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Forum: Who Dies Who Doesnt Docs Decide

20 November 2006

Klatu – at 18:48

Who dies, who doesn’t: docs decide flu pandemic treatment guidelines

Monday, November 20, 2006 | 6:08 PM ET

The Canadian Press

A team of critical care doctors has come up with a tool their colleagues would hope never to have to use: a guide on how to make the life-and-death decisions about who not to treat during a flu pandemic.

The triage protocol, as it is called, suggests a scoring system that would see treatment withheld from people with the least chance of surviving in favour of helping those deemed to be more likely to pull through if they get care.

The protocol, published Monday in the Canadian Medical Association Journal, doesn’t suggest scoring the elderly more harshly based on age alone. But the authors admit advanced age could be a count against care in a future version of their decision tool.

This remains one of the areas requiring further research and community input.

http://tinyurl.com/y5ehx3

Klatu – at 19:01

Comments?

I’m-workin’-on-it – at 19:11

Scary! I figure though that most of these plans are going to end up giving a high priority to the age of an individual.

Jody – at 19:29

I fully expect that the rules will be re-written many times if the severity warrants it.

Klatu – at 19:31

I’m-workin’-on-it – at 19:11 wrote:

Scary! I figure though that most of these plans are going to end up giving a high priority to the age of an individual.


You may find that their authority/ability might be over estimated. Triage will not be restricted to the hospital. The rules of engagment may change.

Retired Paramedic MI – at 19:32

I was first trained as a medic in the US Navy. Hospital Corpsman.

Triage is the art of sorting wounded or sick patients.

The military view of triage as it was taught to me was, Help those first that can help you help others. A broken arm gets attention before an open abdomen.

The Civilian Paramedic view of triage is opposite,

The most injured/closest to death gets transported and treated first.

Somebody has to decide.

Klatu – at 19:33

Jody – at 19:29 wrote:

I fully expect that the rules will be re-written many times if the severity warrants it.


You read my thoughts.

f-w – at 22:05

Treatment may increase your chances during a killer pandemic, but it probably will hardly be a guarentee of survival. Especially as the pandemic continues and the available supplies and equipment are being used for prior patients…

21 November 2006

gharris – at 00:11

From the actual CMAJ paper:- http://tinyurl.com/y9o75q

Methods: We applied a collaborative process using best evidence, expert panels, stakeholder consultations and ethical principles to develop a triage protocol for prioritizing access to critical care resources, including mechanical ventilation, during a pandemic.

Results: The triage protocol uses the Sequential Organ Failure Assessment score and has 4 main components: inclusion criteria, exclusion criteria, minimum qualifications for survival and a prioritization tool.

Interpretation: This protocol is intended to provide guidance for making triage decisions during the initial days to weeks of an influenza pandemic if the critical care system becomes overwhelmed. Although we designed this protocol for use during an influenza pandemic, the triage protocol would apply to patients both with and without influenza, since all patients must share a single pool of critical care resources.


The recent outbreaks of avian influenza (H5N1)1–4 have placed a renewed emphasis on preparing for an influenza pandemic in humans.5,6 Developing plans to deal with the allocation of critical care resources, including mechanical ventilators, which will likely become scarce during a pandemic,6–8 presents a significant challenge. Health care systems in the developed world have rarely encountered the type of resource scarcities envisaged during an influenza pandemic. Models of the potential impact of a pandemic on the Ontario population predict that hospital admissions for influenza will peak at 1823 per day over a 6-week period. 9 This translates to 72% of the total hospital capacity being used by influenza patients. Similarly, the demand for intensive care unit (ICU) resources, solely for patients with influenza, would peak at 171% of current ICU bed capacity and 118% of the ventilator capacity. These figures do not take into account the current usage rate of critical care for patients without influenza, which is nearly at 100%. Nor does this model factor in the availability of human resources. Surge response strategies10 (e.g., scaling back elective procedures, opening additional critical care areas and implementing the use of “mass critical care”11,12) will partially mitigate the sudden demand for medical care during an influenza pandemic; however, these strategies will be inadequate to fully address the demands on the health care system.

Fiddlerdave – at 00:27

Interesting that that comes from a Canadian source. Their lives are much more complicated with national health care for everybody. Its simple here in the states. “Got money?” is the primary relevant question as to whether treatment is indicated. It at least eliminates 35% of the population. The mass closure of ER’s in the USA eliminates these questions nicely. Why does anyone think it will be different during a pandemic? Sure a few public ER’s will be overwhelmed, but the price of beds in non-ER facilities will simply be bid up until supply and demand equalize,and I am sure it will occur in facilities with ERs in a more subtle manner. Non-government health insurance won’t count, they will bankrupt by week 3. Cash or credit card ($100,000 deposit at least) will be best, perhaps a $5000 to $20,000 cash bribe to an admitting authority will be useful too.

You may think I am being facetious. I am not.

gharris – at 00:54

Fiddlerdave I am Canadian and I can tell you that money matters here too, despite our supposedly ‘free’ health care system - not just money but also power/social standing. We are not that removed from the British Class System. Slimy politicians and press barons get far superior health care than the average joe!

crfullmoon – at 11:01

Mass Casualty Event - pandemic influenza included See p 10,

p114 Palliative care chapter; stockpiling morphine and training how to give end-of-life care…

Providing Mass Medical Care with Scarce Resources

http://www.ahrq.gov/research/mce/mceguide.pdf

:-/

NP1 – at 11:44

Fiddlerdave – at 00:27 I know you are not being facetious,but the situation could be a lot more complicated than that. I know plenty of younger RNs who would not work and endanger their famlies for $100,00( or any amount) in that circumstance. If the CFR is high enough money will not buy love or life, let alone a vent with no guaranty of ever getting off of it! Kelly

FrenchieGirlat 12:36

As a mental exercise in triage, you might want to look at the scenarii posted on this thread and decide, if all cases described came together, which would you treat first? Ideas needed for Hospital Plan

And, at another level, you might want to ask your local “palliative homes” just how many morphia pumps they have… In my area, the only palliative home within a 100 kilometers had, in 2004, 14 (electronic) pumps only for 350 dying patients… At the local hospital down my street, they had one doctor, on half-time assignment covering two hospitals, for “pain assessment and control”. At another local hospital, I had to beg for end-of-life powerful medicines (not euthanasia) for my father, even though he was treated in his hospital with his nurses and his colleagues - so status and connections did not help. These were on special order from a provincial hospital 150 kilometers away, the medicines arrived too late as it took them 8 days to be delivered… All this is in a “civilized” country that prides itself on its medical care.

In UK, which is so criticized sometimes about its health care, at least they had a completely basic mechanical device, a syringe full of morphia with a spring, that helped greatly.

So, I have kept the morphia patches that were once ordered and not all of them were used… one never knows.

FrenchieGirlat 12:49

crfullmoon – at 11:01 - That document is very interesting. I hope you won’t mind my having added it to the Wiki Triage section, here

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