In yesterday’s post on parts of Idaho declaring that their hospital systems are on “crisis standards of care” which means triage of scarce resources of staff, stuff and space, there was a very robust discussion in comments. I want to engage with a few themes. But first I want to point everyone to White and Lo’s article in JAMA from March 2020 on how they envision a framework for rationing in a crisis.
Categorical exclusions are not necessary because less restrictive approaches are feasible, such as allowing all patients to be eligible and giving priority to those most likely to benefit.
Flea RN discusses their experience:
As an ED nurse, I do triage every day – we are the definitive destination for every sick person within 50 miles, and have limited resources. Most of the time, we are not close to the limit of what we *could* do, but when we are, those resources need to go to the people who can’t wait; in theory, a person with a ruptured appendix could wait for hours (with the proper antibiotics) before further treatment, but a person with a gunshot wound to their aorta will die if they don’t get surgery now – the gunshot victim goes to the head of the line.
I would just like to make a few points, expanding a bit on what some of you have already said:
- It’s frustrating to hear the press refer to “ICU beds,” as though we could just throw up a few cots and everything would be fixed. An ICU patient (or a very sick ED patient, which is the same thing, just earlier in their hospital course) requires a tremendous amount of resources – specialize Doctors (Intensivists, Nephrologists, Pulmonologists, Cardiologists, just to name a few,) specialized nurses, respiratory therapists, physical therapists. It takes years to train and recruit these people; you can’t just throw up an advertisement on a website and hire new ones….
- Triage happens *fast* – in the ER, by the time you speak to me, I’ve already watched you walk across the room, taken in your skin color and gait, and 95% of the time, I know what I’m going to do with you. I know how many beds are open, how busy the Doctors and Nurses are, how many ambulances are en route, and most of the time, I know where you’re going – the part where we’re talking is mostly filling out paperwork.
- Triage has to be protocolized well ahead of time, and it’s impersonal.
- It’s so tempting to want to push people to the end of the line for their lack of foresight, but that’s a really slippery slope, and even if it’s morally justifiable in the moment, there are powerful economic forces (to which David can speak better than I) which would like nothing better than to be able to deny care for “lifestyle choices” that are anything but. I certainly didn’t take an oath to treat anybody except for those who did something that I don’t agree with. Even if they yell at me when I leave work. If I burn out to the point where I can’t remember that, time for a new profession.
First and foremost, imperfect information makes any kind of treatment decision based on moral hazard to be really, really questionable. Does it matter if the guy in the car accident was wearing a seat belt or texting his office while driving? Does the answer change if he is working two jobs to support disabled dependents? And how would anyone with immediate responsibility for allocating resources know these things?
No, these judgments will be real time with virtually no clear context available for making them. Which raises the second problem: If you introduce this kind of value based judgment, they will not be systematic, but will seem and probably will be practically random. Random is not good and allows for personal bias that often penalizes marginal communities.
Speaking as a middle-aged, cis-gendered, white male with a lot of education and ability to navigate complex bureaucracies to access scarce resources, I should love discretion. Odds are that discretion is going to generate results that are more favorable to me than either random chance or systemic decision rules that take into account evidence and probabilities of desired outcomes. Conversely, marginalized populations that are already systematically screwed are likely to be screwed yet again when there is systemic discretion built into a critical set of decisions.
Allocation of very scarce medical interventions such as organs and vaccines is a persistent ethical challenge. We evaluate eight simple allocation principles that can be classified into four categories: treating people equally, favouring the worst-off, maximising total benefits, and promoting and rewarding social usefulness. No single principle is sufficient to incorporate all morally relevant considerations and therefore individual principles must be combined into multiprinciple allocation systems. We evaluate three systems: the United Network for Organ Sharing points systems, quality-adjusted life-years, and disability-adjusted life-years. We recommend an alternative system—the complete lives system—which prioritises younger people who have not yet lived a complete life, and also incorporates prognosis, save the most lives, lottery, and instrumental value principles.
We can design decision rules that maximize something that we deem important. That something can vary significantly as to who benefits.
Maximizing total lives saved in three weeks produces a very different population of people who may make the triage cut-off than a rule that emphasizes total lives saved in three years. The longer time horizon will prioritize people who have fewer competing risks for death which means prioritizing younger and healthier individuals compared to a short time horizon rule.
We can also prioritize on maximizing total Quality Adjusted Life Years which may again lead to the marginal person making the cut and getting a scarce resource to be younger and healthier than other allocation systems.
We can debate as to whether or not we should be engaged in complete maximization functions or should certain groups be targeted and prioritized. Early on in the pandemic, there was a robust discussion about whether or not medical personnel should be prioritized both as a recognition of the risks that they are taking and a more utilitarian argument that the promise of triage priority to medical personnel who get sick would keep more of the medical system operating as staff would be less likely to leave to protect themselves, and therefore an explicit prioritization of medical personnel for triage could potentially expand capacity and minimize the amount of time systems spent in critical triage.
There are other allocation schemas that prioritize different populations and will have a different marginal patient receiving the last available resource.
Smith discusses the facts of life:
The statistics are stark and convincing: Unvaccinated people are much less likely to survive a stint in ICU than vaccinated ones. Setting aside all moral judgments about personal choices, why wouldn’t this be part of the calculus in figuring out who is most likely to survive?
Yep, this is a major factor of any allocation decision that is not prioritizing sending resources to the worst off but is prioritizing maximizing lives saved with whatever time frame and prioritization window one chooses.
If there is one resource left and two patients who could potentially benefit from that resource, vaccination status is likely to be an underlying factor in the clinical decision making if we have good reason to believe that a vaccinated individual will do better than an unvaccinated individual on that resource. I don’t think vaccination status will be a surface causal factor in decision making but it could, quite plausibly, be a latent factor as it drives probability of survival.
And the Pale Scot
With limited resources the COVID infected unvaccinated DO HAVE the worse outcomes. Sedate them and roll them into a storage room.
All of my family are vacced. If I’m told my niece can’t get into ICU because willfully ignorant aggressively stupid goobers have taken all the slots, well…
Yeah, I get your anger and frustration and rage. I get it.
I am also scared shitless of a system built on subjective deservedness that is incredibly prone to both gaming and bias. Again as a straight, middle age, high SES cis-gendered white male, that system likely works really well for me but it is not a just system.