WE wrote a piece that appeared in The Conversation on August 18 (In Victoria, whether you get an ICU bed could depend on the hospital) that raised concerns over variation and lack of transparency between intensive care unit (ICU) resource allocation guidelines or triage documents in Victorian health services during the pandemic.
These documents are written to guide clinicians in allocating resources should the pandemic situation get to a level where the health service is completely overwhelmed and it is not possible for decisions to be made in a business as usual way. Fortunately, such a situation has not been seen in Victoria. As the COVID-19 patient numbers improve, the need to enact these procedures becomes increasingly remote.
In the 7 September issue of InSight+, Loh and Fleming wrote a response that characterised our work as inaccurate and “causing alarm” and suggested that the focus should be on preventing hospitals needing to make “grave choices”.
We thank Loh and Fleming for their contribution to the discussion of pandemic resource allocation.
We don’t believe that considering one aspect of pandemic planning compromises efforts to prevent the spread of COVID-19. Greater public awareness of proposed resource allocation processes in the event of scarcity could help with prevention efforts. We also believe that the public is entitled to know how these decisions are made.
We noted that some but not all of the Victorian health service documents that we had access to have listed exclusion criteria in their resource allocation guidelines. Loh and Fleming claim we have misunderstood the documents in this regard but without being able to openly state which health service documents have been seen, it is hard to know how they draw this conclusion, except to say that they may have seen other health service procedures that do not contain exclusion criteria, which confirms an issue with variation and transparency.
Loh and Fleming contend that triage plans are not followed as described in our Conversation article, and while they may include exclusion criteria, these are never used in isolation. We agree with Loh and Fleming that decisions about resource allocation should take into account the entirety of the situation, including patient preferences and an expert clinical assessment of the patient’s likelihood to benefit from the intervention in question.
However, these guidelines cover extreme situations beyond normal seasonal emergency department or ICU demand surges. We understand from colleagues in places such as Texas and New York and reports from Lombardi (Langhi, 2020) that triage documents were followed as set due to the demands of the circumstances. An observer of the New York and Texas surges also questioned the variation in care one could receive depending on the destination of one’s ambulance (Fink, 2020). It’s therefore important to create plans in advance that reflect the evidence and our values as a society. The main issue we tried to highlight was the difference in approaches between health services. Some listed exclusion criteria, some did not, and for those that did, their criteria were different. It is the difference and the lack of transparency that we are concerned with.
Loh and Fleming argue that tiebreaker situations, where it is not possible to differentiate between patients with equal needs on the basis of clinical priority alone, is “the stuff of thought experiments”. Yet, the very act of writing a pandemic ICU resource allocation procedure is an acknowledgement of the real possibility that there could be many more unwell and eligible patients who could benefit from ICU-level treatment than there is availability. It is both reasonable and good preparedness to include some provision for tiebreaker options. These need to be ethically justified and considered well ahead of time to avoid clinicians being forced to make decisions on their own in a crisis. Again, our concern lay with the difference in tiebreaker options between Victorian health services, rather than their inclusion.
Our Conversation piece focused on variation in hospital pandemic resource allocation guidelines, particularly relating to ICU. However, we think that highlighting this variation raises questions about other possible variations between health services in the pandemic and the values that underpin them. Are there different visitor policies or personal protective equipment guidelines for staff and patients at different Victorian hospitals even when they are located in areas of similar COVID-19 risk? What other variation occurs between health services and based on what justification?
Loh and Fleming ask us to trust in those who are making decisions because they have “given their professional lives to the noble vocation of health care”. We do not believe that trust should be given (or accepted) on the basis of membership of a profession or organisation. This is a throwback to paternalistic medicine that is no longer accepted. Trust comes from accountability and transparency. Calls for transparency are often met with accusations of scaremongering by those who have to take on the challenging task of engaging with society about their decisions, but as Loh and Fleming point out, transparency and accountability are key to procedural justice.
Lisa Mitchell is Conjoint Clinical Senior Lecturer in the School of Medicine, Faculty of Health at Deakin University.
Emma Tumilty is a Lecturer at Deakin University.
Giuliana Fuscaldo is an Associate Professor at Monash University.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.