EVEN before the onset of the COVID-19 pandemic, we have advocated, along with many others, for the public availability in Australia of ethically informed guidelines and protocols for triage decision making in the event that disaster overwhelms our health systems (here, here and here).
These are not new considerations, but COVID-19 has made the need more pressing, and in this National Palliative Care Week, when better to talk about them?
In the aftermath of high profile disasters such as Hurricane Katrina in New Orleans, and in response to the H1N1 influenza pandemic of 2009, organisations around the world recognised the need to be better prepared with comprehensive plans for the public health response to the wide range of predictable challenges posed by disasters (here and here). And yet, when the COVID-19 pandemic surged once again in the US and the UK (where confirmed COVID-19 mortality has passed 574 000 and 127 000 respectively) and now in India, clinicians swamped by demand were, and are, forced to make unsupported decisions about which patients of those who might benefit would receive treatment (here, here, here, and here). The ABC in Queensland aired an interview on 2 January 2021 with a clinician in the UK who described:
“having to decide the outcome of what is effectively a competition for a ventilator … it’s horrifying … we shouldn’t be having to do it, but we are.”
“now in ‘disaster medicine mode’ and unable to provide high-standard critical care”
And in Los Angeles paramedics were told to “stop transporting patients likely to die”.
The distress of these health care workers will last long after this pandemic is over.
Now, a new article in the MJA (of which WC is a co-author) has identified that Australian clinicians also face potential legal jeopardy from the absence of government protocols and legislation to protect them when they must make triage decisions in a disaster.
In Australia, politicians and public health officials have been admirably successful in leading our community throughout the pandemic, particularly when they have respected the science and acknowledged the morbidity, mortality and disruption that COVID-19 might cause.
Our state and national emergency and disaster preparedness plans aim to address foreseeable organisational and process issues of the response to disasters – and include acronyms, multicoloured flowcharts and the wording on the tabards worn by the various disaster responders (here and here).
It is therefore surprising that, one year after the onset of the COVID-19 pandemic and the very public triage experiences of nations around the world, a straightforward search of the internet for official guidelines or protocols for triage revealed no documents of current relevance – not from the Commonwealth of Australia, nor from any of its states or territories.
There are no guidelines and protocols to support the decision making by the clinicians who will choose which patients will not receive treatment. The general community remains generally unaware that they could be prioritised not to receive treatment, and are therefore unaware of the criteria for making that decision.
The positions of governments around the world have varied greatly. When we reviewed the issue in July 2020, few had published any triage protocols. Since then, however, the dire circumstances in some nations have driven action, including public discussions, that are detailed in an article from the Hastings Center.
Some Australian governments have simply stonewalled – documents prepared by ethicists and/or clinicians have been diverted into arcane bureaucratic or legal mazes as “there was still work to be done” (personal communication), or referred to consultative organisations such as the NHMRC, that has been tasked with creating discussion papers that seem unlikely to provide more than a summary of the various well documented ethical perspectives on triage.
When advice on triage is sought by direct questions, the general response has been to defer to unidentified higher authorities, obfuscate, or provide the informal response that protocols will be made available if the pandemic overwhelms health care services in Australia and triage becomes unavoidable.
Unfortunately, pandemics are not the only reasons that any clinician might need to undertake the onerous task of triage, and some disasters might require the unilateral imposition of decisions with no time for reflection or discussion. Humanitarian health care workers operating in contexts of existing humanitarian crisis such as warfare are all too familiar with the need for preparedness and emergency triage protocols. Simply waiting until health care systems are overwhelmed before preparing for hard problems like triage is not good practice in disaster preparedness.
Imagine that, as a doctor or nurse practitioner, you are working in remote Australia. A minibus laden with local residents or globetrotting tourists rolls on a dusty track and you are confronted with multiple casualties. Perhaps you are on duty in the emergency department of a port city when a huge explosion brings a sudden torrent of severely injured people. Or your waterfront hospital and the nearby airport are inundated by the tidal surge from a cyclone or a tsunami, cutting off all power and drowning computer and telecommunication systems. You are forced into “disaster mode” and can no longer provide the quantity of quality treatment that your community has learned to expect.
As clinicians, any of us may find ourselves suddenly having to make exclusionary triage decisions:
- Have you considered your roles and responsibilities and the ethics of the triage you may have to undertake, and are you prepared to do it?
- Have you had sufficient time to consider how you might prioritise patients in various circumstances?
- Has your community been consulted on its expectations and preferences for triage, and would your patients and/or their families understand and accept the necessity for triage and the reasons that they, or their relative, were being excluded from potentially life-prolonging treatment?
- Do you have access to protocols and guidelines for triage produced by your government and who would you contact directly at any hour of the day or night to take responsibility for providing guidance and clarification on these issues?
- Will the laws of your jurisdiction protect you for the triage decisions that it is your job to make on behalf of your community?
Why might it be that there is there so much resistance from governments to public discussion of triage decision making and the creation and release of documents?
While several colleagues have suggested that some of our leaders lack the courage to discuss triage publicly, we suspect, perhaps charitably, it is more likely that they are worried about the response of the community and/or, like most of us early in our medical careers, they too find talking about death and difficult choices to be very challenging. Unfortunately, as when parents are too embarrassed to talk about sexuality with their children, hesitancy to talk about triage and death is contagious and becomes a problem in its own right, tainting future discussions for everyone.
Unsurprisingly, people do get upset during conversations about their death, or the death of those close to them. And, like most of us, governments also fear that people will blame them, rather than the circumstances, for the distress that is evoked.
Our experience with difficult conversations in palliative care is that we must simply weather distress as a normal response. Over time, even those who have initially focused on the messenger rather than the message eventually feel much better having talked openly about an issue that they had already been worrying about. Countless conversations about inevitable death and the transition to a focus on the pursuit of achievable goals have led to the understanding of our role as being like the catalyst for a chemical reaction – sometimes we have to act as a disruptor of the status quo, and wear the heat, in order to arrive at a more stable state on the other side.
No doubt the many experienced clinicians who undertake this task with great sensitivity, compassion and dignity on a daily basis would be very willing to help our leaders to learn the art of such communication, as they have with countless health care workers in training.
Politicians and health service managers are much more comfortable offering than refusing, and may not be sure how to dampen community hopes and expectations for life-prolonging treatments. The prospective release of protocols for triage when health services are overwhelmed means deciding and revealing the criteria by which clinicians can discriminate (choose) between those who will and will not receive treatment.
Legal advisors to governments may feel that their role is to protect their employers (governments) from the risk that the community or individuals will find them legally responsible for the failure to provide services and pursue those grievances in the courts; that engaging in discussion or providing triage documents is an admission of failure that could be held against governments. However, in doing so, they are creating an unsafe workplace, also a potential legal risk for employers.
We suggest watching the 2015 movie Eye in the Sky for an understanding of the complexity of ethically challenging decision making and the personal burden carried by those who must implement decisions that result in death, and reading Breathtaking: inside the NHS in a time of pandemic (Clarke R; Little, Brown; 2021) to see how health care workers and their communities respond to both openness and obfuscation.
Those of us who work with dying people and their families know that difficult issues tend to get worse if not addressed. A failure by clinicians to talk about the realities of death and dying is, in the long run, far more distressing for patients and their families, and leads to unwise choices and poor outcomes. Done sensitively, candour resets our expectations and facilitates an understanding of the need to pursue achievable outcomes and supports wise choices.
Those who have engaged in broad and open community discussions about resource allocation and triage in disasters have found that, actually, consumers understand the challenges, value the opportunity to participate in discussions about the difficult issues, and are pleased that they can have input into how decisions will be made that may affect them, or their family, personally. Such discussions have also found that the opinions of community members provide different perspectives than those of health care workers or government policymakers.
COVID-19 and other disasters pose real threats that exclusionary triage will become necessary, even yet in Australia. Candid discussions about the nature of disasters as potentially overwhelming events may well cause some distress (probably far less than some might expect), but are necessary if we are to prepare an effective response as a community.
The failure of many governments to engage in challenging conversations about death and dying has left their communities disempowered and unprepared. We believe that, rather than becoming the subjects of extemporised decision making, most members of our community would prefer to be consulted about choices for those who are likely to benefit from, and those who will be refused life-prolonging treatment. They also want the clinicians who must implement the community’s preferences for exclusionary triage to have been given sufficient guidance and training.
The creation through open and public consultation of nationally standardised protocols for triage during disasters is important, not just for COVID-19, but for any of the other calamities that we might face without warning.
It is also in the interests of the community, of government and of clinicians that decision making in the real world of a disaster can operate within a legal framework that reflects the necessary shift in priorities from the rights of each individual to the interests of the community of individuals. Protection for those whose task it is to implement this unavoidable reorientation should be enshrined in law.
The responsibility for preparing for and responding to calamity, including publicly addressing difficult issues, rests with governments. It cannot be shifted to individual clinicians.
“The question of triage is on everyone’s mind,” said Zudin Puthucheary, a doctor and council member of the Intensive Care Society, a professional body. “Who’s going to be making those decisions? Because we’re not trained [or supported] to make them.”
Fourteen months ago, very few clinicians in the UK and the US would have imagined the roles they have been required to take on during this pandemic. Many will have deep emotional scars that will impact on their careers, and while economies may recover relatively quickly, the impact on health care delivery will take many years to repair.
Associate Professor Will Cairns is with the James Cook University School of Medicine and is Consultant Emeritus Palliative Medicine at Townsville University Hospital.
Rachel Coghlan is a researcher at the Centre for Humanitarian Leadership at Deakin University, a palliative care physiotherapist, and a Board Director of Palliative Care Australia.
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.