Ethics of Triage in the Event of an Influenza Pandemic

Ethical-legal dilemmas of nursing practice in emergencies and disasters: a scoping review

OBJECTIVE

To map the ethical-legal dilemmas related to nursing practice in emergency and disaster situations.

METHOD

A scoping review developed in accordance with the JBI method, whose information sources were accessed in databases, in addition to gray literature. The selection was made by reading the titles, abstracts and descriptors, observing eligibility criteria, including two reviewers and a third in case of discrepancies. After reading, data extraction and content analysis of 17 selected studies were carried out.

RESULTS

Thirteen ethical-legal dilemmas were mapped related to professional/functional duty towards the family, lack of personal protective equipment and unsafe conditions at work, preparation and availability for action, skills, limits imposed by victims' religion, obligation to provide care.

CONCLUSION

Professionals, researchers and representatives of the category need to resolve demands that involve acting in emergencies and disasters, (re)cognizing the ethical-legal dilemma, and seeking (re)legal frameworks and observance of the fundamental/ethical principles that govern the profession, in the sense to support decision-making and the development of legally safe practices.

PHYSICIANS’ MORAL DUTIES DURING PANDEMICS

Background

Pandemics with devastating morbidity and mortality have occurred repeatedly throughout recorded history. Each new scourge seems to surprise governments, medical experts, and the public. The SARS CoV-2 (COVID-19) pandemic, for example, arrived as an unwelcome surprise to an unprepared world.

Discussion

Despite humanity's extensive experience with pandemics and their associated ethical dilemmas, no consensus has emerged on preferred normative standards to deal with them. In this article, we consider the ethical dilemmas faced by physicians who work in these risk-prone situations and propose a set of ethical norms for current and future pandemics. As front-line clinicians for critically ill patients during pandemics, emergency physicians will play a substantial role in making and implementing treatment allocation decisions.

Conclusion

Our proposed ethical norms should help future physicians make morally challenging choices during pandemics.

Comparative Analysis of Hydrogen Fluoride Exposed Patients Based on Major Burn Criteria After the 2012 Gumi City Chemical Leak Disaster

This study conducted to analyze and compare the epidemiological and clinical characteristics of hydrogen fluoride exposed patients based on major burn criteria for the appropriate emergency department (ED) response to a mass casualty chemical spill. This retrospective cross-sectional study included the records of patients (n = 199) who visited the ED of Gumi City University Hospital from September 27, 2012, to October 20, 2012. Subjects were included in the major burn group (MBG) if they presented with wounds that required referral to a burn center according to the American Burn Association guidelines or in the non-major burn group (NMBG) if not. Males were predominant in both the MBG (n = 55, 48 males) and NMBG (n = 144, 84 males; p < 0.05). The most prevalent timeline for visiting the ED was the phase which included 9-32 hours post-leak of HF, including 45 patients (81.8%) in the MBG and 122 patients (84.7%) in the NMBG (p < 0.001). The respiratory tract was the site of greatest damage in patients in both the MBG and NMBG (n=47, 85.5% versus n=142, 98.6%, p < 0.001). Regarding dispositions, all patients in the NMBG were discharged (n=144, 100%); however, 8 patients (14.5%) in the MBG underwent other dispositions (discharge againt medical advice, 5 patients; admission, 1; death, 2, p < 0.05). Patient outcomes after major chemical contamination events should be characterized in future studies to maximize the quality of patient care.

Ethics of ICU triage during COVID-19

INTRODUCTION

The coronavirus disease 2019 pandemic has placed intensive care units (ICU) triage at the center of bioethical discussions. National and international triage guidelines emerged from professional and governmental bodies and have led to controversial discussions about which criteria-e.g. medical prognosis, age, life-expectancy or quality of life-are ethically acceptable. The paper presents the main points of agreement and disagreement in triage protocols and reviews the ethical debate surrounding them.

SOURCES OF DATA

Published articles, news articles, book chapters, ICU triage guidelines set out by professional societies and health authorities.

AREAS OF AGREEMENT

Points of agreement in the guidelines that are widely supported by ethical arguments are (i) to avoid using a first come, first served policy or quality-adjusted life-years and (ii) to rely on medical prognosis, maximizing lives saved, justice as fairness and non-discrimination.

AREAS OF CONTROVERSY

Points of disagreement in existing guidelines and the ethics literature more broadly regard the use of exclusion criteria, the role of life expectancy, the prioritization of healthcare workers and the reassessment of triage decisions.

GROWING POINTS

Improve outcome predictions, possibly aided by Artificial intelligence (AI); develop participatory approaches to drafting, assessing and revising triaging protocols; learn from experiences with implementation of guidelines with a view to continuously improve decision-making.

AREAS TIMELY FOR DEVELOPING RESEARCH

Examine the universality vs. context-dependence of triaging principles and criteria; empirically test the appropriateness of triaging guidelines, including impact on vulnerable groups and risk of discrimination; study the potential and challenges of AI for outcome and preference prediction and decision-support.

A conceptual approach to the rationale for SARS-CoV-2 vaccine allocation prioritisation

Currently vaccines protecting from COVID-19 are a scarce resource. Prioritising vaccination for certain groups of society is placed in a context of uncertainty due to changing evidence on the available vaccines and changing infection dynamics. To meet accepted ethical standards of procedural justice and individual autonomy, vaccine allocation strategies need to state reasons for prioritisation explicitly while at the same time communicating the expected risks and benefits of vaccination at different times and with different vaccines transparently. In this article, we provide a concept summarising epidemiological considerations underlying current vaccine prioritisation strategies in an accessible way. We define six priority groups (vulnerable individuals, persons in close contact with the vulnerable, key workers with direct work-related contact with the public, key workers without direct work-related contact to the public, dependents of key workers and members of groups with high interpersonal contact rates) and state vaccine priorities for them. Additionally, prioritisation may follow non-epidemiological considerations including the aim to increase intra-societal justice and reducing inequality. While national prioritisation plans integrate many of these concepts, the international community has so far failed to guarantee equitable or procedurally just access to vaccines across settings with different levels of wealth.

Recomendaciones bioéticas para la pandemia, una perspectiva personalista

La emergencia sanitaria por la pandemia del covid-19 puso en evidencia limitaciones en los sistemas de salud a nivel mundial, lo que hizo necesario un marco bioético que brinde herramientas para orientar la toma de decisiones de los profesionales de la salud ante la escasez de recursos sanitarios. Modelos bioéticos como el principialismo, el utilitarismo y la bioética centrada en la persona buscan enfocar las decisiones clínicas con base en el respeto de los derechos y la dignidad de las personas, a fin de salvaguardar la práctica médica. La bioética centrada en la persona brinda un enfoque dirigido hacia el respeto de su dignidad en situaciones de urgencia sanitaria, para evitar dar un sentido material al hombre. Se requieren criterios de decisión para afrontar los conflictos bioéticos presentes en la práctica clínica, que reduzcan la carga legal, emocional y ética de la toma de decisiones en situaciones de pandemia.

Allocation of intensive care resources during an infectious disease outbreak: a rapid review to inform practice

BACKGROUND

The COVID-19 pandemic has placed sustained demand on health systems globally, and the capacity to provide critical care has been overwhelmed in some jurisdictions. It is unknown which triage criteria for allocation of resources perform best to inform health system decision-making. We sought to summarize and describe existing triage tools and ethical frameworks to aid healthcare decision-making during infectious disease outbreaks.

METHODS

We conducted a rapid review of triage criteria and ethical frameworks for the allocation of critical care resources during epidemics and pandemics. We searched Medline, EMBASE, and SCOPUS from inception to November 3, 2020. Full-text screening and data abstraction were conducted independently and in duplicate by three reviewers. Articles were included if they were primary research, an adult critical care setting, and the framework described was related to an infectious disease outbreak. We summarized each triage tool and ethical guidelines or framework including their elements and operating characteristics using descriptive statistics. We assessed the quality of each article with applicable checklists tailored to each study design.

RESULTS

From 11,539 unique citations, 697 full-text articles were reviewed and 83 articles were included. Fifty-nine described critical care triage protocols and 25 described ethical frameworks. Of these, four articles described both a protocol and ethical framework. Sixty articles described 52 unique triage criteria (29 algorithm-based, 23 point-based). Few algorithmic- or point-based triage protocols were good predictors of mortality with AUCs ranging from 0.51 (PMEWS) to 0.85 (admitting SOFA > 11). Most published triage protocols included the substantive values of duty to provide care, equity, stewardship and trust, and the procedural value of reason.

CONCLUSIONS

This review summarizes available triage protocols and ethical guidelines to provide decision-makers with data to help select and tailor triage tools. Given the uncertainty about how the COVID-19 pandemic will progress and any future pandemics, jurisdictions should prepare by selecting and adapting a triage tool that works best for their circumstances.

Understanding Ethical and Legal Obligations in a Pandemic: A Taxonomy of "Duty" for Health Practitioners

From the ethics perspective, "duty of care" is a difficult and contested term, fraught with misconceptions and apparent misappropriations. However, it is a term that clinicians use frequently as they navigate COVID-19, somehow core to their understanding of themselves and their obligations, but with uncertainty as to how to translate or operationalize this in the context of a pandemic. This paper explores the "duty of care" from a legal perspective, distinguishes it from broader notions of duty on professional and personal levels, and proposes a working taxonomy for practitioners to better understand the concept of "duty" in their response to COVID-19.

COVID-19: instruments for the allocation of mechanical ventilators-a narrative review

After the World Health Organization declared COVID-19 to be a pandemic, the elaboration of comprehensive and preventive public policies became important in order to stop the spread of the disease. However, insufficient or ineffective measures may have placed health professionals and services in the position of having to allocate mechanical ventilators. This study aimed to identify instruments, analyze their structures, and present the main criteria used in the screening protocols, in order to help the development of guidelines and policies for the allocation of mechanical ventilators in the COVID-19 pandemic. The instruments have a low level of scientific evidence, and, in general, are structured by various clinical, non-clinical, and tiebreaker criteria that contain ethical aspects. Few instruments included public participation in their construction or validation. We believe that the elaboration of these guidelines cannot be restricted to specialists as this question involves ethical considerations which make the participation of the population necessary. Finally, we propose seventeen elements that can support the construction of screening protocols in the COVID-19 pandemic.

Operational Recommendations for Scarce Resource Allocation in a Public Health Crisis

The coronavirus disease 2019 pandemic may require rationing of various medical resources if demand exceeds supply. Theoretical frameworks for resource allocation have provided much needed ethical guidance, but hospitals still need to address objective practicalities and legal vetting to operationalize scarce resource allocation schemata. To develop operational scarce resource allocation processes for public health catastrophes, including the coronavirus disease 2019 pandemic, five health systems in Maryland formed a consortium—with diverse expertise and representation—representing more than half of all hospitals in the state. Our efforts built on a prior statewide community engagement process that determined the values and moral reference points of citizens and health-care professionals regarding the allocation of ventilators during a public health catastrophe. Through a partnership of health systems, we developed a scarce resource allocation framework informed by citizens’ values and by general expert consensus. Allocation schema for mechanical ventilators, ICU resources, blood components, novel therapeutics, extracorporeal membrane oxygenation, and renal replacement therapies were developed. Creating operational algorithms for each resource posed unique challenges; each resource’s varying nature and underlying data on benefit prevented any single algorithm from being universally applicable. The development of scarce resource allocation processes must be iterative, legally vetted, and tested. We offer our processes to assist other regions that may be faced with the challenge of rationing health-care resources during public health catastrophes.

Crisis Standards of Care in the USA: A Systematic Review and Implications for Equity Amidst COVID-19

Background

Crisis Standards of Care (CSC) provide a framework for the fair allocation of scarce resources during emergencies. The novel coronavirus disease (COVID-19) has disproportionately affected Black and Latinx populations in the USA. No literature exists comparing state-level CSC. It is unknown how equitably CSC would allocate resources.

Methods

The authors identified all publicly available state-level CSC through online searches and communication with state governments. Publicly available CSC were systematically reviewed for content including ethical framework and prioritization strategy.

Results

CSC were identified for 29 states. Ethical principles were explicitly stated in 23 (79.3%). Equity was listed as a guiding ethical principle in 15 (51.7%); 19 (65.5%) said decisions should not factor in race, ethnicity, disability, and other identity-based factors. Ten states (34.4%) allowed for consideration of societal value, which could lead to prioritization of health care workers and other essential personnel. Twenty-one (72.4%) CSC provided a specific strategy for prioritizing patients for critical care resources, e.g., ventilators. All incorporated Sequential Organ Failure Assessment scores; 15 (71.4%) of these specific CSC considered comorbid conditions (e.g., cardiac disease, renal failure, malignancy) in resource allocation decisions.

Conclusion

There is wide variability in the existence and specificity of CSC across the USA. CSC may disproportionately impact disadvantaged populations due to inequities in comorbid condition prevalence, expected lifespan, and other effects of systemic racism.

Extracorporeal Life Support Organization Coronavirus Disease 2019 Interim Guidelines: A Consensus Document from an International Group of Interdisciplinary Extracorporeal Membrane Oxygenation Providers

The Extracorporeal Life Support Organization (ELSO) Coronavirus Disease 2019 (COVID-19) Guidelines have been developed to assist existing extracorporeal membrane oxygenation (ECMO) centers to prepare and plan provision of ECMO during the ongoing pandemic. The recommendations have been put together by a team of interdisciplinary ECMO providers from around the world. Recommendations are based on available evidence, existing best practice guidelines, ethical principles, and expert opinion. This is a living document and will be regularly updated when new information becomes available. ELSO is not liable for the accuracy or completeness of the information in this document. These guidelines are not meant to replace sound clinical judgment or specialist consultation but rather to strengthen provision and clinical management of ECMO specifically, in the context of the COVID-19 pandemic.

Ethical prioritization of patients during disaster triage: A systematic review of current evidence

INTRODUCTION

Triage is a dynamic and complex decision-making process in order to determine priority of access to medical care in a disaster situation. The elements which should govern an ethical decision-making in prioritizing of victims have been debated for a long time. This paper aims to identify ethical principles guiding patient prioritization during disaster triage.

METHOD

Electronic databases were searched via structured search strategy from 1990 until July 2017. The studies investigating patients' prioritization in disaster situation were eligible for inclusion. All types of articles and guidelines were included.

RESULT

Of 7167 titles identified in the search, 35 studies were included. The important factors identified in patient prioritization were grouped into two categories: medical measures (medical need, likelihood of benefit and survivability) and Nonmedical measures (saving the most lives, youngest first, preserving function of society, protecting vulnerable groups, required resources and unbiased selection). Demographic characteristics, health status of patients, social value of patient, and unbiased selection are discriminatory factors in disaster triage.

CONCLUSION

Various factors have been introduced to consider ethical patient prioritization in disaster triage. Providers' engagement, public education, and ongoing training are required to reach a fair decision.

Always ready, always prepared-preparing for the next pandemic

A future global pandemic is likely to occur and planning for the care of critically ill children is less robust than that for adults. This review covers the current state of federal and regional resources for pediatric care in pandemics, a strategy for pandemic preparation in pediatric intensive care units and regions focusing on stuff, space, staff and systems, considerations in developing surge capacity and triage protocols, special circumstances such as highly infectious and highly lethal pandemics, and a discussion of ethics in the setting of pediatric critical care in a pandemic.

Triage: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement

BACKGROUND

Pandemics and disasters can result in large numbers of critically ill or injured patients who may overwhelm available resources despite implementing surge-response strategies. If this occurs, critical care triage, which includes both prioritizing patients for care and rationing scarce resources, will be required. The suggestions in this chapter are important for all who are involved in large-scale pandemics or disasters with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials.

METHODS

The Triage topic panel reviewed previous task force suggestions and the literature to identify 17 key questions for which specific literature searches were then conducted to identify studies upon which evidence-based recommendations could be made. No studies of sufficient quality were identified. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. Suggestions from the previous task force that were not being updated were also included for validation by the expert panel.

RESULTS

The suggestions from the task force outline the key principles upon which critical care triage should be based as well as a path for the development of the plans, processes, and infrastructure required. This article provides 11 suggestions regarding the principles upon which critical care triage should be based and policies to guide critical care triage.

CONCLUSIONS

Ethical and efficient critical care triage is a complex process that requires significant planning and preparation. At present, the prognostic tools required to produce an effective decision support system (triage protocol) as well as the infrastructure, processes, legal protections, and training are largely lacking in most jurisdictions. Therefore, critical care triage should be a last resort after mass critical care surge strategies.

Pandemic ventilator rationing and appeals processes

In a severe influenza pandemic, hospitals will likely experience serious and widespread shortages of patient pulmonary ventilators and of staff qualified to operate them. Deciding who will receive access to mechanical ventilation will often determine who lives and who dies. This prospect raises an important question whether pandemic preparedness plans should include some process by which individuals affected by ventilator rationing would have the opportunity to appeal adverse decisions. However, the issue of appeals processes to ventilator rationing decisions has been largely neglected in state pandemic planning efforts. If we are to devise just and effective plans for coping with a severe influenza pandemic, more attention to the issue of appeals processes for pandemic ventilator rationing decisions is needed. Arguments for and against appeals processes are considered, and some suggestions are offered to help efforts at devising more rational pandemic preparedness plans.

Literature review and global consensus on management of acute radiation syndrome affecting nonhematopoietic organ systems

OBJECTIVES

The World Health Organization convened a panel of experts to rank the evidence for medical countermeasures for management of acute radiation syndrome (ARS) in a hypothetical scenario involving the hospitalization of 100 to 200 victims. The goal of this panel was to achieve consensus on optimal management of ARS affecting nonhematopoietic organ systems based upon evidence in the published literature.

METHODS

English-language articles were identified in MEDLINE and PubMed. Reference lists of retrieved articles were distributed to conferees in advance of and updated during the meeting. Published case series and case reports of ARS, publications of randomized controlled trials of relevant interventions used to treat nonirradiated individuals, reports of studies in irradiated animals, and prior recommendations of subject matter experts were selected. Studies were extracted using the Grading of Recommendations Assessment Development and Evaluation system. In cases in which data were limited or incomplete, a narrative review of the observations was made.

RESULTS

No randomized controlled trials of medical countermeasures have been completed for individuals with ARS. Reports of countermeasures were often incompletely described, making it necessary to rely on data generated in nonirradiated humans and in experimental animals. A strong recommendation is made for the administration of a serotonin-receptor antagonist prophylactically when the suspected exposure is >2 Gy and topical steroids, antibiotics, and antihistamines for radiation burns, ulcers, or blisters; excision and grafting of radiation ulcers or necrosis with intractable pain; provision of supportive care to individuals with neurovascular syndrome; and administration of electrolyte replacement therapy and sedatives to individuals with significant burns, hypovolemia, and/or shock. A strong recommendation is made against the use of systemic steroids in the absence of a specific indication. A weak recommendation is made for the use of fluoroquinolones, bowel decontamination, loperamide, and enteral nutrition, and for selective oropharyngeal/digestive decontamination, blood glucose maintenance, and stress ulcer prophylaxis in critically ill patients.

CONCLUSIONS

High-quality studies of therapeutic interventions in humans exposed to nontherapeutic radiation are not available, and because of ethical concerns regarding the conduct of controlled studies in humans, such studies are unlikely to emerge in the near future.

Allocating scarce resources in disasters: emergency department principles

Decisions about medical resource triage during disasters require a planned structured approach, with foundational elements of goals, ethical principles, concepts of operations for reactive and proactive triage, and decision tools understood by the physicians and staff before an incident. Though emergency physicians are often on the front lines of disaster situations, too often they have not considered how they should modify their decisionmaking or use of resources to allow the "greatest good for the greatest number" to be accomplished. This article reviews key concepts from the disaster literature, providing the emergency physician with a framework of ethical and operational principles on which medical interventions provided may be adjusted according to demand and the resources available. Incidents may require a range of responses from an institution and providers, from conventional (maximal use of usual space, staff, and supplies) to contingency (use of other patient care areas and resources to provide functionally equivalent care) and crisis (adjusting care provided to the resources available when usual care cannot be provided). This continuum is defined and may be helpful when determining the scope of response and assistance necessary in an incident. A range of strategies is reviewed that can be implemented when there is a resource shortfall. The resource and staff requirements of specific incident types (trauma, burn incidents) are briefly considered, providing additional preparedness and decisionmaking tactics to the emergency provider. It is difficult to think about delivering medical care under austere conditions. Preparation and understanding of the decisions required and the objectives, strategies, and tactics available can result in better-informed decisions during an event. In turn, adherence to such a response framework can yield thoughtful stewardship of resources and improved outcomes for a larger number of patients.

Resource allocation after a nuclear detonation incident: unaltered standards of ethical decision making

This article provides practical ethical guidance for clinicians making decisions after a nuclear detonation, in advance of the full establishment of a coordinated response. We argue that the utilitarian maxim of the greatest good for the greatest number, interpreted only as "the most lives saved," needs refinement. We take the philosophical position that utilitarian efficiency should be tempered by the principle of fairness in making decisions about providing lifesaving interventions and palliation. The most practical way to achieve these goals is to mirror the ethical precepts of routine clinical practice, in which 3 factors govern resource allocation: order of presentation, patient's medical need, and effectiveness of an intervention. Although these basic ethical standards do not change, priority is given in a crisis to those at highest need in whom interventions are expected to be effective. If available resources will not be effective in meeting the need, then it is unfair to expend them and they should be allocated to another patient with high need and greater expectation for survival if treated. As shortage becomes critical, thresholds for intervention become more stringent. Although the focus of providers will be on the victims of the event, the needs of patients already receiving care before the detonation also must be considered. Those not allocated intervention must still be provided as much appropriate comfort, assistance, relief of symptoms, and explanations as possible, given the available resources. Reassessment of patients' clinical status and priority for intervention also should be conducted with regularity.

Clinical review: Considerations for the triage of maternity care during an influenza pandemic--one institution's approach

The ongoing pandemic of 2009 H1N1 swine-origin influenza A has heightened the world's attention to the reality of influenza pandemics and their unpredictable nature. Currently, the 2009 H1N1 influenza strain appears to cause mild clinical disease for the majority of those infected. However, the risk of severe disease from this strain or other future strains remains an ongoing concern and is noted in specific patient populations. Pregnant women represent a unique patient population that historically has been disproportionately affected by both seasonal and pandemic influenza outbreaks. Data thus far suggest that the current 2009 H1N1 outbreak is following this same epidemiologic tendency among pregnant women. The increased predilection to worse clinical outcomes among pregnant women has potential to produce an acute demand for critical care resources that may overwhelm supply in facilities providing maternity care. The ability of healthcare systems to optimize maternal-child health outcomes during an influenza pandemic or other biologic disaster may therefore depend on the equitable allocation of these limited resources. Triage algorithms for resource allocation have been delineated in the general medical population. However, no current guidance considers the unique aspects of pregnant women and their unborn fetuses. An approach is suggested that may help guide facilities faced with these challenges.

Critical appraisal of: triaging pediatric critical care resources during a pandemic: ethical and medical considerations

OBJECTIVE

To identify the ethical norms that should govern the allocation of pediatric critical care resources during a pandemic.

DESIGN

Narrative review.

METHODS

Review the literature on triage and pandemics.

FINDINGS

When care that is functionally equivalent to usual patient care practices can no longer be maintained, resources should be allocated primarily on the basis of medical need and/or benefit. Unequal treatment may be justified to increase the supply of available resources and thereby save more lives. When ethically relevant distinctions can no longer be made between patients, resources should be distributed by chance. Allocation on the basis of quality of life, general contributions to society, or age are potentially problematic. Existing triage protocols inconsistently articulate the relationship between these ethical norms and their specific recommendations. In addition, they have limited applicability in pediatrics principally because of the lack of a simple validated global scoring system, which predicts mortality and/or resource utilization.

CONCLUSIONS

Although research to develop such scoring systems is ongoing, clinicians will need to rely more heavily on individual diagnoses of acute illnesses with high mortality rates and underlying conditions with short life expectancies and on random allocation methods.