emergent themes describing the triage process and experience of triage team members. Results: Among 41 triage team members (mean [SD] age, 50.3 [11.4] years; 21 [51.2%] women) who participated in 12 simulations and 21 follow-up interviews, there were 5 Asian individuals (12.2%) and 35 White individuals (85.4%); most participants worked in urban hospital settings (32 individuals [78.0%]). Three interrelated themes emerged from qualitative analysis: (1) understanding the broader approach to resource allocation: participants strove to understand operational and ethical foundations of the triage process, which was necessary to appreciate their team's specific role; (2) contending with uncertainty: team members could find it difficult or feel irresponsible making consequential decisions based on limited clinical and contextual patient information, and they grappled with ethically ambiguous features of individual cases and of the triage process as a whole; and (3) transforming mindset: participants struggled to disentangle narrow determinations about patients' likelihood of survival to discharge from implicit biases and other ethically relevant factors, such as quality of life. They cited the team's open deliberative process, as well as practice and personal experience with triage as important in helping to reshape their usual cognitive approach to align with this unique task. Conclusions and Relevance: This study found that there were challenges in adapting clinical intuition and training to a distinctive role in the process of scarce resource allocation. These findings suggest that clinical experience, education in ethical and operational foundations of triage, and experiential training, such as triage simulations, may help prepare clinicians for this difficult role.

Patient Information Items Needed to Guide the Allocation of Scarce Life-Sustaining Resources: A Delphi Study of Multidisciplinary Experts.

OBJECTIVE: Plans for allocation of scarce life-sustaining resources during the coronavirus disease 2019 (COVID-19) pandemic often include triage teams, but operational details are lacking, including what patient information is needed to make triage decisions. METHODS: A Delphi study among Washington state disaster preparedness experts was performed to develop a list of patient information items needed for triage team decision-making during the COVID-19 pandemic. Experts proposed and rated their agreement with candidate information items during asynchronous Delphi rounds. Consensus was defined as ≥80% agreement. Qualitative analysis was used to describe considerations arising in this deliberation. A timed simulation was performed to evaluate feasibility of data collection from the electronic health record. RESULTS: Over 3 asynchronous Delphi rounds, 50 experts reached consensus on 24 patient information items, including patients' age, severe or end-stage comorbidities, the reason for and timing of admission, measures of acute respiratory failure, and clinical trajectory. Experts weighed complex considerations around how information items could support effective prognostication, consistency, accuracy, minimizing bias, and operationalizability of the triage process. Data collection took a median of 227 seconds (interquartile range = 205, 298) per patient. CONCLUSIONS: Experts achieved consensus on patient information items that were necessary and appropriate for informing triage teams during the COVID-19 pandemic.

Functionality of Scarce Healthcare Resource Triage Teams During the COVID-19 Pandemic: A Multi-Institutional Simulation Study.

Plans for allocating scarce healthcare resources during the COVID-19 pandemic commonly involve the activation of institutional triage teams. These teams would be responsible for selecting patients who are most likely to survive to be prioritized to receive scarce resources. However, there is little empirical support for this approach. DESIGN: High-fidelity triage-team simulation study. SETTING: Healthcare institutions in Washington state. SUBJECTS: Triage teams, consisting of at least two senior clinicians and a bioethicist. INTERVENTIONS: Participants reviewed a limited amount of deidentified information for a diverse sample of critically ill patients. Teams then assigned each patient to one of five prioritization categories defined by likelihood of survival to hospital discharge. The process was refined based on observation and participant feedback after which a second phase of simulations was conducted. MEASUREMENTS AND MAIN RESULTS: Feasibility was assessed by the time required for teams to perform their task. Prognostic accuracy was assessed by comparing teams' prediction about likelihood of survival to hospital discharge with real-world discharge outcomes. Agreement between the teams on prognostic categorization was evaluated using kappa statistics. Eleven triage team simulations (eight in phase 1 and three in phase 2) were conducted from December 2020 to February 2021. Overall, teams reviewed a median of 23 patient cases in each session (interquartile range [IQR], 17-29) and spent a median of 102 seconds (IQR, 50-268) per case. The concordance between expected survival and real-world survival to discharge was 71% (IQR, 64-76%). The overall agreement between teams for placement of patients into prognostic categories was moderate (weighted kappa = 0.53). CONCLUSIONS: These findings support the potential feasibility, accuracy, and effectiveness of institutional triage teams informed by a limited set of patient information items as part of a strategy for allocating scarce resources in healthcare emergencies. Additional work is needed to refine the process and adapt it to local contexts.

Case Report: What-or who-killed Frank Ramsey? Some reflections on cause of death and the nature of medical reasoning.

Philosopher Frank Ramsey died in 1930 aged only 26. There has been much speculation about the nature of his final illness and the sequence of events which led to his death. To prepare this case report, we traced Ramsey's medical records and combined them with an extensive and unique dataset of contemporaneous sources. We use these to evaluate three possible explanations for Ramsey's illness and its unexpectedly fatal trajectory-infectious (Weil's disease), autoimmune (primary sclerosing cholangitis) and obstructive (gallstones). We explore how uncertainty surrounding each of these possibilities might have influenced Ramsey's doctors' thoughts and actions, including their ill-fated decision to perform the emergency operation that appears to have precipitated his final decline. We then reflect on the unfinished opus on which Ramsey was working when he died-on the nature of truth and how humans reason under conditions of uncertainty. We end with some thoughts linking Ramsey's death to his philosophy.

Teaching Medical Epistemology within an Evidence-Based Medicine Curriculum.

Issue: Epistemology, the branch of philosophy that deals with the nature, value, and use of knowledge, receives little or no formal attention in medical education. Yet the understanding of medical epistemology - focused on what kinds of medical knowledge are relevant to clinical decisions, the strengths and limitations of those different kinds of knowledge, and how they relate to one another and to clinical expertise - represents a critical aspect of medical practice. Evidence: Understanding the meaning of the term "evidence" is one of the fundamental tasks of medical epistemology. Other foundations of the evidence-based medicine movement, such as the "hierarchy of evidence" and the concept of "best" evidence, rest upon epistemological assertions, claims regarding the appropriate kinds and relative value of knowledge in medicine. Here we rely upon the work of philosophers of medicine who have been engaged in debates regarding the epistemic tenets of the evidence-based medicine movement. We argue that medical students and physicians-in-training should learn basic terminology and methods of epistemology as they are being introduced to the concepts and techniques of evidence-based medicine. Implications: The skepticism and critical analysis encouraged by EBM can and should be applied to the underlying assumptions and primary tenets of EBM itself. It is not enough for philosophers to partake in this endeavor; students, trainees, and clinicians need to carefully and constantly examine the reasons and reasoning that coalesce into clinical acumen. Our role as medical educators is to give them the tools, including a basic understanding of epistemology, to do that over a lifetime.

Triage of Scarce Critical Care Resources in COVID-19 An Implementation Guide for Regional Allocation: An Expert Panel Report of the Task Force for Mass Critical Care and the American College of Chest Physicians.

Public health emergencies have the potential to place enormous strain on health systems. The current pandemic of the novel 2019 coronavirus disease has required hospitals in numerous countries to expand their surge capacity to meet the needs of patients with critical illness. When even surge capacity is exceeded, however, principles of critical care triage may be needed as a means to allocate scarce resources, such as mechanical ventilators or key medications. The goal of a triage system is to direct limited resources towards patients most likely to benefit from them. Implementing a triage system requires careful coordination between clinicians, health systems, local and regional governments, and the public, with a goal of transparency to maintain trust. We discuss the principles of tertiary triage and methods for implementing such a system, emphasizing that these systems should serve only as a last resort. Even under triage, we must uphold our obligation to care for all patients as best possible under difficult circumstances.

Experiential knowledge in clinical medicine: use and justification.

Within the evidence-based medicine (EBM) construct, clinical expertise is acknowledged to be both derived from primary experience and necessary for optimal medical practice. Primary experience in medical practice, however, remains undervalued. Clinicians' primary experience tends to be dismissed by EBM as unsystematic or anecdotal, a source of bias rather than knowledge, never serving as the "best" evidence to support a clinical decision. The position that clinical expertise is necessary but that primary experience is untrustworthy in clinical decision-making is epistemically incoherent. Here we argue for the value and utility of knowledge gained from primary experience for the practice of medicine. Primary experience provides knowledge necessary to diagnose, treat, and assess response in individual patients. Hierarchies of evidence, when advanced as guides for clinical decisions, mistake the relationship between propositional and experiential knowledge. We argue that primary experience represents a kind of medical knowledge distinct from the propositional knowledge produced by clinical research, both of which are crucial to determining the best diagnosis and course of action for particular patients.

Mechanisms in clinical practice: use and justification.

While the importance of mechanisms in determining causality in medicine is currently the subject of active debate, the role of mechanistic reasoning in clinical practice has received far less attention. In this paper we look at this question in the context of the treatment of a particular individual, and argue that evidence of mechanisms is indeed key to various aspects of clinical practice, including assessing population-level research reports, diagnostic as well as therapeutic decision making, and the assessment of treatment effects. We use the pulmonary condition bronchiectasis as a source of examples of the importance of mechanistic reasoning to clinical practice.

Person-centred shared decision making.

While multiple versions of shared decision making (SDM) have been advanced, most share two seemingly essential elements: (a) SDM is primarily focused on treatment choices and (b) the clinician is primarily responsible for providing options while the patient contributes values and preferences. We argue that these two elements render SDM suboptimal for clinical practice. We suggest that SDM is better viewed as collaboration in all aspects of clinical care, with clinicians needing to fully engage with the patient's experience of illness and participation in treatment. SDM can only take place within an ongoing partnership between clinician and patient, both respecting the other as a person, not as part of an isolated encounter. Respect for the patient as a person goes beyond respect for their choice. Non-interference is not the only way, or even the most important way, to respect patient autonomy. Knowing the patient as a person and providing an autonomy-supportive context for care are crucial. That is, the clinician must know the patient well enough to be able to answer the patient's question "What would you do, if you were me?" This approach acknowledges clinicians as persons, requiring them to understand patients as persons. We provide examples of such a model of SDM and assert that this pragmatic method does not require excessive time or effort on the part of clinicians or patients but does require direct and particular knowledge of the patient that is often omitted from clinical decisions.

A Philosophical Approach to Addressing Uncertainty in Medical Education.

Conveying the uncertainty inherent in clinical practice has rightly become a focus of medical training. To date, much of the emphasis aims to encourage trainees to acknowledge and accept uncertainty. Intolerance of uncertainty is associated with medical student distress and a tendency in clinicians toward overtreatment. The authors argue that a deeper, philosophical understanding of the nature of uncertainty would allow students and clinicians to move beyond simple acceptance to explicating and mitigating uncertainty in practice.Uncertainty in clinical medicine can be categorized philosophically as moral, metaphysical, and epistemic uncertainty. Philosophers of medicine-in a way analogous to ethicists a half century ago-can be brought into medical education and medical practice to help students and physicians explore the epistemic and metaphysical roots of clinical uncertainty. Such an approach does not require medical students to master philosophy and should not involve adding new course work to an already-crowded medical curriculum. Rather, the goal is to provide students with the language and reasoning skills to recognize, evaluate, and mitigate uncertainty as it arises. The authors suggest ways in which philosophical concepts can be introduced in a practical fashion into a variety of currently existing educational formats. Bringing the philosophy of medicine into medical education promises not only to improve the training of physicians but, ultimately, to lead to more mindful clinical practice, to the benefit of physicians and patients alike.

Treating real people: Science and humanity.

Something important is happening in applied, interdisciplinary research, particularly in the field of applied health research. The vast array of papers in this edition are evidence of a broad change in thinking across an impressive range of practice and academic areas. The problems of complexity, the rise of chronic conditions, overdiagnosis, co-morbidity, and multi-morbidity are serious and challenging, but we are rising to that challenge. Key conceptions regarding science, evidence, disease, clinical judgement, and health and social care are being revised and their relationships reconsidered: Boundaries are indeed being redrawn; reasoning is being made "fit for practice." Ideas like "person-centred care" are no longer phrases with potential to be helpful in some yet-to-be-clarified way: Theorists and practitioners are working in collaboration to give them substantive import and application.

Competing and conflicting interests in the care of critically ill patients.

Medical professionals are expected to prioritize patient interests, and most patients trust physicians to act in their best interest. However, a single patient is never a physician's sole concern. The competing interests of other patients, clinicians, family members, hospital administrators, regulators, insurers, and trainees are omnipresent. While prioritizing patient interests is always a struggle, it is especially challenging and important in the ICU setting where most patients lack the ability to advocate for themselves or seek alternative sources of care. This review explores factors that increase the risk, or the perception, that an ICU physician will reason, recommend, or act in a way that is not in their patient's best interest and discusses steps that could help minimize the impact of these factors on patient care.

Clinical judgement in precision medicine.

Precision medicine, which aims to individualize care based upon the unique combination of genetic, environmental, and lifestyle features in particular patients, will require an evolution in clinical decision making. Practitioners of precision medicine will need to utilize an expanded body of medical knowledge derived from a wide variety of sources. Clinical judgement in the case-based reasoning necessary for individualizing care will involve understanding and utilizing methodological approaches not commonly invoked in medicine, including mechanistic and qualitative research results. Instead of searching for an answer in the published literature, precision medicine demands clinical judgement that finds the reasons for clinical decisions within, not without, the patient.

The Evolving Ethics of Dialysis in the United States: A Principlist Bioethics Approach.

Throughout the history of dialysis, four bioethical principles - beneficence, nonmaleficence, autonomy and justice - have been weighted differently based upon changing forces of technologic innovation, resource limitation, and societal values. In the 1960s, a committee of lay people in Seattle attempted to fairly distribute a limited number of maintenance hemodialysis stations guided by considerations of justice. As technology advanced and dialysis was funded under an amendment to the Social Security Act in 1972, focus shifted to providing dialysis for all in need while balancing the burdens of treatment and quality of life, supported by the concepts of beneficence and nonmaleficence. At the end of the last century, the importance of patient preferences and personal values became paramount in medical decisions, reflecting a focus on the principle of autonomy. More recently, greater recognition that health care financial resources are limited makes fair allocation more pressing, again highlighting the importance of distributive justice. The varying application and prioritization of these four principles to both policy and clinical decisions in the United States over the last 50 years makes the history of hemodialysis an instructive platform for understanding principlist bioethics. As medical technology evolves in a landscape of changing personal and societal values, a comprehensive understanding of an ethical framework for evaluating appropriate use of medical interventions enables the clinician to systematically negotiate and optimize difficult ethical situations.