Who Gets to Live? In Certain Hospitals God No Longer Decides
BY
The word “triage” stems from the French trier, which means “to sort.”
The idea was popularized in the late 1700s during the French Revolution,
when Napoleon Bonaparte’s campaign into Egypt and Syria led
to a large number of wounded.
A French military surgeon, Dominique Jean Larrey, came up with the idea
of sorting casualties for care based on the severity of the soldiers’ wounds,
regardless of their rank. (Larrey even treated enemy soldiers—earning him
a reputation that spurred the Prussian calvary to save his life
when he was captured.)
Two centuries later, the goal of triage in emergency medicine
remains the same: to provide the greatest amount of good for the
greatest number of individuals. But as large parts of the United States
face soaring numbers of coronavirus cases, medical staff are grappling
with how to stay true to this principle.
Eighteen states are currently in what’s considered the “red zone”
by the White House coronavirus task force, meaning they had more than
100 new cases per 100,000 people last week. Additionally, 14 states currently
have more than 70 percent of their ICU capacity occupied.
Texas has stopped reporting which of its hospitals have exceeded their capacity
for COVID-19 patients. But signs point to a caseload crisis:
One children’s hospital in Houston is now admitting adult patients,
and the U.S. military is sending
medical staff to help support the state’s beleaguered doctors. This week,
a county in Texas announced its COVID-19 unit was full, and transfers to
other overwhelmed hospitals were becoming impossible. “Our doctors
are going to have to decide who receives treatment, and who is sent home
to die by their loved ones,” the Starr County Memorial Hospital said
in a news release.
In Arizona, intensive care unit beds are 90 percent full, morgues have run
out of space, and counties are ordering refrigerated trucks to store
additional bodies. In the midst of this surge, Arizona is the first state
to enact crisis care standards—protocols for when healthcare systems
are so overwhelmed by a catastrophic event that they can’t provide
normal care to patients.
Such dire straits raise important questions: how best to care for patients
when there aren’t enough resources to go around—and who has to make
those triage decisions.
The balancing act
Triage is fundamentally about balancing consequences, says Nathaniel Raymond,
lecturer at Jackson Institute of Global Affairs at Yale University, where
he teaches disaster response. One of the terrible realities of triage, he says,
is that decisions are zero sum: Treating one person usually means not treating
another. So it’s important that before an emergency, medical systems have
agreed on how these decisions will be made fairly, and have communicated
those guidelines transparently both to health care providers and the public.
The first principle of triage is to make ethical decisions. Raymond calls it
a “Star Trek problem, between Kirk and Spock,” referring to the 1982 movie
in which the starship officers had to choose between serving “the needs
of the many” versus the needs of one person.
Ethics will not eliminate tragedy. In some cases, the application of ethics
will contribute to it.
NATHANIEL RAYMOND, YALE UNIVERSITY
“Ethics in any setting, but especially triage, exist for one purpose:
To identify the conflicts,” Raymond says. “Ethics will not eliminate tragedy.
In some cases, the application of ethics will contribute to it.”
During the pandemic, medical staff have tried first to rapidly expand hospital
capacity. At the Veteran’s Affairs Ann Arbor Healthcare System in Michigan,
this meant building walls, piping, and ductwork to make negative pressure
COVID-19 wards, where air is captured to try to avoid viral spread.
But pulmonary care physician Hallie Prescott says that wasn’t enough.
To work well, triage plans must be vetted and practiced in advance.
Otherwise clinical decision-makers will be put under a huge amount of stress.
HISTORY
Surprise cave discoveries may double the time people lived in the Americas
As cases began materializing in Michigan in March, Prescott was part
of the triage team responsible for allocating scarce resources if the need arose.
The team ran through mock scenarios such as running out of ventilators,
and prepared the system to activate crisis standards of care. Fortunately,
they haven’t yet had to do so.
“Having to tell a family that due to the circumstances, you’re not able
to offer certain treatments—the thought of having those conversations
is a strong motivation to do everything possible to avoid shortages
in the first place,” she says.
Planning ahead also helps hospitals innovate. As COVID-19 hit New York,
Kathy Hibbert, the director of medical intensive care units at
Massachusetts General Hospital in Boston, helped set up a highly
unusual system: MGH and other regional hospitals worked together to
transfer not only sick patients, but also resources such as ventilators
between competing hospitals based on their capacity and need. During the
peak of Boston’s surge, that helped MGH cope with 500 patients in their ICU.
This kind of cooperation between competing institutions is rare.
“To my knowledge, it’s never happened before,” Hibbert says. She recommends
that doctors in other hard-hit areas start contacting their counterparts now,
“even if they’re not yet in a capacity crunch, so lines of communication are open.”
A plan for the darkest moments
Prescott knew there was a chance that her hospital in Michigan might be
overwhelmed with COVID-19 patients—and then staff would need to know
how to decide who to treat first.
In the U.S., the National Association of EMS physicians incorporated widely
accepted best practices into the SALT Mass Casualty Triage Algorithm in 2006.
This method sorts patients into three categories based on the severity of their
condition, assesses what patients in each category need, and then provides
lifesaving interventions. To help eliminate bias, Prescott’s hospital decided
that patients would receive a score to place them in one of three categories,
but within each category, they would be treated in random lottery order.
She says the triage team tried to be as specific as possible about the rules
and their intricacies, “so everyone can see they’ve been fairly applied.”
Even with plans in place, though, the moral distress of choosing between patients
exacts a mental toll on physicians, many of whom are already struggling with
burnout during this extended crisis. Even before the pandemic,
the United States had a nursing shortage—to say nothing of the lack of
respiratory therapists, physical therapists, and doctors.
“The scarcest resource is not stuff, the scarcest resource is actually people,”
says Julia Lynch, a University of Pennsylvania professor of political science
researching health policy.
It’s easier to produce a ventilator
than a skilled ICU nurse.
DEENA KELLY COSTA, UNIVERSITY OF MICHIGAN
This spring, Lynch examined 68 triage guidance documents around the country;
only 37 addressed staffing shortages. Medical professionals in Texas,
Michigan, Pennsylvania, and Massachusetts told National Geographic
that such shortages
were currently limiting their abilities to provide care, and the
U.S. Centers for Disease Control and Prevention anticipate healthcare
facilities may experience
staffing shortages during the pandemic.
“It’s easier to produce a ventilator than a skilled ICU nurse,”
says Deena Kelly Costa, assistant professor in the School of Nursing at the
University of Michigan. “It takes two to four years to finish your degree,
at least six months of experience to be proficient. That’s a long time.”
To make matters worse, hundreds of foreign doctors have reportedly had their
visas put on hold by the Trump Administration, despite an exemption
that’s supposed to allow their entry. “That hits our most under-resourced
hospitals the hardest, as they rely on people with visas to bring doctors
to underserved areas,” Hibbert says.
How to weigh a life
This inequality in resources directly affects patient care. As the U.S. faces an
escalating curve of COVID-19 cases, Raymond says it’s essential to consider how
“decades of compounded racial disparity contribute to vulnerability.”
“It’s really important to recognize we are rationing medical care all the time—I
n the US, we fundamentally ration it by ability to pay,” says Lynch. She believes
that long-standing disparities in access to healthcare have likely worsened the
pandemic, because lacking regular and appropriate healthcare has left many
Americans with pre-existing conditions that put them at risk for severe
cases of COVID-19.
In Arizona, for example, triage decisions involve scoring each patient based on
a medical assessment that includes considering the patient’s likelihood of dying
within one and five years. While this decision is hypothetically made without
regard to race or ethnicity, people of color are more likely to have conditions
such as heart disease that limit their life expectancy.
I thought surely if other people knew
inequality was causing people to die,
they would take it more seriously.
JULIA LYNCH, UNIVERSITY OF PENNSYLVANIA
Like many health researchers, Lynch has been discouraged watching the ways
coronavirus has deepened structural inequities. “I thought surely if other
people knew inequality was causing people to die, they would take it more
seriously,” Lynch says. She hopes coronavirus is finally demonstrating
“how awful the consequences of severe inequality are.”
In the face of such inequality, Raymond says coordinated federal leadership
is especially important—and currently lacking. He worries about conflicting
triage standards, adding “we’ve already seen this with testing”—for example,
the preferential allocation of scarce tests to professional athletes. Raymond
believes that a national rule-based system with transparent standards is more
likely to treat all patients fairly, ensuring care doesn’t just go to the richest or
the most well-connected.
In the midst of America’s crisis, doctors working in low-resource settings can
offer valuable lessons, says Tammam Aloudat, a Syrian doctor who is deputy
executive director of the Access Campaign at the medical aid nonprofit
Doctors Without Borders/Médecins Sans Frontières (MSF).
"My last mission was in a pediatric hospital in the south of Niger, where we
had 700 beds and almost all patients had severe malnutrition or malaria,
and quite high mortality,” Aloudat says. “Doctors on the ground needed
to make judgments that lead to some surviving and others not, depending
on their situation and the available care—and that is an extremely difficult
task and a very traumatic one.”
He suggests hospital administrations should consult doctors and the community
to help providers make fair decisions. Medical professionals should also
discuss their patients together on a regular basis and make collective decisions.
When trying to decide whether to remove a COVID-19 patient who’s not
improving from a much-needed ventilator, having multiple opinions can
help distribute the moral and mental burden of removing care.
While Aloudat agrees with Raymond on the importance of having a
rule-based system, he emphasizes the importance of not being too prescriptive.
Rigid rules can become overly restrictive when applied to ongoing pandemics
because it’s not always clear which patients will deteriorate or improve, he says:
“People on the ground have the best knowledge of their patients.”
Aloudat suggests adopting a justice-guided but utilitarian approach.
His example: During the 2015 Ebola outbreak in West Africa, testing capacity
lagged, but clinicians had to decide which patients would be admitted to the
hospital where they would certainly be exposed if they weren’t already ill.
MSF’s solution was to develop a new ward, where people waiting for test
results could be quarantined from the community.
“Previous generations of medics didn’t have to do this balancing in the U.S.,”
Aloudat says. But now, every decision seems to come with a cost:
“In a low-resource setting, on all levels of care there’s always more demand
than supply. One has to choose.”
The idea was popularized in the late 1700s during the French Revolution,
when Napoleon Bonaparte’s campaign into Egypt and Syria led
to a large number of wounded.
A French military surgeon, Dominique Jean Larrey, came up with the idea
of sorting casualties for care based on the severity of the soldiers’ wounds,
regardless of their rank. (Larrey even treated enemy soldiers—earning him
a reputation that spurred the Prussian calvary to save his life
when he was captured.)
Two centuries later, the goal of triage in emergency medicine
remains the same: to provide the greatest amount of good for the
greatest number of individuals. But as large parts of the United States
face soaring numbers of coronavirus cases, medical staff are grappling
with how to stay true to this principle.
Eighteen states are currently in what’s considered the “red zone”
by the White House coronavirus task force, meaning they had more than
100 new cases per 100,000 people last week. Additionally, 14 states currently
have more than 70 percent of their ICU capacity occupied.
Texas has stopped reporting which of its hospitals have exceeded their capacity
for COVID-19 patients. But signs point to a caseload crisis:
One children’s hospital in Houston is now admitting adult patients,
and the U.S. military is sending
medical staff to help support the state’s beleaguered doctors. This week,
a county in Texas announced its COVID-19 unit was full, and transfers to
other overwhelmed hospitals were becoming impossible. “Our doctors
are going to have to decide who receives treatment, and who is sent home
to die by their loved ones,” the Starr County Memorial Hospital said
in a news release.
In Arizona, intensive care unit beds are 90 percent full, morgues have run
out of space, and counties are ordering refrigerated trucks to store
additional bodies. In the midst of this surge, Arizona is the first state
to enact crisis care standards—protocols for when healthcare systems
are so overwhelmed by a catastrophic event that they can’t provide
normal care to patients.
Such dire straits raise important questions: how best to care for patients
when there aren’t enough resources to go around—and who has to make
those triage decisions.
The balancing act
Triage is fundamentally about balancing consequences, says Nathaniel Raymond,
lecturer at Jackson Institute of Global Affairs at Yale University, where
he teaches disaster response. One of the terrible realities of triage, he says,
is that decisions are zero sum: Treating one person usually means not treating
another. So it’s important that before an emergency, medical systems have
agreed on how these decisions will be made fairly, and have communicated
those guidelines transparently both to health care providers and the public.
The first principle of triage is to make ethical decisions. Raymond calls it
a “Star Trek problem, between Kirk and Spock,” referring to the 1982 movie
in which the starship officers had to choose between serving “the needs
of the many” versus the needs of one person.
Ethics will not eliminate tragedy. In some cases, the application of ethics
will contribute to it.
NATHANIEL RAYMOND, YALE UNIVERSITY
“Ethics in any setting, but especially triage, exist for one purpose:
To identify the conflicts,” Raymond says. “Ethics will not eliminate tragedy.
In some cases, the application of ethics will contribute to it.”
During the pandemic, medical staff have tried first to rapidly expand hospital
capacity. At the Veteran’s Affairs Ann Arbor Healthcare System in Michigan,
this meant building walls, piping, and ductwork to make negative pressure
COVID-19 wards, where air is captured to try to avoid viral spread.
But pulmonary care physician Hallie Prescott says that wasn’t enough.
To work well, triage plans must be vetted and practiced in advance.
Otherwise clinical decision-makers will be put under a huge amount of stress.
HISTORY
Surprise cave discoveries may double the time people lived in the Americas
As cases began materializing in Michigan in March, Prescott was part
of the triage team responsible for allocating scarce resources if the need arose.
The team ran through mock scenarios such as running out of ventilators,
and prepared the system to activate crisis standards of care. Fortunately,
they haven’t yet had to do so.
“Having to tell a family that due to the circumstances, you’re not able
to offer certain treatments—the thought of having those conversations
is a strong motivation to do everything possible to avoid shortages
in the first place,” she says.
Planning ahead also helps hospitals innovate. As COVID-19 hit New York,
Kathy Hibbert, the director of medical intensive care units at
Massachusetts General Hospital in Boston, helped set up a highly
unusual system: MGH and other regional hospitals worked together to
transfer not only sick patients, but also resources such as ventilators
between competing hospitals based on their capacity and need. During the
peak of Boston’s surge, that helped MGH cope with 500 patients in their ICU.
This kind of cooperation between competing institutions is rare.
“To my knowledge, it’s never happened before,” Hibbert says. She recommends
that doctors in other hard-hit areas start contacting their counterparts now,
“even if they’re not yet in a capacity crunch, so lines of communication are open.”
A plan for the darkest moments
Prescott knew there was a chance that her hospital in Michigan might be
overwhelmed with COVID-19 patients—and then staff would need to know
how to decide who to treat first.
In the U.S., the National Association of EMS physicians incorporated widely
accepted best practices into the SALT Mass Casualty Triage Algorithm in 2006.
This method sorts patients into three categories based on the severity of their
condition, assesses what patients in each category need, and then provides
lifesaving interventions. To help eliminate bias, Prescott’s hospital decided
that patients would receive a score to place them in one of three categories,
but within each category, they would be treated in random lottery order.
She says the triage team tried to be as specific as possible about the rules
and their intricacies, “so everyone can see they’ve been fairly applied.”
Even with plans in place, though, the moral distress of choosing between patients
exacts a mental toll on physicians, many of whom are already struggling with
burnout during this extended crisis. Even before the pandemic,
the United States had a nursing shortage—to say nothing of the lack of
respiratory therapists, physical therapists, and doctors.
“The scarcest resource is not stuff, the scarcest resource is actually people,”
says Julia Lynch, a University of Pennsylvania professor of political science
researching health policy.
It’s easier to produce a ventilator
than a skilled ICU nurse.
DEENA KELLY COSTA, UNIVERSITY OF MICHIGAN
This spring, Lynch examined 68 triage guidance documents around the country;
only 37 addressed staffing shortages. Medical professionals in Texas,
Michigan, Pennsylvania, and Massachusetts told National Geographic
that such shortages
were currently limiting their abilities to provide care, and the
U.S. Centers for Disease Control and Prevention anticipate healthcare
facilities may experience
staffing shortages during the pandemic.
“It’s easier to produce a ventilator than a skilled ICU nurse,”
says Deena Kelly Costa, assistant professor in the School of Nursing at the
University of Michigan. “It takes two to four years to finish your degree,
at least six months of experience to be proficient. That’s a long time.”
To make matters worse, hundreds of foreign doctors have reportedly had their
visas put on hold by the Trump Administration, despite an exemption
that’s supposed to allow their entry. “That hits our most under-resourced
hospitals the hardest, as they rely on people with visas to bring doctors
to underserved areas,” Hibbert says.
How to weigh a life
This inequality in resources directly affects patient care. As the U.S. faces an
escalating curve of COVID-19 cases, Raymond says it’s essential to consider how
“decades of compounded racial disparity contribute to vulnerability.”
“It’s really important to recognize we are rationing medical care all the time—I
n the US, we fundamentally ration it by ability to pay,” says Lynch. She believes
that long-standing disparities in access to healthcare have likely worsened the
pandemic, because lacking regular and appropriate healthcare has left many
Americans with pre-existing conditions that put them at risk for severe
cases of COVID-19.
In Arizona, for example, triage decisions involve scoring each patient based on
a medical assessment that includes considering the patient’s likelihood of dying
within one and five years. While this decision is hypothetically made without
regard to race or ethnicity, people of color are more likely to have conditions
such as heart disease that limit their life expectancy.
I thought surely if other people knew
inequality was causing people to die,
they would take it more seriously.
JULIA LYNCH, UNIVERSITY OF PENNSYLVANIA
Like many health researchers, Lynch has been discouraged watching the ways
coronavirus has deepened structural inequities. “I thought surely if other
people knew inequality was causing people to die, they would take it more
seriously,” Lynch says. She hopes coronavirus is finally demonstrating
“how awful the consequences of severe inequality are.”
In the face of such inequality, Raymond says coordinated federal leadership
is especially important—and currently lacking. He worries about conflicting
triage standards, adding “we’ve already seen this with testing”—for example,
the preferential allocation of scarce tests to professional athletes. Raymond
believes that a national rule-based system with transparent standards is more
likely to treat all patients fairly, ensuring care doesn’t just go to the richest or
the most well-connected.
In the midst of America’s crisis, doctors working in low-resource settings can
offer valuable lessons, says Tammam Aloudat, a Syrian doctor who is deputy
executive director of the Access Campaign at the medical aid nonprofit
Doctors Without Borders/Médecins Sans Frontières (MSF).
"My last mission was in a pediatric hospital in the south of Niger, where we
had 700 beds and almost all patients had severe malnutrition or malaria,
and quite high mortality,” Aloudat says. “Doctors on the ground needed
to make judgments that lead to some surviving and others not, depending
on their situation and the available care—and that is an extremely difficult
task and a very traumatic one.”
He suggests hospital administrations should consult doctors and the community
to help providers make fair decisions. Medical professionals should also
discuss their patients together on a regular basis and make collective decisions.
When trying to decide whether to remove a COVID-19 patient who’s not
improving from a much-needed ventilator, having multiple opinions can
help distribute the moral and mental burden of removing care.
While Aloudat agrees with Raymond on the importance of having a
rule-based system, he emphasizes the importance of not being too prescriptive.
Rigid rules can become overly restrictive when applied to ongoing pandemics
because it’s not always clear which patients will deteriorate or improve, he says:
“People on the ground have the best knowledge of their patients.”
Aloudat suggests adopting a justice-guided but utilitarian approach.
His example: During the 2015 Ebola outbreak in West Africa, testing capacity
lagged, but clinicians had to decide which patients would be admitted to the
hospital where they would certainly be exposed if they weren’t already ill.
MSF’s solution was to develop a new ward, where people waiting for test
results could be quarantined from the community.
“Previous generations of medics didn’t have to do this balancing in the U.S.,”
Aloudat says. But now, every decision seems to come with a cost:
“In a low-resource setting, on all levels of care there’s always more demand
than supply. One has to choose.”
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