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An outside garage is used for triage at the entrance to the Moncucco Hospital in Lugano, March 2020. Photo: trapezoidal
Triage in overcrowded hospitals: on this basis, doctors make decisions about life and death
When nursing staff and intensive care beds are in short supply, hospitals suddenly have to turn away patients who depend on intensive care treatment. Which patient has priority? A look at the guidelines of the Swiss Academy of Medical Sciences provides information.
The first hospitals are reaching their limits: the beds in the intensive care unit are almost completely occupied in individual institutions. If possible, other hospitals are used or capacities are expanded. But what if that is no longer enough? Then, according to Martin Ackermann, chair of the national Covid 19 task force, a triage will take place. Doctors must decide which patient should receive vital treatment and which should not.
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Without a doubt a brutal decision. And the question inevitably arises: on what basis does the doctor decide? Larger hospitals have ethics teams, some have developed their own guidelines. The guidelines of the Swiss Academy of Medical Sciences (SAMS) and the Swiss Society of Intensive Care Medicine apply as the basis for all doctors and hospitals.
SAMS explains that such “rationing decisions” place a very high burden on medical personnel. “It is even more important that comparable criteria for admission and stay in the intensive care unit are used throughout Switzerland.” Doctors do not decide in a vacuum, nor on the basis of sympathy or financial advantage.
The four basic principles of medical ethics
SAMS guidelines adhere to widely recognized basic medical and ethical principles:
- 1. Principle of autonomy: The patient’s wishes regarding intensive and emergency treatment are clarified from the beginning. Scarce resources should never be used for treatments that a patient does not want to use.
- 2. Justice: Available resources must be distributed without discrimination, that is, without unjustified unequal treatment based on age, sex, place of residence, nationality, religious affiliation, social status, insured status or chronic disability. The process must be fair, factually justified and transparent. In this way, arbitrary decisions in particular can be avoided.
- 3. Save as many lives as possible: In conditions of acute shortage, all measures are aimed at minimizing deaths. Decisions must be made in such a way that as few people as possible get seriously ill or die.
- 4. Protection of the professionals involved: If the specialists involved are absent due to infection, even more people die if there is an acute shortage. That is why they must be protected as much as possible from infections, but also from physical and psychological overload.
The prospect of a short-term cure is crucial
So far the principles. How can a decision be derived from this?
If patients must be rejected due to total overload, triage is the short-term prognosis is crucial. SAMS puts it this way:
“When entering the intensive care unit, the highest priority is given to those patients who will benefit the most from intensive care.”
This also means: although age itself should not be a criterion (see the basic principle of the prohibition of discrimination), it is now relevant anyway. Older people suffer from diseases more often; With Covid-19, mortality is also related to age and therefore must be taken into account.
That drew criticism in the spring. In particular, in the case of overloaded intensive care units, this means that people over the age of 85 are no longer allowed in. The same is true for patients with moderate dementia, for patients with other serious chronic diseases and an estimated survival time of less than 24 months. These criteria are also set out in the SAMS guidelines. According to the “Sunday newspaper,” the specifications will be revised this week.
Young people are not always at an advantage
Bernhard Rütsche, professor of ethics, explained the triage procedure in an interview with the “NZZ” in March: “The deciding factor is for which patient a particular treatment is medically particularly urgent and particularly useful”. The scarce resources will be used mainly for those who are seriously ill.
“If it is no longer possible to treat all those who are critically ill, then priority should be given to those with the best chance of survival.” Rather, this means that treatments should only be denied to those for whom they hardly help. They are then treated palliatively.
According to Rütsche, if a decision is made, a young person would not automatically be given preference over an older person, even if they potentially lived longer.
“The decisive factor in assessing the prognosis is the probability of survival in the short term with the help of intensive therapy, but not the life expectancy in the medium or long term.”
Ultimately, it comes down to the medical benefit of the specific treatment. And the state of health is also a deciding factor here.
A decision that does not leave doctors indifferent
To be sure, the decision remains a tough one: it is a matter of life and death. Daniel Scheidegger, an ethicist, anesthetist and former head of the intensive care unit at Basel Cantonal Hospital, told Tamedia newspapers in March: “The priority is those who have the best chance of survival and recovery. That is the guiding principle on which medical personnel must act. “
This is a “very emotional experience” for the doctors and nurses involved. Scheidegger: “Something like that gets stuck.” As far as possible, no one should have to make such difficult decisions. In the current case, the population can do their part and meet the requirements of the Federal Council.
