{"id":1896,"date":"2020-04-03T15:40:32","date_gmt":"2020-04-03T19:40:32","guid":{"rendered":"http:\/\/web.colby.edu\/coronaguidance\/?p=1896"},"modified":"2020-08-04T15:43:17","modified_gmt":"2020-08-04T19:43:17","slug":"catholic-bioethics-ethical-triage","status":"publish","type":"post","link":"https:\/\/web.colby.edu\/coronaguidance\/2020\/04\/03\/catholic-bioethics-ethical-triage\/","title":{"rendered":"National Catholic Bioethics Center: Ethical Concerns with COVID-19 Triage Protocols"},"content":{"rendered":"<p class=\"\">Since the onset of the coronavirus pandemic, The National Catholic Bioethics Center has fielded numerous questions regarding COVID-19\u00a0triage protocols. We have reviewed a number of such protocols from both Catholic and secular sources; and while we do not question the need for appropriate policies or question the good motives of their authors, we do have concerns.<\/p>\n<p class=\"\">We offer this document to alert Catholic (and other) health care providers of elements within these protocols that may conflict with an institution\u2019s mission and Catholic identity.<\/p>\n<h2>GENERAL ISSUES OF CONCERN<\/h2>\n<ul>\n<li>\n<p class=\"\">Various protocols claim as their goal \u201cmaximizing population outcomes\u201d or \u201cproviding the greatest good to the greatest number.\u201d Such language is utilitarian. The Catholic moral tradition does not accept utilitarian principles as an independent or constitutive source of ethical guidance, because such principles can be used to justify actions that undermine the dignity of the human person. Health care professionals need to be aware of the utilitarian sources of these terms and carefully evaluate the means by which triage protocols seek to \u201cmaximize the greatest good.\u201d<\/p>\n<\/li>\n<li>\n<p class=\"\">Some protocols maintain that triage teams should not incorporate beliefs or ethical principles that are not specifically addressed in the protocol. This is problematic. The majority of protocols we have reviewed were written by secular sources and, as such, do not incorporate Catholic moral teaching in general or the principles of Catholic health care ethics in particular (see the USCCB\u2019s <a href=\"http:\/\/www.usccb.org\/about\/doctrine\/ethical-and-religious-directives\/upload\/ethical-religious-directives-catholic-health-service-sixth-edition-2016-06.pdf\" target=\"_blank\" rel=\"noopener\"><em>Ethical and Religious Directives for Catholic Health Care Services<\/em><\/a>). The NCBC stresses that any COVID-19\u00a0triage protocol must be implemented in accord with the Catholic moral tradition.<\/p>\n<\/li>\n<\/ul>\n<h2>TRIAGE TEAMS<\/h2>\n<ul>\n<li>\n<p class=\"\">Protocols we have reviewed typically call for the creation of a triage team (or committee) whose purpose is to evaluate COVID-19\u00a0patients and, utilizing objective clinical indicators, to prioritize which patients will receive critical care treatments, most notably a ventilator. This triage team is also frequently charged with determining\u2014again based on clinical indicators\u2014when clinical care interventions ought to be withdrawn. The NCBC holds that triage teams can be morally justified. They can help ensure objectivity in decision making, minimize conflicts of interests, and mitigate moral distress for the care team. The NCBC recommends that an ethicist or a member of the hospital ethics committee be included on the triage team.<\/p>\n<\/li>\n<li>\n<p class=\"\">Some protocols offer the doctor, patient, or family members the ability to appeal a triage team decision. The NCBC suggests that protocols explicitly allow care team members to advocate for their patients during such an appeals process. This will foster transparency, level the playing field regarding medical knowledge, and ensure that any concerns that may have not been adequately addressed are heard and reviewed.<\/p>\n<\/li>\n<\/ul>\n<h2>CRITERIA FOR DETERMINING PATIENT PRIORITY SCORES<\/h2>\n<ul>\n<li>\n<p class=\"\">Patient priority scores for critical care resources allocation should be determined using objective clinical criteria for short-term survival, such as Sequential Organ Failure Assessment (SOFA) or similar. Categorical exclusions based solely on an individual\u2019s age, disability, or medical condition (if it does not impact short-term COVID-19\u00a0survival) constitute unjust discrimination and are immoral.<\/p>\n<\/li>\n<li>\n<p class=\"\">Various protocols we have reviewed calculate a patient\u2019s priority score using (1) \u201clikelihood of short-term survival\u201d based on SOFA (or similar) score, and (2) \u201clikelihood of long-term survival\u201d based on the presence or absence of comorbid conditions. Likelihood of long-term survival and the assessment of comorbid conditions deserve attention for the following reasons:<\/p>\n<\/li>\n<\/ul>\n<ol>\n<li>\n<p class=\"\">Little if any indication is offered for what \u201clikelihood of long-term survival\u201d means within the context of assigning priority scores to COVID-19\u00a0patients. How does a triage team objectively apply \u201clikelihood\u201d as a criterion? How long is \u201clong-term,\u201d and do <em>more years<\/em> of long-term survival outweigh <em>fewer years<\/em> of long-term survival? Answering these questions becomes a utilitarian calculus, a values-laden judgment about a patient\u2019s quality of life in the longer term, well beyond the acute situation.<\/p>\n<\/li>\n<li>\n<p class=\"\">Protocols state that the presence or absence of a comorbid condition \u201cmay influence\u201d a patient\u2019s survival. Again, these offer little or no indication about what \u201cmay influence\u201d means, particularly in a triage setting. In addition, no discussion examines whether \u201cmay influence\u201d offers sufficient justification for including comorbidity as a criterion for determining priority score.<\/p>\n<\/li>\n<li>\n<p class=\"\">The protocols offer examples of comorbidities that may influence survival, but they never provide an exhaustive list. (Some acknowledge this fact.) What objective criteria are being used to determine the comorbidities identified in the protocols versus those that are not?<\/p>\n<\/li>\n<li>\n<p class=\"\">Specific comorbidities listed in the protocols include the qualifiers \u201cmoderate\u201d and \u201cmoderately severe.\u201d What exactly do these terms mean? How does a triage team objectively apply them to determine a patient\u2019s priority score?<\/p>\n<\/li>\n<\/ol>\n<ul>\n<li>\n<p class=\"\">Each protocol we have reviewed states that age is not an exclusionary factor for receiving critical care. However, in some protocols age actually becomes a factor through \u201ctie breaker\u201d determinations. Certain protocols state that in situations involving a priority score \u201ctie\u201d between two (or more) patients, age becomes the deciding factor for which of them receives critical care. The terminology varies in different protocols (\u201clife-cycle principle,\u201d \u201csaving the most life-years,\u201d \u201cexperience life-stages,\u201d \u201ccycles of life,\u201d or \u201cequal opportunity to pass through the stages of life\u201d), but the operative principle is the same: decisions about who will, and will not, receive critical care are based on age.<\/p>\n<\/li>\n<\/ul>\n<h2>WITHDRAWING CRITICAL CARE INTERVENTIONS<\/h2>\n<ul>\n<li>\n<p class=\"\">Various protocols state that physicians can withdraw critical care from patients who they believe have no chance at survival <em>regardless<\/em> of the patient\u2019s or the surrogate\u2019s wishes. While some circumstances might warrant a physician\u2019s order to cease critical care interventions, this cessation should only happen after appropriate communication with the patient or surrogate about the triage situation and the medical recommendation. This communication should include the burdens and clinical expectation of no recovery and offer the patient or surrogate the opportunity to voluntarily discontinue the intervention. After appropriate communication and opportunity for voluntary discontinuation, and in light of a triage situation in which others\u2019 lives are at stake, physicians should be able to override unreasonable patient or surrogate demands to continue intensive care support.<\/p>\n<\/li>\n<\/ul>\n<h2>DNRS<\/h2>\n<ul>\n<li>\n<p class=\"\">Various protocols allow physicians to unilaterally assign a code status of \u201cdo not resuscitate\u201d (DNR) to critically ill COVID-19\u00a0patients. Such a unilateral decision could be problematic if the DNR order is implemented without any input from the patient or surrogate, or if such an order is implemented universally among patients with COVID-19\u00a0solely on the basis of their COVID-19\u00a0diagnosis. However, in a crisis situation that offers no opportunity to communicate with the patient and\/or surrogate, physicians should be able to place DNR orders under a triage protocol when the clinical facts offer no reasonable expectation of recovery from resuscitation.<\/p>\n<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>[April 3, 2020]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Since the onset of the coronavirus pandemic, The National Catholic Bioethics Center has fielded numerous questions regarding COVID-19\u00a0triage protocols. We have reviewed a number of such protocols from both Catholic and secular sources; and while we do not question the need for appropriate policies or question the good motives of their authors, we do have [&hellip;]<\/p>\n","protected":false},"author":10812,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"ngg_post_thumbnail":0,"footnotes":""},"categories":[514272],"tags":[],"_links":{"self":[{"href":"https:\/\/web.colby.edu\/coronaguidance\/wp-json\/wp\/v2\/posts\/1896"}],"collection":[{"href":"https:\/\/web.colby.edu\/coronaguidance\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/web.colby.edu\/coronaguidance\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/web.colby.edu\/coronaguidance\/wp-json\/wp\/v2\/users\/10812"}],"replies":[{"embeddable":true,"href":"https:\/\/web.colby.edu\/coronaguidance\/wp-json\/wp\/v2\/comments?post=1896"}],"version-history":[{"count":1,"href":"https:\/\/web.colby.edu\/coronaguidance\/wp-json\/wp\/v2\/posts\/1896\/revisions"}],"predecessor-version":[{"id":1897,"href":"https:\/\/web.colby.edu\/coronaguidance\/wp-json\/wp\/v2\/posts\/1896\/revisions\/1897"}],"wp:attachment":[{"href":"https:\/\/web.colby.edu\/coronaguidance\/wp-json\/wp\/v2\/media?parent=1896"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/web.colby.edu\/coronaguidance\/wp-json\/wp\/v2\/categories?post=1896"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/web.colby.edu\/coronaguidance\/wp-json\/wp\/v2\/tags?post=1896"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}