Triage plan details whom to let die during a pandemic
Treatment blueprint gives severely hurt, elderly lower priority
http://www.sfgate.com/cgi-bin/article.cgi?file=/c/a/2008/05/05/MNM210GNVM.DTL
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 whom 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, 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 published today 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 duty 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 will 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, 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.
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."
