Ethics: Triage First Come, First Serve

Transcription

1 Department of Anesthesiology and Critical Care Medicine Hadassah Medical Center Ethics: Triage First Come, First Serve Charles L. Sprung, M.D.

2 ETHICAL PRINCIPLES AUTONOMY BENEFICENCE NONMALEFICENCE JUSTICE

3 THE SPECTRUM OF TRIAGE TRIAGE CHAIN ELEMENTS FLOW LIMITATIONS HOME/INSTITUTION/ OTHER HOSPITAL ER/ DEPARTMENT ICU SELF TRIAGE PRE- ICU TRIAGE ICU TRIAGE INFLOW RESOURCE AVAILABILITY RESOURCE UTILISATION DEPARTMENT POST-ICU TRIAGE OUTFLOW HOME LEVIN PD, SPRUNG CL. INTENSIVE CARE MED 2001;27;

4 ICU FINAL SELECTION CRITERIA Medical benefit Life expectancy Medical need or urgency Prospect of successful treatment Need Merit Committee Market Social worth Societal contribution and status Age Mental functioning Self created health risks Compensatory justice Iatrogenic injuries Chance or queuingfirst come, first serve

5 ICU TRIAGE Non objective factors used for decisions Doctor or family pressure and persistence Age Difficulty in caring for the patient (ventilation) ICU census Elective surgery Location in hospital Seniority of requesting and triaging physician Examining patient or not Socioeconomic status Interpersonal relationships Hospital priorities

6 Consensus on ICU Triage

7 American Thoracic Society Recommendations When demand for ICU beds exceeds supply, medically appropriate patients should be admitted on a first-come, first-served basis. Because comparing degrees of benefit or need between patients competing for ICU care is morally problematic, as long as patients meet thresholds for medical need and benefit, they should be treated the same. Am J Respir Crit Care Med 1997;156:

8 American Thoracic Society Recommendations The use of first-come, first-served is an egalitarian approach for fair ICU resource allocation. Defining benefit using an objective method to predict ICU outcomes with an ICU scoring systems. Statistical models derived from large ICU databases Scores are based on patients receiving ICU care. Value judgment deciding what minimal differences in predicted survival rates are morally compelling. Certain patients (chronic disorders, elderly) denied ICU access because they have less potential benefit. Am J Respir Crit Care Med 1997;156:

9 Sprung CL. Intensive Care Medicine 2013;39:

10 SCCM Ethics Committee. JAMA 1994;271:1200; Sprung CL. ICM 2013;39:1916 ICU TRIAGE Limited Medical Suitability May exclude whether beds available or not Irreversible brain damage or multi-organ failure Unresponsive metastatic carcinoma Should exclude whether beds available or not Persistent, vegetative or permanently unconscious state Brain dead, non-organ donor Patients refusing intensive care

11 First come, first served Definition First patient admitted to the hospital's ED? First patient developing the need for ICU care? First patient to whom an ICU bed was promised? First patient the triage physician heard about? First patient the triage physician accepted?

12 First come, first served Definition Will first come, first served be used only for deciding which patient should be admitted to the ICU or for deciding which patient should be admitted vs. discharged from the ICU?

13 ICU triage An objective triage score should be used by physicians to help triage patients to ICU - 100% Agreed Sprung CL. Intensive Care Medicine 2013;39:

14 Sprung CL. Crit Care Med 2012;40:

15 First-come, First-served Decisions to be made for all patients should not be made on a first come, first served basis 100% Agreed Sprung CL. Intensive Care Medicine 2013;39:

16 How large does the benefit have to be? A chance of survival < 1% (1 in 100) A chance of survival < 0.2% (1 in 500) A chance of survival < 0.1% (1 in 1,000)

17 How large does the benefit have to be? 48% - if chance of survival < 1% (1 in 100) 65% - if chance of survival < 0.2% (1 in 500) 77% - if chance of survival < 0.1% (1 in 1,000) Sprung CL. Intensive Care Medicine 2013;39:

18 A compromise: Trials of therapy It may be appropriate to give a patient with little likelihood of benefit from ICU care a trial of limited duration of ICU care. If ICU care does not significantly improve the patient s condition after the agreed time, the patient should be discharged from the ICU and/or therapies limited 94% Agreed Sprung CL. Intensive Care Medicine 2013;39:

19 ICU Triage in Pandemics

20 Sprung CL. Intensive Care Med 2010:36:

21 Care of the Critically Ill and Injured During Pandemics and Disasters Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement Chest 2014; Oct 1;146 (4 Suppl): e1s-e177s

22 ICU Triage in Pandemics and Disasters Pandemics and MCE can generate many critically ill patients that can overwhelm health care resources Triage is used to guide the prioritization of limited resources following disasters In severe circumstances insufficient ICU bed availability may result in avoidable deaths Sprung CL. Intensive Care Med 2010:36:

23 ICU Triage in Pandemics and Disasters Triage protocols for ICUs are needed to prioritize limited resources and mitigate avoidable deaths Triage criteria should be objective, ethical, transparent, applied equitably and publicly disclosed Sprung CL. Intensive Care Med 2010:36:

24 ICU Triage in Pandemics and Disasters Developing fair and equitable policies for the greatest good for the greatest number of patients may require restricting services to patients likely to benefit from ICU care Usual treatments and standards of practice may be impossible to deliver Sprung CL. Intensive Care Med 2010:36:

25 ICU Triage in Pandemics and Disasters Exclusion criteria for patients who are not ICU candidates: Patients with a poor prognosis despite ICU care Patients requiring resources that cannot be provided Patients whose underlying illness has a poor prognosis with a high likelihood of death or those who are too well Sprung CL. Intensive Care Med 2010:36:

26 ICU Triage in Pandemics and Disasters ICU triage of patients remains controversial Recommendations to accept patients likely to benefit most from ICU or on a first come, first served basis Each institution should determine its own triage criteria using senior clinicians in a transparent fashion All critically ill patients should be assessed by a triage officer applying inclusion and exclusion criteria together possibly with a prioritization tool to determine qualification for ICU admission Sprung CL. Intensive Care Med 2010:36:

27 ICU Triage in Pandemics and Disasters Triage policy triage patients based on improved incremental survival rather than on a first-come, first-served basis when a substantial incremental survival difference favors resources to another patient. We suggest health-care systems establish in advance, a formal legal and systematic structure for triage in order to facilitate effective implementation of triage in the event of an overwhelming disaster. We suggest tertiary-care triage protocols for use during a disaster that overwhelms or threatens to overwhelm resources be developed with inclusion and exclusion criteria. Christian MD. Chest 2014 Oct 1;146(4 Suppl):e61S-74S

28 ICU Triage in Pandemics and Disasters Triage systems based even on limited evidence are ethically preferable to those based on clinical judgment alone. Currently, the most ethically appropriate method is to prospectively define patients who meet ICU inclusion and exclusion criteria and then consistently apply a prospectively developed, objective protocol. When there is insufficient evidence upon which to formulate objective clinical criteria, after applying inclusion and exclusion criteria, allocating available critical care resources among patients of equivalent prognosis by a fair and random process (eg, a first-come, first-served system or lottery) might be ethically justifiable but logistically challenging Biddison LD. Chest 2014 Oct 1;146(4 Suppl):e145S-155S

29 Department of Anesthesiology and Critical Care Medicine Hadassah Medical Center Ethics: Triage First Come, First Serve Charles L. Sprung, M.D.