From the Guidelines
During a national emergency crisis with limited critical care resources, an ethically sound process consistent with crisis standards of care would involve implementing a fair, transparent, and objective triage system based on medical criteria and likelihood of benefit, as recommended by the most recent study in 2022 1.
Key Principles of Triage
The triage system should prioritize patients with the greatest likelihood of survival with treatment while considering both short-term and long-term outcomes. The process should avoid allocation based on social status, ability to pay, or other non-medical factors, and instead focus on maximizing overall population benefit.
- Regular reassessment of patients' conditions is essential to ensure resources remain with those most likely to benefit.
- The triage system should be publicly disclosed, consistently applied, and adaptable as the situation evolves.
- This approach balances the ethical principles of beneficence, non-maleficence, justice, and respect for persons while acknowledging the difficult reality that not all patients can receive optimal care during a crisis, as supported by previous studies 1.
Implementation of Triage
The most appropriate approach is to establish a triage committee separate from direct patient care to make allocation decisions based on predetermined criteria, rather than having bedside clinicians make these difficult choices.
- Triage criteria should be objective, ethical, transparent, applied equitably and be publicly disclosed, as emphasized in earlier guidelines 1.
- Critical care triage protocols for mass casualty events should only be triggered when critical care resources across a broad geographic area are or will be overwhelmed despite all reasonable efforts to extend resources or obtain additional resources, as noted in the literature 1.
Critical Clinical Prioritization
In situations where resources are scarce but not yet at the crisis level, critical clinical prioritization can be used to manage resources effectively, as illustrated in a case study from NYCH+H/Bellevue Hospital 1.
- This approach involves creative and novel methods of managing resources to sustain the entire population of patients requiring them, and is distinct from crisis triage of scarce resources.
From the Research
Ethically Sound Crisis Standards of Care
The process consistent with ethically sound crisis standards of care during a national emergency crisis involves several key principles, including:
- Directing limited resources towards patients most likely to benefit from them 2
- Upholding the obligation to care for all patients as best possible under difficult circumstances 2
- Ensuring transparency to maintain trust 2
- Applying ethical principles such as "number of lives saved", "transparency", "equity", and "respect of person and their autonomy" 3
- Using tiebreakers such as "younger first/life cycle" and "lottery" 3
Allocation of Scarce Critical Care Resources
The allocation of scarce critical care resources should be guided by a multi-principle ethical model that prioritizes the protection of life and health of the largest number of people 3. This model should be objective, ethical, transparent, applied equitably, and publicly disclosed 3.
Triage and Resource Allocation
Triage systems should be implemented as a last resort, and should serve to allocate scarce resources in a way that maximizes the number of lives saved 2. The decision-making process should be guided by ethical principles and should take into account the prognostic tools available to allocate critical resources 3.
Hospital Preparedness and Response
Hospitals have taken various actions to prepare for increased demand for intensive care during public health emergencies, including canceling elective surgeries and nonsurgical procedures, and scaling up ICU capacity using existing clinical space and staffing 4. However, the adoption of triage protocols and protocols to connect multiple patients to a single ventilator has been limited 4.