March 2020
Differences between mass casualty triage and pandemic
31/03/20 14:36
New one-page MORAL Balance Framework
29/03/20 10:12
We have created a new one-page version of MORAL Balance.
It lacks the Balancing Box - but may allow for quicker use and documentation.
First - be clear about what decision you are trying to make.
Second - identify and Make sure of the facts and Outcomes of Relevance to the Agents (an agent is anyone who cares about or is impacted by the decision).
Third - Level out the arguments. Try and achieve a Balanced decision.
Fourth - document decision (use the framework to guide documentation or place this sheet in the notes)
It lacks the Balancing Box - but may allow for quicker use and documentation.
First - be clear about what decision you are trying to make.
Second - identify and Make sure of the facts and Outcomes of Relevance to the Agents (an agent is anyone who cares about or is impacted by the decision).
Third - Level out the arguments. Try and achieve a Balanced decision.
Fourth - document decision (use the framework to guide documentation or place this sheet in the notes)
UK intensivists are better prepared for the COVID moral test ahead
27/03/20 09:33
The below is the Ethicus 2 study. In the UK, for patients who die in the ICU, intensivists are nearly two times more likely to have made a treatment withdrawal decision compared to our Southern colleagues in Italy and Spain.
In Ethicus 1 (2003) we were 2.6 times more likely.
What can be seen is that Southern intensive care has become more like Northern intensive care over time.
Taking responsibility for actually making a decision regarding patient prognosis and discussing this with families and moving to comfort care and palliation. Rather than allowing nature to take its long course on an intensive care ventilator (holding death artificially at bay over many days) until an ‘outside force’ intervenes such as cardiac arrest or brain death occurs.
It’s about leadership, it’s about being willing and able to look yourself in the mirror at night, it’s about patient (minimising suffering) and family (not offering false hope) care.
UK intensivists have been trained for this, though the fear of overwhelming numbers and the moral distress we will all feel is very real at the moment.
The tragedy of COVID-19 is that our Southern friends and colleagues are being forced to learn this in days and weeks rather than over a culture change of years. Ethicus 3 will look very different, even after COVID-19.
The USA has its own set of problems (yep, huge ones) as well illustrated in the proposal.
https://www.health.ny.gov/regulations/task_force/reports_publications/docs/ventilator_guidelines.pdf
“A patient’s attending physician provides all clinical data to a triage officer/committee. At Steps 2 and 3, a triage officer/committee examines a patient’s clinical data and uses this information to assign a color code to the patient. The color (blue, red, yellow, or green) determines the level of access to a ventilator.”
Which has been repeated in this week’s NEJM
https://www.nejm.org/doi/full/10.1056/NEJMp2005689?query=RP
Where it is proposed that, “Rationing is performed by a triage officer or a triage committee composed of people who have no clinical responsibilities for the care of the patient.”
This is a derogation of responsibility and it won't work.
It comes from US system where intensive care doctors work for patients not with patients like we do in the UK.
Sadly, USA intensive care doctors seem not to be used to making patient decisions with families and want someone else to shoulder the moral responsibility.
Or like the NEJM paper says the responsibility in the triage committee will be application of exclusion criteria, such as:
NEJM also says, ‘Similarly, the physicians, nurses, or respiratory therapists who are caring for the patient should not be required to carry out the process of withdrawing mechanical ventilation; they should be supported by a team that is willing to serve in this role and that has skills and expertise in palliative care and emotional support of patients and families.”
Once again delegating responsibility and care to others.
I wonder if the problem is that intensivists in the USA not only work for patients and their families (rather than with) they also work for ‘ologists’.
Cardiologist, neurologist, pulmonologist and surgeons (not an ‘ologist’ but you get the idea).
See open (USA) and closed (UK, Australia) models of intensive care.
Who is even going to be on these triage committees? I would be astonished if it is an intensivist – someone who actually understands intensive care?
Leaving all that aside it just won’t work.
This committee will be death by magic number rather than individualised patient care.
They will not have all the facts and outcomes of relevance at their disposal to make individual patient care decisions.
Front line doctors will quickly learn they should just duck responsibility:
Family saying please save my relative.
Doctor says - if it was me yes - but not me - it is the panel that decides.
Families will quickly learn to game the system – learn the rules that are being applied and lie.
If you want to know who is better placed for the moral test of our time?
It’s here in the UK.
We have been making patient centred decisions for years in intensive care.
And we have the national leadership to support it.
Look and compare UK national intensive care guidance:
UK intensive care doctors will not be sacrificing what my own ethics committee recently restated for our Trust and the NHS; that even in a time of global pandemic we must prioritise the ethics of:
Dale
In Ethicus 1 (2003) we were 2.6 times more likely.
What can be seen is that Southern intensive care has become more like Northern intensive care over time.
Taking responsibility for actually making a decision regarding patient prognosis and discussing this with families and moving to comfort care and palliation. Rather than allowing nature to take its long course on an intensive care ventilator (holding death artificially at bay over many days) until an ‘outside force’ intervenes such as cardiac arrest or brain death occurs.
It’s about leadership, it’s about being willing and able to look yourself in the mirror at night, it’s about patient (minimising suffering) and family (not offering false hope) care.
UK intensivists have been trained for this, though the fear of overwhelming numbers and the moral distress we will all feel is very real at the moment.
The tragedy of COVID-19 is that our Southern friends and colleagues are being forced to learn this in days and weeks rather than over a culture change of years. Ethicus 3 will look very different, even after COVID-19.
The USA has its own set of problems (yep, huge ones) as well illustrated in the proposal.
https://www.health.ny.gov/regulations/task_force/reports_publications/docs/ventilator_guidelines.pdf
“A patient’s attending physician provides all clinical data to a triage officer/committee. At Steps 2 and 3, a triage officer/committee examines a patient’s clinical data and uses this information to assign a color code to the patient. The color (blue, red, yellow, or green) determines the level of access to a ventilator.”
Which has been repeated in this week’s NEJM
https://www.nejm.org/doi/full/10.1056/NEJMp2005689?query=RP
Where it is proposed that, “Rationing is performed by a triage officer or a triage committee composed of people who have no clinical responsibilities for the care of the patient.”
This is a derogation of responsibility and it won't work.
It comes from US system where intensive care doctors work for patients not with patients like we do in the UK.
Sadly, USA intensive care doctors seem not to be used to making patient decisions with families and want someone else to shoulder the moral responsibility.
Or like the NEJM paper says the responsibility in the triage committee will be application of exclusion criteria, such as:
- irreversible shock (ah yes, that is sort of obvious)
- assessment of mortality risk using the Sequential Organ Failure Assessment (SOFA) score (so its a magic number – Pallis said it right in 1983 “Many Americans have a touchingly naive faith in the supremacy of machines.”
- repeat assessments over time, such that patients whose conditions is not improving are removed from the ventilator. (Ok I accept this one but that’s the day job of an intensivist not a triage committee)
NEJM also says, ‘Similarly, the physicians, nurses, or respiratory therapists who are caring for the patient should not be required to carry out the process of withdrawing mechanical ventilation; they should be supported by a team that is willing to serve in this role and that has skills and expertise in palliative care and emotional support of patients and families.”
Once again delegating responsibility and care to others.
I wonder if the problem is that intensivists in the USA not only work for patients and their families (rather than with) they also work for ‘ologists’.
Cardiologist, neurologist, pulmonologist and surgeons (not an ‘ologist’ but you get the idea).
See open (USA) and closed (UK, Australia) models of intensive care.
Who is even going to be on these triage committees? I would be astonished if it is an intensivist – someone who actually understands intensive care?
Leaving all that aside it just won’t work.
This committee will be death by magic number rather than individualised patient care.
They will not have all the facts and outcomes of relevance at their disposal to make individual patient care decisions.
Front line doctors will quickly learn they should just duck responsibility:
Family saying please save my relative.
Doctor says - if it was me yes - but not me - it is the panel that decides.
Families will quickly learn to game the system – learn the rules that are being applied and lie.
If you want to know who is better placed for the moral test of our time?
It’s here in the UK.
We have been making patient centred decisions for years in intensive care.
And we have the national leadership to support it.
Look and compare UK national intensive care guidance:
- Ensure you have a shared understanding of what the problems are (e.g Covid is suspected; known heart disease requiring frequent hospital admissions with limited exercise tolerance, this means the patient is at high risk of severe illness and may die).
- Discuss what the likely outcomes are. Try to help the patient identify which outcomes are most important to them and their family.
- Be clear about what treatments are being proposed or available. If a treatment is not considered sufficiently beneficial to be offered, this will need communicating carefully and compassionately.
- Agree the proposed treatment plan and care you will be organising, for example treatment on the ward, treatment on intensive care, or links to palliative care.
- Include discussion of specific treatments that are important to the patient, e.g CPR.
UK intensive care doctors will not be sacrificing what my own ethics committee recently restated for our Trust and the NHS; that even in a time of global pandemic we must prioritise the ethics of:
- Individualised care decisions
- Shared decision-making
- Explanation
- Meet the health needs of non COVID-19 patients
- Have trust in NHS staff
Dale
Don’t let the ethics of despair infect the intensive care unit
26/03/20 11:22
MORAL Balance up on the Journal of Medical Ethics Blog.
Our thanks to David Shaw for leading this piece.
Our thanks to David Shaw for leading this piece.
The ethics of reverse triage or ventilator throughput.
26/03/20 07:56
There is lots of discussion in ICU circles about reverse triage.
It goes something like this:
“Two people need a ventilator, one is in the emergency department, young, needing intubation, the other is on the ICU, elderly perhaps, not doing so well. If they had both arrived into the ED simultaneously and there was only one ventilator; the ICU doctor would have triaged to treat the young person first. So, given the actual scenario, reverse triage suggests the ICU doctor should go up to ICU and remove the ventilator and adopt palliation for the current patient already in the ICU, to make the ventilator available for the young person in the emergency department who has a greater chance of benefiting.”
It’s attractive in its utilitarian simplicity but misunderstands triage which was designed for simultaneous mass casualties. Only in simultaneous mass casualties is it as simple as ‘one or another’.
It goes back to the typical ICU conundrum of the ‘last bed’. We wrote about this in our paper.
“The current resource limitations of the ‘last bed’ have a potential, rather than definite, ability to limit timely access to the intensive care for another patient (justice). Not infrequently, in analysing the situation using MORAL balance, additional options present themselves…. it might be that, on close examination, the last bed is illusory, and that additional resource can be found to accommodate the patient… However, in other circumstances, the last bed may not be illusory, but absolutely real [and] the facts and outcomes of relevance for the clinical scenario are altered. One can see how this might swing the balance leading to a different decision.”
We have found that the larger an ICU the more illusory the ‘last bed’ is.
The more ventilators you have the greater chance a change in one of your patients, for better or worse, will occur.
The better.
Don’t just focus on the admissions and ventilator numbers – focus on your ventilator throughput. The coming off of ventilation for ICU patients and making this as safe and swift as possible will be just as important as planning for who goes on. Try and be accurate in your assessment.
Who in your critical care is leading the ‘coming off’ group? It is just as important as the who gets admitted group.
The worse.
Let’s look at some simple numbers for worse.
(I appreciate someone cleverer than me could analyse this in more detail).
A tertiary referral 21 bed ICU, 100% occupancy (pretty standard in UK), ICU mortality 15%, mean length of stay for those who die 6 days. Died in ICU is 200 patients per year.
i.e. approximately 1 death every 2 days.
If we were to double the number of ICU beds and fill them with a similar cohort of patients, we might have one death / day.
But international COVID-19 data suggests 50% mortality, mean length of stay for those who die 4 days.
It’s not just one death / day but multiple deaths a day.
And ICUs are gearing up for 3-4 times greater number of ventilated beds.
Sadly, in this pandemic, and experience from Italy and Spain suggests, we are looking at a death every few hours.
A large number of beds mean a larger throughput.
Focus on those getting better, off a ventilator.
Focus on those getting worse, by reassessing their survival chances.
But don’t follow the Swiss guidance – “Patients in the ICU must be assessed regularly (at least every 48 hours) and interprofessionally.”
48 hours!
UK standard is twice a day consultant review – outside of pandemic situations.
Pandemic situations call for greater input, not less.
Here are our suggestions (and we know it is hard!)
Acutely
Assess ventilated ICU patients’ multiple times per day by a senior intensivist, with colleague and MDT support.
It goes something like this:
“Two people need a ventilator, one is in the emergency department, young, needing intubation, the other is on the ICU, elderly perhaps, not doing so well. If they had both arrived into the ED simultaneously and there was only one ventilator; the ICU doctor would have triaged to treat the young person first. So, given the actual scenario, reverse triage suggests the ICU doctor should go up to ICU and remove the ventilator and adopt palliation for the current patient already in the ICU, to make the ventilator available for the young person in the emergency department who has a greater chance of benefiting.”
It’s attractive in its utilitarian simplicity but misunderstands triage which was designed for simultaneous mass casualties. Only in simultaneous mass casualties is it as simple as ‘one or another’.
It goes back to the typical ICU conundrum of the ‘last bed’. We wrote about this in our paper.
“The current resource limitations of the ‘last bed’ have a potential, rather than definite, ability to limit timely access to the intensive care for another patient (justice). Not infrequently, in analysing the situation using MORAL balance, additional options present themselves…. it might be that, on close examination, the last bed is illusory, and that additional resource can be found to accommodate the patient… However, in other circumstances, the last bed may not be illusory, but absolutely real [and] the facts and outcomes of relevance for the clinical scenario are altered. One can see how this might swing the balance leading to a different decision.”
We have found that the larger an ICU the more illusory the ‘last bed’ is.
The more ventilators you have the greater chance a change in one of your patients, for better or worse, will occur.
The better.
Don’t just focus on the admissions and ventilator numbers – focus on your ventilator throughput. The coming off of ventilation for ICU patients and making this as safe and swift as possible will be just as important as planning for who goes on. Try and be accurate in your assessment.
Who in your critical care is leading the ‘coming off’ group? It is just as important as the who gets admitted group.
The worse.
Let’s look at some simple numbers for worse.
(I appreciate someone cleverer than me could analyse this in more detail).
A tertiary referral 21 bed ICU, 100% occupancy (pretty standard in UK), ICU mortality 15%, mean length of stay for those who die 6 days. Died in ICU is 200 patients per year.
i.e. approximately 1 death every 2 days.
If we were to double the number of ICU beds and fill them with a similar cohort of patients, we might have one death / day.
But international COVID-19 data suggests 50% mortality, mean length of stay for those who die 4 days.
It’s not just one death / day but multiple deaths a day.
And ICUs are gearing up for 3-4 times greater number of ventilated beds.
Sadly, in this pandemic, and experience from Italy and Spain suggests, we are looking at a death every few hours.
A large number of beds mean a larger throughput.
Focus on those getting better, off a ventilator.
Focus on those getting worse, by reassessing their survival chances.
But don’t follow the Swiss guidance – “Patients in the ICU must be assessed regularly (at least every 48 hours) and interprofessionally.”
48 hours!
UK standard is twice a day consultant review – outside of pandemic situations.
Pandemic situations call for greater input, not less.
Here are our suggestions (and we know it is hard!)
Acutely
- Stick the tube in (intubate) the young person – get someone to bag them.
- Wait, something is likely to change, for better or worse on the ICU, another option will materialise.
- Make individualised decisions for each patient.
Assess ventilated ICU patients’ multiple times per day by a senior intensivist, with colleague and MDT support.
- Focus on your ventilator throughput. The coming off. For better or worse.
- Duration of need for ventilation will swing the MORAL balance.
- But keep assessing, as accurately as you can, each ventilated patient as an individual.
A,B,D,C,Es of Good Communication
25/03/20 11:53
Adapted from NHSBT’s Deceased Donation Course for Intensive Care Medicine Trainees, which has provided end of life communication training to over 350 delegates and faculty. Download.
Additional Hints
Accuracy
- say truth, admit if you don’t know
- it is ok to mention resource constraints and its decision impact
Brevity
- don’t fill the silence with your voice
- in grief thinking slows, even on the phone allow silence
- listen and give time for questions, “What questions do you have?
Clarity
- use unambiguous language, simple non-medical words
- “can’t save, going to die, dying, won’t suffer”
Delivery
- structure as a narrative - warning shot (sets scene), circumstances (explains reasons, telegraphs decision), decision then silence
- use appropriate non-verbal technique, if phone tone of voice
Empathy
- explicitly state your sympathy “I am so sorry” “it is awful”
- give comfort
Additional Hints
- If an ethical framework was used to guide the decision, use the identified facts and relevant outcomes to help communicate the reason and decision and aid documentation.
- Think of the When (right time), Who (right people), Where (right place), What and Why (right content), How (right structure, right delivery).
- Prioritise trust (listener trusts your judgement) over knowledge (listener has a detailed understanding of the facts and reasons).
Don’t give into South Park Ethical Thinking
24/03/20 12:50
There is an episode in South Park – can’t remember which one, which goes something like this….
A blizzard hits South Park and some adults are stranded in a building.
They propose drawing straws and cannibalism in order to stay alive.
“What are you diabetic,” the short straw drawer begs.
They had only been stranded for a few hours!
COVID-19 will hit different regions and different hospitals, differently.
We must individualise our ethical response and use of resources.
Some patients – even non COVID patients – need our help now.
Don’t draw up the draw bridge of the hospital castle too soon.
Don’t lock out patients who are trying to get in, who you can still help.
For some of us the invading army is still days away.
Do what you can now.
Don’t give into South Park Ethical Thinking.
Dale
Pandemic Ethics are not just about COVID patients (Part 2)
23/03/20 09:28
An urgent question facing many NHS leaders in hospitals is, how do we meet the needs of non COVID-19 patients.
One such area is non COVID-19 cancer patients awaiting surgery?
How should one ethically prioritise these patients when resources (people, theatre space, ward and critical care beds, community help) are extremely limited.
A MORAL Balance Analysis can be viewed here.
My thanks to members of Nottingham University Hospitals NHS Trust's Ethics of Clinical Practice Committee who helped identify additional facts and outcomes of relevance.
Missing any facts or outcomes of relevance that you think are important? Would you weigh and balance differently? Come up with a different suggested checklist.
There are hundreds of these decisions needing to be made.
The MORAL Balance framework could be a tool that helps you.
Download a generic template and use. Even better send back to us and we will upload.
Dale
One such area is non COVID-19 cancer patients awaiting surgery?
How should one ethically prioritise these patients when resources (people, theatre space, ward and critical care beds, community help) are extremely limited.
A MORAL Balance Analysis can be viewed here.
My thanks to members of Nottingham University Hospitals NHS Trust's Ethics of Clinical Practice Committee who helped identify additional facts and outcomes of relevance.
Missing any facts or outcomes of relevance that you think are important? Would you weigh and balance differently? Come up with a different suggested checklist.
There are hundreds of these decisions needing to be made.
The MORAL Balance framework could be a tool that helps you.
Download a generic template and use. Even better send back to us and we will upload.
Dale
The Moral Test of our Generation
22/03/20 13:49
COVID-19 is the moral test of our generation.
I would see it as the biggest test since the Second World War.
It is testing us as a society – our health systems, our governments, our communities.
It is testing us as individuals.
My colleague Dr Harvey was concerned that many are failing the individual test.
This was his post on Facebook.
https://www.facebook.com/899475530/posts/10163357356595531/?d=n
Dale
I would see it as the biggest test since the Second World War.
It is testing us as a society – our health systems, our governments, our communities.
It is testing us as individuals.
My colleague Dr Harvey was concerned that many are failing the individual test.
This was his post on Facebook.
https://www.facebook.com/899475530/posts/10163357356595531/?d=n
Dale
Pandemic Ethics are not just about COVID patients (Part 1)
21/03/20 08:13
In all the talk, emails, What’s App messages, 24 hours a day media frenzy, you might start to believe that COVID patients are the only patients.
The other patients are still there…
Hoping they won’t need medical attention – perhaps delaying too long.
Hoping they can still get the treatment they need (operations, medications, a lifesaving transplant).
Hoping they can leave hospital as soon as possible.
I have been posed or overheard three ethical dilemmas in the last 48 hours. In none of these scenarios does the patient/s have COVID-19 but all are affected by the pandemic.
1. You're a surgeons doing a laparotomy for bowel obstruction tonight – do you create a stoma and perhaps have the patient out of hospital soon (if they can manage with a stoma bag at home) or carry out a primary anastomosis which may mean more time in hospital before the bowel is working (but less community input with stoma care)?
2. How do you prioritise patients in need of surgery for cancer now that theatre capacity has been given over to ICU COVID care?
3. Should a ward restrict the mobility, using chemical or physical restraint, of wandering patients who lack capacity during COVID 19?
The last one was posed to me by a group email from the UK Clinical Ethics Network.
I performed a MORAL Balance Analysis and sent it back. What do you think of the analysis?
Missing any facts or outcomes of relevance that you think are important? Would you weigh and balance differently?
That’s ok. Using the MORAL Balance framework does not mean we will all get the same answer.
It is tool for exploring and trying to objectify the ethical problem, identifying why and where differences of conclusions might be, and helping with final decision-making and documentation - because in the end a decision must be made.
Dale
The other patients are still there…
Hoping they won’t need medical attention – perhaps delaying too long.
Hoping they can still get the treatment they need (operations, medications, a lifesaving transplant).
Hoping they can leave hospital as soon as possible.
I have been posed or overheard three ethical dilemmas in the last 48 hours. In none of these scenarios does the patient/s have COVID-19 but all are affected by the pandemic.
1. You're a surgeons doing a laparotomy for bowel obstruction tonight – do you create a stoma and perhaps have the patient out of hospital soon (if they can manage with a stoma bag at home) or carry out a primary anastomosis which may mean more time in hospital before the bowel is working (but less community input with stoma care)?
2. How do you prioritise patients in need of surgery for cancer now that theatre capacity has been given over to ICU COVID care?
3. Should a ward restrict the mobility, using chemical or physical restraint, of wandering patients who lack capacity during COVID 19?
The last one was posed to me by a group email from the UK Clinical Ethics Network.
I performed a MORAL Balance Analysis and sent it back. What do you think of the analysis?
Missing any facts or outcomes of relevance that you think are important? Would you weigh and balance differently?
That’s ok. Using the MORAL Balance framework does not mean we will all get the same answer.
It is tool for exploring and trying to objectify the ethical problem, identifying why and where differences of conclusions might be, and helping with final decision-making and documentation - because in the end a decision must be made.
Dale
We can resist the ethics of Despair
19/03/20 10:41
We just need to remember that A,B,C comes before D.
Ask – when you are struggling either with a patient or just coping emotionally – ask for help, talk to those whose opinions you value. There are people who want to help us. The medical students of Nottingham just emailed saying – “Need some assistances with childcare (or anything else!)… Hundreds of Nottingham Medical Students have expressed a wish to support you as much as possible whilst our placements and teaching have been postponed.”
Brave – put on your brave face. That’s the ICU mask – brave and calm – even when the #£&% is hitting the fan. The more senior you are the braver you must be. Smile. It’s contagious. On my unit yesterday there was tension, there was fear but more smiles than I have ever seen.
Collaboration
ICU is a team sport. Work like it is. We can and will get through this.
Collaborate with others in the hospital – we are on the same side.
Collaborate with families – we are ALL on the side of the patient.
Clarity
Be clear in your mind with what you need. Be clear in your direction to others. Short emails, short messages.
Be clear with families. They know things are bad as much as we do.
Compassion
For each other, for our families, for our patients, for yourself.
Say thank you. Say I am sorry. Sometimes words are all we have. Sometimes they are enough.
Resist the ethics of despair.
KC,KS,WYH (keep calm, keep safe, wash your hands)
Dale
A
Ask – when you are struggling either with a patient or just coping emotionally – ask for help, talk to those whose opinions you value. There are people who want to help us. The medical students of Nottingham just emailed saying – “Need some assistances with childcare (or anything else!)… Hundreds of Nottingham Medical Students have expressed a wish to support you as much as possible whilst our placements and teaching have been postponed.”
B
Brave – put on your brave face. That’s the ICU mask – brave and calm – even when the #£&% is hitting the fan. The more senior you are the braver you must be. Smile. It’s contagious. On my unit yesterday there was tension, there was fear but more smiles than I have ever seen.
C - Remember your 3Cs
Collaboration
ICU is a team sport. Work like it is. We can and will get through this.
Collaborate with others in the hospital – we are on the same side.
Collaborate with families – we are ALL on the side of the patient.
Clarity
Be clear in your mind with what you need. Be clear in your direction to others. Short emails, short messages.
Be clear with families. They know things are bad as much as we do.
Compassion
For each other, for our families, for our patients, for yourself.
Say thank you. Say I am sorry. Sometimes words are all we have. Sometimes they are enough.
Resist the ethics of despair.
KC,KS,WYH (keep calm, keep safe, wash your hands)
Dale