Manitoba needs pandemic triage guidelines

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This article was published 28/05/2021 (1774 days ago), so information in it may no longer be current.

TRIAGE: noun — (In medical use) the assignment of degrees of urgency to wounds or illnesses to decide the order of treatment of a large number of patients or casualties.

Manitoba doesn’t have enough intensive care beds to cope with desperately ill COVID-19 patients. We don’t have enough critical-care nurses. We don’t have enough respiratory therapists.

In consequence, some patients get the ICU bed they need, some have to be shipped out of town and some are consigned to the hospital’s hallway. Who should make these life-and-death allocative decisions, and on what basis? Should triage decisions be left to the discretion of individual physicians at the bedside or should there be provincial triage guidelines?

The critical-care shortages which have precipitated the current crisis were eminently foreseeable. After the third wave of COVID infections wreaked havoc in Ontario and Saskatchewan, urgent warnings were addressed to the Pallister government: tighten public-health restrictions immediately; and, while you’re at it, put sufficient health-care resources in place to prevent the expected “third wave” from collapsing our health-care system.

The warnings were ignored. Ideological rigidity combined with wilful blindness rendered the government impotent. So, when the predicted crisis hit and Manitoba took top spot in North America for per capita COVID-19 infections, our hospitals couldn’t cope. The only option for the health-care system is medical rationing.

On an emergency basis, some very sick patients are being sent for treatment out-of-province: to Thunder Bay, Windsor and Ottawa, Ont. If arrangements can be made, others may be sent to North and South Dakota.

The purpose of triage guidelines when rationing decisions become unavoidable is to make the most efficient use of essential health-care resources. Only some patients can receive optimal treatment. Others will be left to deteriorate. Still others will die.

Now the ethical questions: who should decide which patients will receive priority life-saving treatments? Equally important, on what basis will these life-and-death decisions be made?

Doctors Manitoba is calling urgently for the establishment of provincial triage guidelines. Otherwise, allocative decisions will have to be made by individual doctors at their patients’ bedside. Instead of asking, “Would my patient benefit from admission to the ICU?” the doctor would be required to ask “Which of my eligible patients will be most likely to benefit? Or “Which will benefit most?”

For doctors to make this kind of life-and-death choice among their eligible patients seems inconsistent with the fundamental principle of the Hippocratic oath: the life and health of my patient will be my first consideration.

In situations where some patients will likely benefit greatly from an ICU bed, while others will benefit only marginally, traditional physician ethics comes under pressure. “First come, first served” doesn’t seem like an ethically defensible moral rule when the patient who came first is unlikely to survive long while the patient who came second has a more favourable prognosis. Nor does the “first come” principle help when a decision has to be made concerning the withdrawal of life support.

Moreover, giving individual doctors sole discretionary power to withhold or withdraw life-support would impose on them a heavy moral and emotional burden. Worse, it would also lead to arbitrary and unfair differences in the way patients are treated.

Quebec has a COVID-19 triage plan in place. Quebec doctors are authorized not only to withhold life-support from patients but also to remove patients from life-support if it’s judged that their prognosis has deteriorated. As with all triage plans, the goal is to free up resources for those most likely to benefit.

Ontario also has triage plan. The Ontario guidelines mandate hospital ICUs to withhold life-support from patients unlikely to survive at least 12 months. Unlike Quebec, Ontario patients already on life-support will not have that support withdrawn if it might conceivably benefit them, no matter how poor their prognosis.

There’s clearly a trade-off. Quebec’s guidelines will likely save more lives; but Ontario’s guidelines will give patients and their families the security of knowing that once treatment has commenced it will not be discontinued even if there are other candidates with a greater likelihood of benefiting.

Since these triage decisions affect all of us, the issues and the options should be openly discussed.

Manitoba’s government should heed the advice of Doctors Manitoba. We urgently need provincial triage guidelines. More than that, however, the public needs to see that the guidelines are reasonable and fair. In a time of pandemic, trust is the most precious resource possessed by public-health officials. Once lost, it can be difficult or impossible to regain.

Arthur Schafer is founding director of the Centre for Professional and Applied Ethics at the University of Manitoba. He was an expert adviser to the federal government panel on immunity passports.