Craig Klugman, Ph.D., professor of bioethics and health humanities at DePaul University, recently published the following definition of triage.
Triage is a process for determining which patients will receive limited resources in a time of scarcity. The patients who are the sickest, have the least chance of recovery, and who require the most resources are often provided with comfort care to ease the dying rather than aggressive interventions. Those who are sick but not in emergency need may wait a while to be treated or just sent home. The ones who get resources are those who have a high likelihood of recovery with some interventions for a short time [ex: ventilator].
In COVID-19, triage will determine who gets ICU beds, ventilators and ECMO. When a vaccine is first created, triage will determine who gets the inoculation first.
Triage is a process adopted from the battlefield, where the injured are sorted for needed levels of care. We grew up watching M*A*S*H on TV (1972-1983) and learned the term long ago. It is a necessary process during times of heavy demand for extremely scarce resources and is a familiar process utilized in hospital emergency rooms around the country. It is also employed during disasters.
A factor that enters into the decision-making around triage includes whether someone will benefit from the immediate treatment. That is to say, with immediate treatment, will this person survive? The goal in triage is to maximize the number of survivors.
The unknown trajectory for the WHO designated COVID-19 pandemic leaves the entire US health system without the agility to prepare adequately, especially as the virus picks and chooses its own communities along with the transmission rate in those areas. If we look at the estimates floated by various governmental experts, the likelihood of having enough ventilators, strategically located as an example, is remote.
Enter, triage or another word rarely used because it is politically toxic, rationing. Today, rationing is implicit, but a pandemic brings it out into the open. It becomes explicit, for all to see. It is not pretty. This will be a fact of life if the most alarming projections are realized.
Rationing has been happening for years. It is not about throwing “grandma off the cliff” and is both insulting and ignorant to characterize the need for such a discussion in those words. The population is exploding with the elderly, chronically ill, transplant candidates, the opioid crisis and many more expensive conditions requiring treatment.
Triage decisions are not political, even though there will be those who determine such sensationalism promotes their agenda. It is easy to generate a social media hashtag# on Twitter and assign some fault to a government agency or political party or administration. If being honest, there are no clean hands on either side of the political aisle. There is plenty of accountability to go around. In any case, these are not recent shortcomings. There has been an incremental failing over decades, parties and agencies.
COVID-19 will bring the discussion to the public that has occurred in bioethical circles for years. In a world of extremely limited/scarce resources, triage aka rationing is necessary. The US citizenry is accustomed to an “I want what I want when I want it” mentality. This is unrealistic and is unsustainable, as we have seen from various healthcare cost projections.
Not everyone who is in severe respiratory distress will be placed on a ventilator. The triage protocol will make the decision. The discussion at every hospital in this country will be “how can the best outcome be achieved for the greatest number of people with the limited resources available to us?” In the field of ethics, this is called utilitarianism.
A ventilator does not save a patient’s life without the attention of dedicated staff to monitor the ventilator and patient. In a pandemic, there is a severe strain on an already challenged labor pool. If another hundred thousand ventilators became available, would there be enough nurses to stand by the equipment 24/7?
To this point, most of what we hear across media is a focus on equipment. Healthcare delivery is a labor-intensive industry. So, grabbing and hoarding all of the masks and other personal protective equipment that our healthcare professionals need to do their job is counterproductive. Triage will also consider the availability of personnel. It Is critical that those now active are kept healthy and protected.
Optimistically, our respect for the need for social distancing and hand washing will mitigate the impact on Americans. This means everyone has to do their share of following the rules. Even if one thinks this is an over-reaction, in the meantime, it needs to be taken seriously. A cavalier attitude could be the beginning of a chain or a link in the chain that affects your loved one, your mother, father, sister, brother, children and more.
If at the end of this rolling outbreak, we find that the impact on our society’s health is minimal, we either did our job by pulling our oars in the same direction or it was just another over-reaction to a nothing-burger. Is it worth testing that theory? I don’t think so. We are our brother’s keeper.