Who should MDs let die in a pandemic?

[Blackadder1916]

Though this article discusses recommendations from an American group, it does provide some food for thought for Canadians should such a pandemic occur. 

Who should MDs let die in a pandemic? Report offers answers

By LINDSEY TANNER, AP Medical Writer Mon May 5, 9:47 AM ET

CHICAGO - Doctors know some patients needing lifesaving care won't get it in a flu pandemic or other disaster.  The gut-wrenching dilemma will be deciding who to let die.

Now, an influential group of physicians has drafted a grimly specific list of recommendations for which patients wouldn't be treated.  They include the very elderly, seriously hurt trauma victims, severely burned patients and those with severe dementia.

The suggested list was compiled by a task force whose members come from prestigious universities, medical groups, the military and government agencies.  They include the Department of Homeland Security, the Centers for Disease Control and Prevention and the Department of Health and Human Services.

The proposed guidelines are designed to be a blueprint for hospitals "so that everybody will be thinking in the same way" when pandemic flu or another widespread health care disaster hits, said Dr. Asha Devereaux.  She is a critical care specialist in San Diego and lead writer of the task force report.

The idea is to try to make sure that scarce resources — including ventilators, medicine and doctors and nurses — are used in a uniform, objective way, task force members said.

Their recommendations appear in a report appearing Monday in the May edition of Chest, the medical journal of the American College of Chest Physicians.

"If a mass casualty critical care event were to occur tomorrow, many people with clinical conditions that are survivable under usual health care system conditions may have to forgo life-sustaining interventions owing to deficiencies in supply or staffing," the report states.

To prepare, hospitals should designate a triage team with the Godlike task of deciding who will and who won't get lifesaving care, the task force wrote.  Those out of luck are the people at high risk of death and a slim chance of long-term survival. But the recommendations get much more specific, and include:

_People older than 85.

_Those with severe trauma, which could include critical injuries from car crashes and shootings.

_Severely burned patients older than 60.

_Those with severe mental impairment, which could include advanced Alzheimer's disease.

_Those with a severe chronic disease, such as advanced heart failure, lung disease or poorly controlled diabetes.

Dr. Kevin Yeskey, director of the preparedness and emergency operations office at the Department of Health and Human Services, was on the task force.  He said the report would be among many the agency reviews as part of preparedness efforts.

Public health law expert Lawrence Gostin of Georgetown University called the report an important initiative but also "a political minefield and a legal minefield."

The recommendations would probably violate federal laws against age discrimination and disability discrimination, said Gostin, who was not on the task force.

If followed to a tee, such rules could exclude care for the poorest, most disadvantaged citizens who suffer disproportionately from chronic disease and disability, he said.  While health care rationing will be necessary in a mass disaster, "there are some real ethical concerns here."

James Bentley, a senior vice president at American Hospital Association, said the report will give guidance to hospitals in shaping their own preparedness plans even if they don't follow all the suggestions.

He said the proposals resemble a battlefield approach in which limited health care resources are reserved for those most likely to survive.

Bentley said it's not the first time this type of approach has been recommended for a catastrophic pandemic, but that "this is the most detailed one I have seen from a professional group."

While the notion of rationing health care is unpleasant, the report could help the public understand that it will be necessary, Bentley said.

Devereaux said compiling the list "was emotionally difficult for everyone."

That's partly because members believe it's just a matter of time before such a health care disaster hits, she said.

"You never know," Devereaux said. "SARS took a lot of folks by surprise. We didn't even know it existed."
_________
On the Net:

CHEST: http://www.chestjournal.org
U.S. Govt.: http://www.pandemicflu.gov

 

[George Wallace]

In Canada, the Civil Libertarians would tear that to shreads citing the Charter of Human Rights.

 

[Michael OLeary]

In Canada, the Civil Libertarians would tear that to shreds citing the Charter of Human Rights.

Yup, they would demand that the available resources be spread so thin that the potential casualties were maximized as a result.

 

[MedTechStudent]

Anyone ever read "The Stand"?

Thats what this seams to be ramping up to....

 

[Fusaki]

Isn't there some sort of Canadian Law that would hand over the responsibility in a disaster such as this to the military? I always figured that it was perfectly legal to curb certain civil liberties in a state of emergency - and the authority to triage casualties seems perfectly rational in this case.

But then again, I assumed that someone already had this plan all sorted out. If The Bomb was dropped and the cold war went hot, someone must have had a plan for dealing with widespread casualties... right?

???

 

[Michael OLeary]

Isn't there some sort of Canadian Law that would hand over the responsibility in a disaster such as this to the military? I always figured that it was perfectly legal to curb certain civil liberties in a state of emergency - and the authority to triage casualties seems perfectly rational in this case.

But then again, I assumed that someone already had this plan all sorted out. If The Bomb was dropped and the cold war went hot, someone must have had a plan for dealing with widespread casualties... right?

???

Start your reading here:

Emergencies Act ( 1985, c. 22 (4th Supp.) )
http://laws.justice.gc.ca/en/showtdm/cs/E-4.5

 

[George Wallace]

Isn't there some sort of Canadian Law that would hand over the responsibility in a disaster such as this to the military? I always figured that it was perfectly legal to curb certain civil liberties in a state of emergency - and the authority to triage casualties seems perfectly rational in this case.

But then again, I assumed that someone already had this plan all sorted out. If The Bomb was dropped and the cold war went hot, someone must have had a plan for dealing with widespread casualties... right?

???

Unfortunately, since the Wall came down, it seems like the Federal Government has totally given up on the Emergency Measures Organization and all of its various incarnations.  Even with 911 to open up our eyes to some of life's perils, Canada seems to be going backwards, instead of forwards.  Problems found in all the studies done since 911 have not been solved.  Consolidated "Emergency Headquarters" have not been developed in major centers.  None of the various branches of Government seem to be cooperating with other branches, be they Federal, Provincial, Municipal, or Regional.  Sadly it seems as if the Chretien Liberals are still in the background saying: "If we ignore the problem, it will go away."

 

[Bigmac]

    This could actually happen and Canada is definitely in the mix. The SARS outbreak was a warning to how unprepared this country really is. Immigration is increasing in Canada and with it is possibilities of outbreaks of diseases we have not seen in a long time. For example tuberculosis has returned. Many immigrants arrive without any immunizations and some refuse to be immunized out of cultural or religious reasoning.

    An example of a scary thought is we no longer immunize for smallpox. Would this country be prepared for an outbreak of smallpox??

    Thankfully most schools have strict guidelines on immunizations for children. Believe it or not there are also many born Canadian families that believe it is wrong to immunize their children for reasons like home schooling. Unless your child lives in a sterile bubble they will be exposed to something sooner or later.  My advice to all, please , please immunize your children. The diseases are here and you are gambling with your children's lives if they do not get immunized!

  As far as worse case scenario of pandemics it can happen now. China is currently dealing with a new strain of Enterovirus outbreak in thousands of children with 26 deaths already. What happens if they can't control and isolate it??  How many people travel back and forth from China to other countries such as Canada?!

    The problem is we can speculate what diseases may potentially outbreak but Canada and many other countries are not fully prepared for the worse case scenario such as a pandemic.

 

[daftandbarmy]

Who should MDs let die in a pandemic?

Lawyers. Well, personal injury lawyers anyways.

Then all those with bad piercings, followed closely by those old farts with fedoras driving in front of me at 5 mph, rude people in customer service roles, the crack head that broke into my truck and stole my DVD player (and all his crack head friends) and - of course - everyone who sports those sappy, motivational bumper stickers preaching idiotic 'isms' of one kind or another.

There, got the triage list going for you.

 

[1feral1]

Regardless of a pandemic situation look at New Orleans a few yrs back, when a certain storm blew in.

Imagine the carnage from coast to coast. Death would be everywhere, many of the already chronically ill would succumb to this disease anyways because of being weakened by their current ailments. I am sure the medical personnel would show compassion and empathy towards patients and their families, but the situation would be overwehlming to say the least.

Whether you are 10 and sick or 70 and sick, each of us has earned the equal right for appropiate medical treatment IMHO. To pick and choose who lives and dies would be a rough decision to make if it had to be.

 

[ENGINEERS WIFE]

daftandbarmy, could you be a little more specific? ;D

 

[observor 69]

When asked what are some of the memorable books I have read this one always comes up:

The Great Influenza: The Epic Story of the Deadliest Plague In History (Hardcover)
by John M. Barry (Author) "ON SEPTEMBER 12, 1876, the crowd overflowing the auditorium of Baltimore's Academy of Music was in a mood of hopeful excitement, but excitement without frivolity..."

http://www.amazon.com/Great-Influenza-Deadliest-Plague-History/dp/0670894737

 

[Bigmac]

ON THE MONEY
Plan for long life, without pandemic
NANCY STANCILL
Should doctors let people older than 85 die in a flu pandemic?

A Monday news story saying a U.S. task force recommends denying lifesaving care in a pandemic or other disaster to some folks -- including healthy people above 85 -- was unsettling.

They're talking about my mother, soon to be 86. My friend Karen's father, who is 92. Another friend's grandmother, 102.

These people live life joyfully, with their minds and hearts intact. My mother relishes foreign travel. Karen's father loves bird watching. The 102-year-old grandmother plays a mean hand of bridge.

Financial planners, who routinely urge clients to base their planning on living to 95 or more, were aghast when I told them the news.

"I hope that none of my clients ever have people who want to make that decision for them," said Paul Boggs, a certified financial planner with R.P. Boggs and Co. in Lake Wylie, S.C. "That doesn't sit easy with me."

He said he has clients who are active in their 90s, including a few who still work daily at their companies.

Diane Davis, a certified financial planner in Charlotte, said she is amazed at such a recommendation, given that medical advances are increasing longevity all the time.

"A lot of us baby boomers would have an issue with that," she said.

It seems counterintuitive that the task force, influential physicians from universities, medical groups and government, would recommend letting people over 85 die in a flu pandemic.

The proposed guidelines are designed to be a blueprint "so that everybody will be thinking in the same way" in a disaster, Asha Devereaux, a critical care physician from San Diego and lead writer of the report, told the Associated Press.

Task force members said the idea is to allocate scarce resources, such as ventilators, medicine and doctors and nurses, in a uniform way. In addition to those over 85, the guidelines would cut out people with severe chronic disease and mental impairment.

Eighty-five doesn't seem so old anymore, especially when today's young folks have a heightened chance of living to 100.

http://www.charlotte.com/business/story/611580.html

    Food for thought I guess? My grandmother just turned 90 and is as sharp and vibrant as ever. I would want the medical system to treat her the same as any other patient under normal circumstances.

    But this thread is posing the question of a pandemic when the medical system is stretched to the limit, demand is higher than supply and decisions must be made quickly based on who has the best chance of survival. Triage would have to be done and unpopular decisions would have to be made.

 

[Michael OLeary]

    But this thread is posing the question of a pandemic when the medical system is stretched to the limit, demand is higher than supply and decisions must be made quickly based on who has the best chance of survival. Triage would have to be done and unpopular decisions would have to be made.

There are many who would say the medical system is already stretched to its limit, with staff and funding shortages already driving closure of hospitals and reductions in bed spaces.  The situations being discussed in this thread are when there is clearly not enough resources to deal with the number of sick and injured.  In that case, real decisions have to be made regarding who gets treated and who doesn't. It's not a matter of just trying to keep everyone "comfortable" until the doctor gets there, it's realizing that for some there will be no doctor, no matter how carefully the resources are managed.  No amount of rhetorical outrage over the potential for someone's grandmother to be triaged out of the equation is going to change the sheer mathematical reality of the situation.

 

[PMedMoe]

If it's a flu pandemic, you can include those who didn't get the flu shot! 

 

[MedTechStudent]

If it's a flu pandemic, you can include those who didn't get the flu shot! 

You mean that flu shot that I get every year as a formality and still get the flu? 

Thats not fair 

 

[Armymedic]

There is two "types" of triage options in any given cas vs resources medical scenario.

1. its the massive amount of casualties overwhelms to resources avail (medical supplies, facilities)

2. The mass of casualties overwhelm the avail medical personnel. (MDs and nurses are also being killed off)

If in a pandemic, the 2nd triage option becomes an issue, no guidelines nor legal well-to-doers are going to be able to stop people from reducing their work from those who can't be saved to those they feel they can. People forget that our medical pers are people to who can and will be struck down in a viral pandemic.


BTW- My personal opinion says it is wrong to set and age...there are unhealthy people in their 20-40's. And what of those thousands of immuno-comprimised people (HIV), do we "waste" vaccines on them?

 

[Gunner98]

Just remember the heartache and criticism that was expressed over the elderly abandoned during Hurricane Katrina in New Orleans.  Never easy to make these choices, despite their necessity.  Hospital and nursing home evacuations are challenging at the best of times.

 

[observor 69]

There is two "types" of triage options in any given case vs resources medical scenario.

1. its the massive amount of casualties overwhelms to resources avail (medical supplies, facilities)

2. The mass of casualties overwhelm the avail medical personnel. (MDs and nurses are also being killed off)

If in a pandemic, the 2nd triage option becomes an issue, no guidelines nor legal well-to-doers are going to be able to stop people from reducing their work from those who can't be saved to those they feel they can. People forget that our medical pers are people to who can and will be struck down in a viral pandemic.


BTW- My personal opinion says it is wrong to set and age...there are unhealthy people in their 20-40's. And what of those thousands of immuno-comprimised people (HIV), do we "waste" vaccines on them?

During the SARS crisis in Toronto health care workers and their families were concerned about what might be brought home from the hospital.

 

[Blackadder1916]

I've had a chance to briefly view the referenced article (actually 5 articles) in Chest and found that it makes good reading for anyone interested in disaster planning, whether from a health sector perspective or not.  While it makes good copy to focus on a "perception" that the authors of this report (and one of the principals is from Canada) are suggesting that no medical services be provided to individuals who fall into defined categories, closer examination of the report shows that it is not such a cut and dried recommendation.

The following are abstracts (and link to the full text) of the articles in Chest.

Summary of Suggestions From the Task Force for Mass Critical Care Summit, January 26–27, 2007*   full text

Executive Summary
This Supplement on the management of mass critical care for ill patients represents the consensus opinion of a multidisciplinary panel convened under the umbrella of the Critical Care Collaborative Initiative. Expert recommendations on this subject are needed. Most countries have insufficient critical care staff, medical equipment, and ICU space to provide timely, usual critical care to a surge of critically ill victims. If a mass casualty critical care event were to occur tomorrow, many people with clinical conditions that are survivable under usual health-care system conditions may have to forgo life-sustaining interventions owing to deficiencies in supply or staffing. As a result, US and Canadian authorities have called for the development of comprehensive plans for managing mass casualty events, particularly for the provision of critical care. This Supplement includes the following: (1) a review of current US and Canadian baseline critical care preparedness and response capabilities and limitations, (2) a suggested framework for critical care surge capacity, (3) suggestions for minimum resources ICUs will need for mass critical care, and (4) a suggested framework for allocation of scarce critical care resources when critical care surge capacity remains insufficient to meet need. This Supplement is intended to aid clinicians and disaster planners in providing a coordinated and uniform response to mass critical care.

Mass casualty events occur frequently worldwide.3 Fortunately, the vast majority of these do not generate overwhelming numbers of critically ill victims. Attention to mass critical care, however, has been stimulated by the severe acute respiratory syndrome epidemic of 2002–2003,45 recent natural disasters, concern for intentional catastrophes, and the looming threat of a serious influenza pandemic.  To guide preparedness for such events, the Task Force for Mass Critical Care (hereafter referred to as the Task Force) was convened. It comprised 37 experts from fields including bioethics, critical care, disaster preparedness and response, emergency medical services, emergency medicine, infectious diseases, hospital medicine, law, military medicine, nursing, pharmacy, respiratory care, and local, state, and federal government planning and response. Several members of the Critical Care Collaborative (http://www.chestnet.org/institutes/cci/ccc.php) initiated the project and assembled a steering committee for project development and administration. Members of this steering committee included representatives from the organizational members of the Critical Care Collaborative as well as several unaffiliated North American disaster experts. This steering committee then selected members of the broader Task Force on the basis of their expertise and experience.

Definitive Care for the Critically Ill During a Disaster:

Current Capabilities and Limitations       full text

In the twentieth century, rarely have mass casualty events yielded hundreds or thousands of critically ill patients requiring definitive critical care. However, future catastrophic natural disasters, epidemics or pandemics, nuclear device detonations, or large chemical exposures may change usual disaster epidemiology and require a large critical care response. This article reviews the existing state of emergency preparedness for mass critical illness and presents an analysis of limitations to support the suggestions of the Task Force on Mass Casualty Critical Care, which are presented in subsequent articles. Baseline shortages of specialized resources such as critical care staff, medical supplies, and treatment spaces are likely to limit the number of critically ill victims who can receive life-sustaining interventions. The deficiency in critical care surge capacity is exacerbated by lack of a sufficient framework to integrate critical care within the overall institutional response and coordination of critical care across local institutions and broader geographic areas.

A Framework for Optimizing Critical Care Surge Capacity     full text

Background: Plausible disasters may yield hundreds or thousands of critically ill victims. However, most countries, including those with widely available critical care services, lack sufficient specialized staff, medical equipment, and ICU space to provide timely, usual critical care for a large influx of additional patients. Shifting critical care disaster preparedness efforts to augment limited, essential critical care (emergency mass critical care [EMCC]), rather than to marginally increase unrestricted, individual-focused critical care may provide many additional people with access to life-sustaining interventions. In 2007, in response to the increasing concern over a severe influenza pandemic, the Task Force on Mass Critical Care (hereafter called the Task Force) convened to suggest the essential critical care therapeutics and interventions for EMCC.

Task Force suggestions: EMCC should include the following: (1) mechanical ventilation, (2) IV fluid resuscitation, (3) vasopressor administration, (4) medication administration for specific disease states (eg, antimicrobials and antidotes), (5) sedation and analgesia, and (6) select practices to reduce adverse consequences of critical illness and critical care delivery. Also, all hospitals with ICUs should prepare to deliver EMCC for a daily critical care census at three times their usual ICU capacity for up to 10 days.

Discussion: By using the Task Force suggestions for EMCC, communities may better prepare to deliver augmented critical care in response to disasters. In light of current mass critical care data limitations, the Task Force suggestions were developed to guide preparedness but are not intended as strict policy mandates. Additional research is required to evaluate EMCC and revise the strategy as warranted.

Medical Resources for Surge Capacity*       full text

Background: Mass numbers of critically ill disaster victims will stress the abilities of health-care systems to maintain usual critical care services for all in need. To enhance the number of patients who can receive life-sustaining interventions, the Task Force on Mass Critical Care (hereafter termed the Task Force) has suggested a framework for providing limited, essential critical care, termed emergency mass critical care (EMCC). This article suggests medical equipment, concepts to expand treatment spaces, and staffing models for EMCC.

Methods: Consensus suggestions for EMCC were derived from published clinical practice guidelines and medical resource utilization data for the everyday critical care conditions that are anticipated to predominate during mass critical care events. When necessary, expert opinion was used.

Task Force major suggestions: The Task Force makes the following suggestions: (1) one mechanical ventilator that meets specific characteristics, as well as a set of consumable and durable medical equipment, should be provided for each EMCC patient; (2) EMCC should be provided in hospitals or similarly equipped structures; after ICUs, postanesthesia care units, and emergency departments all reach capacity, hospital locations should be repurposed for EMCC in the following order: (A) step-down units and large procedure suites, (B) telemetry units, and (C) hospital wards; and (3) hospitals can extend the provision of critical care using non-critical care personnel via a deliberate model of delegation to match staff competencies with patient needs.

Discussion: By using the Task Force suggestions for adequate supplies of medical equipment, appropriate treatment space, and trained staff, communities may better prepare to deliver augmented essential critical care in response to disasters.

A Framework for Allocation of Scarce Resources in Mass Critical Care*       full text

Background: Anticipated circumstances during the next severe influenza pandemic highlight the insufficiency of staff and equipment to meet the needs of all critically ill victims. It is plausible that an entire country could face simultaneous limitations, resulting in severe shortages of critical care resources to the point where patients could no longer receive all of the care that would usually be required and expected. There may even be such resource shortfalls that some patients would not be able to access even the most basic of life-sustaining interventions. Rationing of critical care in this circumstance would be difficult, yet may be unavoidable. Without planning, the provision of care would assuredly be chaotic, inequitable, and unfair. The Task Force for Mass Critical Care Working Group met in Chicago in January 2007 to proactively suggest guidance for allocating scarce critical care resources.

Task Force suggestions: In order to allocate critical care resources when systems are overwhelmed, the Task Force for Mass Critical Care Working Group suggests the following: (1) an equitable triage process utilizing the Sequential Organ Failure Assessment scoring system; (2) the concept of triage by a senior clinician(s) without direct clinical obligation, and a support system to implement and manage the triage process; (3) legal and ethical constructs underpinning the allocation of scarce resources; and (4) a mechanism for rapid revision of the triage process as further disaster experiences, research, planning, and modeling come to light.

For those who may be interested in how Canada is approaching a potential problem with pandemic influenza they can read The Canadian Pandemic Influenza Plan for the Health Sector.