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  • In case of a pandemic, who gets to live? Report offers answers

    Source: http://www.victoriaadvocate.com/news...ry/240264.html

    In case of a pandemic, who gets to live? Report offers answers


    BY LINDSEY TANNER - THE ASSOCIATED PRESS
    May 04, 2008 - 9:25 p.m.

    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 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 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. 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 T, 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.?

  • #2
    Re: In case of a pandemic, who gets to live? Report offers answers

    Here are some specifics as to who will not get life-saving care:

    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.


    I'll be curious to see the full report. Here's the plan from New York state that Florida1 posted recently:

    The salvage of human life ought to be placed above barter and exchange ~ Louis Harris, 1918

    Comment


    • #3
      Re: In case of a pandemic, who gets to live? Report offers answers

      Why those lists remembered some others ...

      It would be much more ethicaly to establish now that the laws would be derogated to military war laws:

      "The recommendations would probably violate federal laws against age discrimination and disability discrimination, said Gostin, who was not on the task force.
      ...
      He said the proposals resemble a battlefield approach in which limited health care resources are reserved for those most likely to survive."

      Comment


      • #4
        Re: In case of a pandemic, who gets to live? Report offers answers

        Source: http://www.ama-assn.org/amednews/200...rl20609.htm#s1

        PROFESSIONAL ISSUES
        Formula for rationing care: Task forces plan for disaster
        The threat of pandemic influenza and other mass-casualty disasters poses a vexing ethical dilemma for doctors.

        The deadly aftermath of Hurricane Katrina and concerns about a pandemic avian influenza have driven disaster preparedness and surge capacity planning, but physicians and others are starting to wrestle with perhaps an even trickier set of issues.

        What if, despite efforts to ramp up capacity and provide disaster response at the local, state and federal levels, the number of seriously ill patients exceeds the supply of critical care resources needed to keep them alive? Who should get care?

        Perhaps the dilemma would be most acute in an influenza epidemic, when 30% to more than half of infected patients could require ventilator-assisted breathing -- far outstripping availability of machines.

        Two recently published reports by physician-led task forces spelled out objective clinical criteria to determine who would be eligible for ventilators and other critical care resources and how to prioritize that use. The central ethical principle underlying the guidelines is that resources should be allocated to patients with the best odds of survival.

        The larger idea, experts said, is to devise an acceptable ethical framework to save the most lives, help protect physicians from legal repercussions and enhance public confidence in the health system's response.

        "It's extremely important to examine this as scientifically and rationally as possible before an event because once an event happens, we are not going to have the luxury of time to sit back and look at how to allocate limited resources," said Kristi L. Koenig, MD, director of public health preparedness at the University of California, Irvine, School of Medicine.

        "We will need to know ahead of time the logistics of how to optimize outcomes for a population of patients," said Dr. Koenig, speaking on behalf of the American College of Emergency Physicians. "We will no longer be able to focus solely on rescuing the individual patient, but rather on doing the most good for the most people and saving the most lives."
        A rationing algorithm

        A 58-page May supplement to the journal Chest featured the recommendations of a 37-member task force spearheaded by the American College of Chest Physicians and drawing representatives from the U.S. Dept. of Health and Human Services, Centers for Disease Control and Prevention and other organizations. Most of the suggestions focus on how to prepare for a mass-casualty disaster and ramp up capacity once it hits, but the report also offers advice on disaster triage and resource allocation.

        "Surge first, that is the focus," said Asha V. Devereaux, MD, MPH, lead author of the Chest resource-allocation article and a Coronado, Calif., critical care physician. Rationing "should never need to happen. The goal of this is that you're so prepared that this thought would be obsolete."

        But should a regional triage panel determine that medical need exceeds supply, the Chest report recommends denying or taking off ventilators patients with a greater than 80% chance of dying in the hospital. That decision would be made using the Sequential Organ Failure Assessment score, which measures levels of oxygenation, platelets, bilirubin, hypotension, consciousness and creatinine.

        Care would be prioritized according to the patients' most recent SOFA score and the daily trend of that score. The criteria are intended to be fair to all patients, with no special access to resources for people such as health care workers, police or firefighters.

        The criteria would be adjusted constantly by the central triage committee in response to changes in the availability of critical care resources, alleviating front-line physicians of those decisions. Patients exceeding the survivability threshold would receive palliative care.

        The Chest supplement is the latest in a series of efforts to lay out ethical criteria for rationing critical care in a major disaster. A Nov. 21, 2006, Canadian Medical Assn. Journal article recommended using SOFA scores to ration care. Canadian doctors and ethicists are especially attuned to the problem after a severe acute respiratory syndrome epidemic that killed 43 Canadians in 2002 and 2003.

        In March, similar recommendations from the New York State Dept. of Health's Task Force on Life & the Law were published in the AMA's Disaster Medicine and Public Health Preparedness journal. "There is a large degree of consensus, but lots of room for additional research," said Tia Powell, MD, executive director of the New York task force.

        The AMA has policy on the ethics of quarantine, but none on rationing critical care resources in a disaster.

        Dr. Powell and others said the new disaster standards can be implemented only with a green light from state governments that give legal protection to physicians and other health professionals who follow the guidelines in good faith.

        But not everyone agrees with the proposed guidelines.

        "The disaster mind-set has to be about getting the greatest good for the greatest number, not who we exclude and how we ration," said John H. Armstrong, MD, a trauma surgeon at the University of Florida and a member of the AMA disaster medicine journal's editorial board. "These situations are very dynamic, so we need more of a discussion about how we make decisions rather than guidelines which can take on the flavor of absolutes. Absolutes really don't work."

        Dr. Armstrong and others said the reports focused too heavily on the ethical ramifications of pandemic flu. Future plans should address other mass-casualty disasters, such as massive high-energy explosions, he said.

        Bioethicist Thomas H. Murray, PhD, a New York task force member, said working through allocation choices now is the right thing to do. Not to do so, he said, would "be a failure of planning, a failure of nerve and a failure of conscience."

        ADDITIONAL INFORMATION:
        Disaster response

        A disaster preparedness task force says hospitals should have a uniform approach to triaging patients when critical care resources become scarce following a mass-casualty disaster. Rationing should:

        * Occur only after all efforts to increase capacity have failed.
        * Be proportional to the actual shortfall in resources.
        * Occur uniformly, be transparent and abide by objective medical criteria.
        * Apply equally to withholding and withdrawing life-sustaining treatments, based on the principle that they are ethically equivalent.
        * Not mean denying supportive medical or palliative care to patients deemed ineligible for critical care.

        Source: "Definitive Care for the Critically Ill During a Disaster: A Framework for Allocation of Scarce Resources in Mass Critical Care: From a Task Force for Mass Critical Care Summit Meeting, January 26-27, 2007, Chicago, IL," Chest, May

        By Kevin B. O'Reilly, AMNews staff. June 9, 2008.

        Comment


        • #5
          Re: In case of a pandemic, who gets to live? Report offers answers

          "
          Surge first, that is the focus," said Asha V. Devereaux, MD, MPH, lead author of the Chest resource-allocation article and a Coronado, Calif., critical care physician. Rationing "should never need to happen. The goal of this is that you're so prepared that this thought would be obsolete."
          Yes!!! At least 1 person is thinking straight.

          Rationing should:
          * Not mean denying supportive medical or palliative care to patients deemed ineligible for critical care.
          I truly hope that those people who will be denied:
          1. antivirals
          2. prepandemic vax,
          3. pandemic vax
          4. ventilators
          will at least get some type of care/pain meds in the end.

          In view of all the wasteful spending our govt does, it just makes me angry that we even have to be talking about some of these things.
          The salvage of human life ought to be placed above barter and exchange ~ Louis Harris, 1918

          Comment


          • #6
            Re: In case of a pandemic, who gets to live? Report offers answers

            New Abstracts from Journal of Infectious Diseases about pandemic vaccines prioritization for reduction of years of life lost (http://www.flutrackers.com/forum/sho...ewpost&t=71828).

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