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Harvard Medical School Dean George Q. Daley and two other Medical School faculty advocated for the use of “triage committees” within individual hospitals to address a potential shortage of ventilators nationwide in an article published in the New England Journal of Medicine late last month.
Robert D. Truog and Christine Mitchell — the Director and Executive Director of the Harvard Center for Bioethics, respectively — co-authored the paper, which was in part a reaction to reports from countries hit hard by the novel coronavirus.
Daley wrote in an emailed statement that in the weeks leading up to the article, he had been in contact with colleagues in China, Switzerland, Germany, and Italy.
“I became aware of hospital systems becoming overwhelmed, leaving physicians unable to deliver the highly individualized care they have come to expect,” he wrote. “This raised the question of traditional triage in settings usually restricted to battlefields, now that the battlefield is our hospitals.”
In Italy, 10 to 25 percent of patients hospitalized due to COVID-19 required a ventilator. The Centers for Disease Control and Prevention estimates that 2.4 million to 21 million Americans will require hospitalization — but there are just 62,000 full-function ventilators and 98,000 basic ventilators in the nation, plus an additional 8,900 in a federal stockpile, according to the paper.
Accordingly, the paper predicted that the number of patients in need of ventilation could range from 1.4 to 31 patients per ventilator.
If faced with such a shortage, the authors recommended that decisions regarding which patients should receive ventilators be made by a designated “triage committee” rather than the medical professionals performing direct patient care. Per the paper, triage committees would be made up of volunteers “who are respected clinicians and leaders among their peers and the medical community.”
According to the paper, committees would allow doctors and nurses to maintain their roles as advocates for their patients and remove the weight of decisions from individual providers, among other benefits.
Mitchell, who is a registered nurse, said triage committees will also help ensure decisions are consistent and remove the possibility that different providers make different decisions in similar cases.
“You're worried particularly around the principle of justice and fairness and ensuring that not just the right people received the right resources, which of course is critical, but also that similar cases get treated similarly,” Mitchell said. “That's an expectation of fairness.”
Mitchell and Daley both said “ad hoc” decisions leave more room for bias and errors than a committee-led process.
“I have more reservations about leaving such challenging clinical decisions to individuals acting alone in the heat of moment and subject to potential influences from external forces,” Daley wrote. “Triage committees are set up so that the principles upon which decisions are made are as fair as possible and based on the best evidence available.”
Edwin L. “Ned” Palmer, a doctor at Boston Children’s Hospital and a member of the ethics faculty at the Medical School, said he found the paper “incredibly valuable.”
“Everybody across the country, every health system, will be challenged with these decisions in the coming weeks,” he said. “At this point, it doesn't seem a question of if, it's a question of when.”
Palmer said he supported the use of triage committees because they help shield healthcare providers from the “discord and disconnect” that comes with the choice to remove a patient from a ventilator.
“If these triage panels have one truly tangible benefit, it hopefully absolves you of some of that decision making, and overall reduces your burnout so that you can continue to work,” Palmer said. “I think one of one of the greatest losses here would be losing the nursing, the respiratory therapist, and the physician workforce to depression, to burnout, to post traumatic stress responses, because they were forced to make this decision.”
“In Italy, they had clinicians weeping in the hallways,” he added. “There has been numerous, numerous interviews with Italian intensive care doctors who were being forced to make decisions without support.”
—Staff writer Camille G. Caldera can be reached at firstname.lastname@example.org. Follow her on Twitter @camille_caldera.
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