Triaging for adult critical care in the event of overwhelming need

Abstract

Introduction: Predictions of the need for critical care within the H1N1 influenza pandemic suggested overwhelming need beyond potential resources, necessitating rationing of care via triaging.

Method: The triage model described was derived from informed discourse within a conjoined NHS and University Clinical Ethics Committee, supplemented by specialists in intensive care and infectious diseases. THE MODEL: The triage methodology described is justified ethically primarily upon 'utilitarian' principles within an aggregate public health model, with additional reference to 'fairness'. Advantages of such a model, which partially suspends usual clinical judgment applied to individuals in favour of also utilizing organ failure scores, include minimization of aggregate influenza morbidity and mortality, and minimization of psychological stress upon staff making triaging decisions. Legally, in England and Wales, the model is uncontentious as regards rationing of admission to critical care; however, the law adopts 'futility' as the core justification for withdrawal of treatment, applied to the individual, thus failing to allow for rationing through triaging individuals out of critical care in the interest of other patients with better chances of survival. There is therefore a mismatch between a clinically and ethically acceptable model of triaging, based upon a public health approach, and the law, based upon the paradigm of the individual patient.

Conclusion: The good fortune that the H1N1 pandemic was less severe than predicted, allowing time for calm consideration, debate and decision making about what model of triaging should be adopted whenever it might be necessary in the future. It is in the interest of the health of the nation, and government, to decide upon a critical care triaging model while there is not an imminent health service crisis.