Triage of Mechanical Ventilation in an Epidemic: Ethical Implications

Lea Brandt, OTD, OTR/LProgram Director/ Clinical Assistant Professor School of Health ProfessionsFaculty, MU Center for Health Ethics

ObjectivesIdentify public health implications for U.S.

Discuss ethical implications

Provide foundation for discussion regarding community action

Provide foundations for professional decision making in the event of a pandemic

Potential Problem

Many epidemic and bioterrorist agent illnesses involve respiratory failure. Mechanical ventilation is a frequently required intervention but one that is in limited supply.Triage criteria must be developed that depend on:

clinical indicators of survivabilityresource utilization to allocate scarce healthcare resourcescost benefit ratios

Mass Casualty Incident

A Public Health or Medical Emergency that could overwhelm and comprise the ability of the medical system response capabilities

Surge CapacityThe Healthcare system’s ability to expand quickly beyond normal services to meet an increased demand for medical care in the event of a biological or large scale emergency

Agency for Healthcare Research and Quality (AHRQ)

Greatest

LeastAircraft Accident

Major Flooding

LOCAL, REGIONAL, & STATE FEDERAL

Hurricane

Weapons ofMass

DestructionPandemicPandemic

Impact

SurgeSurgeGenerated From Both Natural and Events

Greatest

Field Triage

EmergencyDept

Inpatient

Critical Care

SecondarySecondarySurgeSurge

Impact

SurgeSurge

Preparing for Pandemic Influenza

Impact of Past Influenza PandemicsPandemic Excess Mortality Populations

1918-19Spanish Flu

500,000 AffectedPersons <65 years

1957-58Asian Flu

70,000 Infants, elderly

1968-69Hong Kong Flu

36,000 Infants, elderly

1977-78Russian Flu

8,300 Young (persons <20)

Startling Statistics105,000 ventilators available in U.S. and even during a regular flu season, 100,000 are in use (McNeil, 2006)National Preparedness Plan indicates a potential need for 742,500 ventilators in a worst case scenario pandemic.$3.8 billion authorized for flu preparedness by Congress, estimated that to buy enough ventilators for a flu outbreak similar to that of 1918 $18 billion required.

Other Barriers to Provision of CareED overcrowding reported by 91% of ED directorsDecrease of inpatient bed capacity by 4.4% nationwide.Shortage of qualified nursesLack of “surge capacity”>10 day LOS for ICU patients with acute respiratory syndromeLack of trained Respiratory Therapists

Estimated Impact on Local Community

Columbia Area population

100,000 persons

Ten % affected by pandemic influenza

10,000 persons

Twenty % of those too sick to care for selves

2,000 persons

Twenty % of those require hospitalization i.e. no family to provide care, complications

400 persons

Existing Research in Triage

Select papers have discussed triage in disaster settings.CDC and OSHA are in the process of setting standards, but there are not specific plans in place for each region.MU Center for Health Ethics is working with the Department of HHS to develop criteria and a plan for Missourians.

Triage

Hick and O’Laughlin identified 3 Tiers for provision of Mechanical Ventiliation: Tier 3 Ethical Issues AriseSpecific criteria to be agreed upon by committee:1. Restriction of treatment based on disease

specific epidemiology and survival data for patient sub-groups. (may be age based)

2. Expansion of pre-existing disease classes that will not be offered ventilator support.

3. Applying scoring to the triage process and establishing a cutoff score above which mechanical ventilation will not be offered.

Community Discussion

BHC Standing and Concerns34 ventilators; 5 typesUse is dependent on electricity, and availability of medical gases and cylinders.Staff other than respiratory therapists would need to be trained Criteria for placing a patient on a hand ventilator would need to be developedBHC has 10 disposable vents, conscious patients would struggle to get the air needed on this vent.Additional vents would be needed from K.C. and St. Louis, if possible.

Community Discussion

UMHC Standing and Concerns82 ventilators; 5 typesUse is dependent on electricity, and availability of medical gases and cylinders.Staff other than respiratory therapists would need to be trained Criteria for placing a patient on a hand ventilator would need to be developedThe emergency trailers have a multitude of the disposable resuscitators but their use if very limited.

Whose life is more valuable?Whose life is more valuable?

Decision Maker?

Ethical Discussion

We need a regional plan that is well coordinated and consistent between facilities.

Who should decide which patients receive mechanical ventilation?Who can decide whether on patient’s life is more valuable than another’s?Who should develop the criteria?

Choosing an ethics model

Traditional focus on patient autonomy was deemed ineffective for resource poor environments

Utilitarian or “distributive justice” model is more effective for scarce resource allocation

Fundamental Ethical Values

FairnessRespectRespect for PersonSolidarityLimiting Harm

Fairness: Healthcare resources are allocated fairly with a special

concern for the most vulnerable

With limited resources:

The fair distribution of resources is governed not by what is best for the individual, but rather by the principle of “the greater good of the community”

Decisions will be made that result in certain people getting these resources and others not getting these resources

Not every need will be able to be addressed in a disaster.

Respect*Each person must know that they will always be cared for and will be treated with dignity.

A person is, by nature, worthy of esteem and respect

They should be assured that they will be provided with dignified comfort care

With limited resources:

some persons will receive treatmentsome will receive limited treatmentsome will receive palliative treatment

Respect for Person:

Each person is a unique individual and is to be valued despite gender, ethnicity, age, religion, social status, economic value or any other variable

All persons must be treated fairly, justly and with dignity.

SolidarityEach individual must consider the needs of others Each person makes a commitment not only to family and loved ones but also to the community

With Limited resources:

Each person has an obligation to care for the otherEach person must consider the greater good of the community rather than one’s own self-interest.

Nonmaleficence: Limiting Harm

Do No Harm

With limited resources:

• Healthcare professionals may not be able to meet the needs of all patients

• Healthcare professionals will do as much good as possible for each patient, which means “limiting harm done to patients” because of the lack of necessary resources.

Example, with hospitals filled with patients, patients, who would normally be hospitalized, may need to be cared for at home. In this case, there will be public messages available to help family members take care of sick persons at home.

Disaster Ethics is a set of principles and values that direct:

• Duties• Obligations• Parameters

Disaster Ethics is the study of what ought to be done in a disaster situation.

Post Katrina, we need to reset our expectations. We need to realize that, in a disaster, things will not always go well; people will die; some people may not get treatment

Procedural Values

ReasonablenessTransparency/ OpennessInclusivenessResponsivenessResponsibility

ReasonablenessReasonableness is the quality of being believable and acceptable by the average person

With Limited Resources:

Treatment decisions are to be based on science, evidence, practice, experience and principles and be guided by the values that are identified in this document

Both healthcare workers and the public should at least understand that science, evidence, practice, experience and principles are being used for addressing healthcare decisions in a disaster

Transparency/Openness:

The process of discussing the guidelines in this document and how these guidelines will be applied in a disaster is open to public discussion and scrutiny

This period of discussion is an opportunity for both healthcare workers and the public to provide their recommendations about editing the guidelines and to have their recommendations recognized and acted upon.

Inclusiveness

These guidelines are being drafted and any decisions made are to be made explicitly with the intent of including the views of healthcare workers and the public.

There should be opportunities to engage healthcare workers and the public in the decision-making process and to have a methodology for making their opinions known and knowing that their opinions are acted upon.

Responsiveness

There are to be opportunities to revisit and revise guidelines as new information emerges, especially throughout the actual crisis

There are to be mechanisms to address comments, recommendations, disputes and complaints

Healthcare Organizations must plan for the fair distribution of resources

Rationale: Must ensure that there is a process in place at their healthcare organization for the fair distribution of resources. Includes both the educational opportunities for clinicians to be informed of the guidelines for ethical decision-making A process for making ethical decisions accomplished through a vehicle such as an “Ethics Committee” with clinical input that meets to review criteria for admission, discharges, procedures, allocation of scarce resources.

HC Organizations must be non-competitive

Rationale: To achieve “the greater good for the community” leaders must set aside competitive goals and do what is best for the community. Leaders must ensure that there are agreements in place for the sharing of supplies, equipment and personnel and also for the triaging and acceptance of patients, based on what is best for the patients and the community.

Duty to Care

The “duty to care” is a duty incumbent upon healthcare professionals. However, all healthcare workers provide essential functions and all contribute to patient care.

Thus, this “duty” is incumbent upon all healthcare workers. Especially in high-risk incidents, all healthcare workers along with other critical infrastructure workers will be faced with conflicting obligations.

Duty to Care

This same “duty” applies to everyone, because, in a disaster, when there are limited resources, each person has an obligation to care for others, knowing that with limited resources, all must all think of the greater good rather than think only of themselves.

Healthcare Workers' Dilemma• Do I report to work to care for those to

whom I have professionally committed myself?

• Or do I stay at home to care for my spouse and family to whom I have also committed myself?

• Some employees will obviously be faced with conflicting obligations and some will not show up for work because of these conflicts

With limited personnel, how far out of my scope of practice may I work, knowing that,

without the care and treatment I provide, patients may be harmed?

If there are insufficient supplies of personal protective equipment, should I put myself

and my fellow caregivers and other patients at risk and to continue to care for contagious

patients without the benefit of personal protective equipment?

‘‘There’s going to have to be rationing at every level,’’ said Emergency officials around the

country are just beginning to raise the possibility, in public, that doctors may have to deny life-saving treatment to some patients.

Dr. Richard Herman, chief of emergency medicine at Caritas Good Samaritan Medical Center in Brockton.

Employees working in a disaster will have many physical, social, emotional and spiritual needs, causing “moral distress”, which is the result of a

person who knows what the right thing to do is, but cannot do it because of lack of materials or human

resources.

Projections of the amount of personal protective equipment needed in a pandemic show that there

would not be sufficient funds to purchase the large quantities needed, let alone finding the storage space for this personal protective equipment.

This high potential for these shortages of personal protective equipment raises two serious ethical

dilemmas for the healthcare organization “Flu Surge” from the Centers for Disease Control (CDC),

Is there a point at which the healthcare organization will need to say “There is nothing more that we can do for our patients?”

OSHA recognizes that the amounts of personal protective equipment required will be significant,

costly and difficult to inventory. However, OSHA offers no guidance, at the present

time, about options available to healthcare organizations when such shortages of personal

protective equipment occur.

“Pandemic Influenza Preparedness and Response Guidance forHealthcare Workers and Healthcare Employers” (OSHA 332805 2007) p 46,

Altered Standards of Care????

The term "altered standards" has not been defined, but generally is assumed to mean a shift to providing care and allocating scarce equipment, supplies, and personnel in a way that saves the largest number of lives in contrast to the traditional focus on saving individuals

Moving ForwardIdentify and acknowledge system limitations at a regional level.Identify if there are current related policies developed by community hospitals, i.e. University, VA, Ellis Fischel, BHC, Fitzgibbon…Identify potential champions in each hospital that are willing to assist in standardizing criteria.Organize focus groups including representatives from community healthcare organizations.Ultimately develop a contingency plan to address such a situation in advance.

Proposed Criteria Development1. Provide guidelines for individual

physicians with regard to withdrawal, which will improve consistency and decrease need for defense of position.

2. Implemented on a regional not institutional basis

3. Include liability protections for providers and institutions

4. Restrictions should apply equally to those infected and those hospitalized for other reasons.

Criteria Development continued1. Implemented in a tiered fashion.2. Tiers should be based on objective

determinations of effectiveness of care affecting survival and of allocation.

3. Final tier should ideally provide a numeric assessment of survival probability.

4. Numeric scoring system should rely on clinical variables and should involve simple calculations easily understood and correlated with survival.

Bird Flu Hits Florida!Bird Flu Hits Florida!

References

2006, State Expert Panel, Inpatient/Outpatient Surge Capacity: HRSA Wisconsin Hospital Preparedness Program

2005, Upshur, R.; Faith, K.; Gibson, J.; Thompson, A.; Tracy, C.; Wilson, K.; Singer ,P. Stand on Guard For Thee, Ethical considerations in preparedness planning for pandemic influenza; A report of the University of Toronto Joint Centre of Bioethics Pandemic Influenza Working Group

2005, Agency for Healthcare Research and Quality and the Office of the Assistant Secretary for Public Health Emergency Preparedness, U.S. Department of Health and Human Services, Altered Standards of Care in Mass Casualty Events, Bioterrorism and Other Public Health Emergencies

2006, 7:5 Ruderman, C.; Tracy, S.; Bensimon,C.; Bernstein,M.; Hawryluck,L.; Zlotnik, R; Shaul2, 5 and Ross EG ; Upshur,S.; Upshur,R.; On pandemics and the duty to care: whose duty? who cares? Published: 20 April BMC Medical Ethics

2007, Roberts, M.; Hodge, J.; Gabreil, E.: Hick, J.; Cantrill, S.; Wilkinson, A.; Matzo, M.; Mass Medical Care with Scarce Resources Published: February Agency for Healthcare Research and Quality

Helpful Web Sites

http://bioterrorism.rutgers.edu/www.cdc.gov www.who.in/en/www.fao.orgwww.oie.org