Without triage guidelines we are flying blind

FEW of us would be happy boarding a flight if we knew that the pilots did not have the knowledge and skills to deal with both the predictable and the unexpected challenges that might threaten a safe landing.

Recently, I had a conversation with a pilot friend who (like many of his colleagues) is in the middle of recertification following a protracted stand-down due to COVID-19. Before they can crew an airplane again, every pilot must confirm their knowledge, demonstrate the collaborative skills and problem-solving abilities that are at the core of flight deck effectiveness, and refresh their complex practical skills of flying.

After a period of classroom learning and study, they embark on simulator training in which they are exposed to a wide range of challenging situations. We may imagine these might be familiar scenarios, such as engine failures and the aborted landings due to heavy rain or another plane lingering too long on the runway, which I have experienced several times. However, my friend told me that, while they do rehearse these, in reality they have no idea what challenges they will be posed when they roll up to the simulator. Their high-pressure training places a great emphasis on responding to circumstances about which they have little information and for which they must problem-solve using what they do know. The goal is to land safely, at which point the challenge has been met.

The management of an airline is responsible for ensuring that pilot training provides sufficient information and practical experience for a competent pilot to be able to solve solvable problems and maximise the likelihood that they will be able to retrieve an adverse situation, and that their pilots have achieved these training goals. An airline that failed to do this would lose its operating licence, and would be liable for any adverse consequences.

Jumping to the more complex domain of health care, we now find ourselves facing the possibility that our health systems will be overwhelmed by COVID-19, and that clinicians across a number of disciplines will have no choice but to engage in the dynamic challenge of triage.

The mix of the parameters that shape triage decisions changes continuously – the numbers of patients, the demographics of the patients who are seriously ill, the geographical distribution of patients, sociocultural mix of the patients, the scope and scale of the co-morbidities and pandemic morbidity of patients, the availability and skill mix of healthworkers, the availability of beds, ventilators and medications, the capacity to transport patients, the rules that are set to reduce transmission and the willingness of the population to adhere to them, and even the genetics and pathogenicity of the infectious agent.

As a consequence, decision making must adapt continuously and the clinicians who must make decisions about who will and will not be treated require a nuanced understanding of the grounds on which decisions should be made. Currently in Australia, the doctors who would be expected to undertake such triage (as is now happening in Alaska) have not been told on what grounds they should base their decision making, or given the time to prepare for doing it. Nor have they been given legal protection for undertaking what would be inescapably necessary.

Even though we have been warned repeatedly about the risk of our complex health system being overwhelmed, the community at large have also not been encouraged to prepare for that possibility. Many people would benefit from engaging in Advance Care Planning, both to consider their goals and preferences, and to understand the consequences for them should they develop severe COVID-19. Some would prefer not to receive intensive treatments such as ventilation in the intensive care unit. Others would discover from discussions with their doctor that they are already not well enough to survive intensive life-prolonging treatments for COVID-19 that would almost certainly cause them harm. Both they and the health care system would benefit from the early documentation of such treatment decisions in an Advance Care Directive. Many people also need a reminder to review their will and enduring power of attorney, something we should all do regularly, even if we are young and healthy.

Almost everyone I talk to as I move around our community is aware that being overwhelmed means that difficult choices of resource allocation and exclusionary triage will be necessary. Many older persons (such as me and many of my friends) believe that, appropriately, we will have a lower priority than younger and fitter people, particularly those with dependent children. Former patients who I have known since I was a GP talk about the conversations they have had with their spouses about prioritisation – one told me that their spouse had said that those who had refused vaccination should have a low priority. On a number of occasions over the past few weeks I have heard indigenous community representatives and disability advocates who were panel members on the ABC program The Drum raise their concerns that pandemic decision-making might disproportionately impact their communities.

One doctor from a remote community told me that, when they discussed triage with their team, they realised that in the absence of guidance from government, the community would know who had made triage decisions. Local clinicians would be held individually responsible for the consequences and this could create long term difficulties in their relationship with their community.

And we have already been hearing how the high proportion of exhausted and burned-out health workers who are reconsidering their longer term commitment to health care will threaten the workforce required for the huge challenge of the post-pandemic health care backlog. The burden of needing to make triage decisions without guidance, support or sanction has been a major contributor to this elsewhere in the world. And yet, here in Australia, the doctors, nurses, paramedics and others who will carry the responsibility of making and then telling patients and their families of their triage decisions have received no guidance or support.

For example, in NSW documents to support triage and resource allocation decision-making have been developed but have never emerged into the light of day. In Queensland, a working group including representatives of the Clinical Senate worked closely with Health Consumers Queensland, including through broad public consultation, to create the Queensland ethical framework to guide clinical decision making in the COVID-19 pandemic. This document was made available on the Queensland health website in April 2021. The authors of the Framework subsequently wrote a paper describing the process of consultation as an exemplar for dealing with triage and resource allocation planning. This was submitted and accepted by an international peer reviewed journal for inclusion in a special edition devoted to the response to the pandemic. Queensland Health quietly withdrew the Framework from its website after several months, and the article was withdrawn from the journal just before publication.

Perhaps it is time to ask our elected representatives and the state and national senior public servants responsible for health care why they have been so unwilling to engage in discussion about triage. They alone have the authority to gather the opinions of their community, consider the views of ethicists and other academic experts, and produce national and/or statewide triage guidelines for our community. To do so is a duty of leadership during a disaster.

The passengers of the Boeing737 MAX aircraft that crashed in Indonesia and Ethiopia would have reconsidered their journeys had they been told that their pilots had not been trained to be able to deal with the failure of a vital system that Boeing’s training manuals did not describe. Highly skilled practitioners in any field can only exercise their skills with competence and leadership if they are provided with sufficient information, support and authority — for an example of exemplary competence and leadership watch Captain Chesley [Sully] Sullenberger describe landing his plane on the Hudson River.

Unfortunately, we have already embarked on our pandemic journey. Doctors and other clinicians know that there is a very real possibility that they will need to engage in active triage (rather than the passive triage of treatment delay that is already in place). However, they have not been provided with the instructions and the support necessary to undertake this task in accordance with the preferences of their community. Without the release soon of guidelines for triage, it may be too late to prepare adequately, and the consequences will play out over many years.

Dr Will Cairns OAM is Consultant Emeritus at Townsville University Hospital and Associate Professor at James Cook 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.