Formula for rationing care: Task forces plan for disaster

The deadly aftermath of Hurricane Katrina and concerns about a pandemic avian influenza have driven disaster preparedness and surge capacity planning, but physicians and others are starting to wrestle with perhaps an even trickier set of issues.

What if, despite efforts to ramp up capacity and provide disaster response at the local, state and federal levels, the number of seriously ill patients exceeds the supply of critical care resources needed to keep them alive? Who should get care?

Perhaps the dilemma would be most acute in an influenza epidemic, when 30% to more than half of infected patients could require ventilator-assisted breathing -- far outstripping availability of machines.

Two recently published reports by physician-led task forces spelled out objective clinical criteria to determine who would be eligible for ventilators and other critical care resources and how to prioritize that use. The central ethical principle underlying the guidelines is that resources should be allocated to patients with the best odds of survival.

The larger idea, experts said, is to devise an acceptable ethical framework to save the most lives, help protect physicians from legal repercussions and enhance public confidence in the health system's response.

"It's extremely important to examine this as scientifically and rationally as possible before an event because once an event happens, we are not going to have the luxury of time to sit back and look at how to allocate limited resources," said Kristi L. Koenig, MD, director of public health preparedness at the University of California, Irvine, School of Medicine.

"We will need to know ahead of time the logistics of how to optimize outcomes for a population of patients," said Dr. Koenig, speaking on behalf of the American College of Emergency Physicians. "We will no longer be able to focus solely on rescuing the individual patient, but rather on doing the most good for the most people and saving the most lives."

A rationing algorithm

A 58-page May supplement to the journal Chest featured the recommendations of a 37-member task force spearheaded by the American College of Chest Physicians and drawing representatives from the U.S. Dept. of Health and Human Services, Centers for Disease Control and Prevention and other organizations. Most of the suggestions focus on how to prepare for a mass-casualty disaster and ramp up capacity once it hits, but the report also offers advice on disaster triage and resource allocation.

"Surge first, that is the focus," said Asha V. Devereaux, MD, MPH, lead author of the Chest resource-allocation article and a Coronado, Calif., critical care physician. Rationing "should never need to happen. The goal of this is that you're so prepared that this thought would be obsolete."

But should a regional triage panel determine that medical need exceeds supply, the Chest report recommends denying or taking off ventilators patients with a greater than 80% chance of dying in the hospital. That decision would be made using the Sequential Organ Failure Assessment score, which measures levels of oxygenation, platelets, bilirubin, hypotension, consciousness and creatinine.

Care would be prioritized according to the patients' most recent SOFA score and the daily trend of that score. The criteria are intended to be fair to all patients, with no special access to resources for people such as health care workers, police or firefighters.

The criteria would be adjusted constantly by the central triage committee in response to changes in the availability of critical care resources, alleviating front-line physicians of those decisions. Patients exceeding the survivability threshold would receive palliative care.

The Chest supplement is the latest in a series of efforts to lay out ethical criteria for rationing critical care in a major disaster. A Nov. 21, 2006, Canadian Medical Assn. Journal article recommended using SOFA scores to ration care. Canadian doctors and ethicists are especially attuned to the problem after a severe acute respiratory syndrome epidemic that killed 43 Canadians in 2002 and 2003.

In March, similar recommendations from the New York State Dept. of Health's Task Force on Life & the Law were published in the AMA's Disaster Medicine and Public Health Preparedness journal. "There is a large degree of consensus, but lots of room for additional research," said Tia Powell, MD, executive director of the New York task force.

The AMA has policy on the ethics of quarantine, but none on rationing critical care resources in a disaster.

Dr. Powell and others said the new disaster standards can be implemented only with a green light from state governments that give legal protection to physicians and other health professionals who follow the guidelines in good faith.

But not everyone agrees with the proposed guidelines.

"The disaster mind-set has to be about getting the greatest good for the greatest number, not who we exclude and how we ration," said John H. Armstrong, MD, a trauma surgeon at the University of Florida and a member of the AMA disaster medicine journal's editorial board. "These situations are very dynamic, so we need more of a discussion about how we make decisions rather than guidelines which can take on the flavor of absolutes. Absolutes really don't work."

Dr. Armstrong and others said the reports focused too heavily on the ethical ramifications of pandemic flu. Future plans should address other mass-casualty disasters, such as massive high-energy explosions, he said.

Bioethicist Thomas H. Murray, PhD, a New York task force member, said working through allocation choices now is the right thing to do. Not to do so, he said, would "be a failure of planning, a failure of nerve and a failure of conscience."