Triage Ethics For Multiple Patients and Limited Resources

One of the most difficult challenges healthcare professionals can face is in a mass casualty incident with limited resources and multiple patients. In such cases we try and follow the principle, the greatest good for the greatest number of people. But sometimes this isn't so simple when it isn't an imminent question of life or death. The staff treating earthquake survivors at the Hopital Sacre Coeur in Haiti is dealing with such a situation and has sought the advice from the National Catholic Bioethics Center in Philadelphia. Here is the problem they face,

The National Catholic Bioethics Center received a call recently from a priest volunteering in Haiti at a Catholic hospital run by the Sovereign Military Hospitaller Order of St. John of Jerusalem, of Rhodes and of Malta. The hospital is facing critical decisions regarding the distribution of scarce medical resources among those in desperate need. They had only one ventilator, and the patient who was on it was consuming most of the hospital’s oxygen and needed round-the-clock attention by a physician. Everyone agreed that care for this one patient was making unavailable to others access to the hospital’s scarce resources. The problem was tragically reinforced later when an injured nineteen year old woman arrived who needed short-term ventilator support. Thirty more wounded, the priest said, were to arrive later that day. Inevitably, others would also need access to the one ventilator available at the hospital. “We have very little supplies here. The American physicians are not used to this. What should be done?” the priest inquired. “There is a feeling that the ventilator should be taken from the man in the unconscious state, but I reminded everyone that his life was no less important than any other here.”

In discussion, it became clear that an objective policy was needed to direct the use of their one critically-important ventilator that would apply equally to all patients, and that provided guidance for its use. However, an “objective” policy must also be flexible in order to be applied in such an extraordinary situation in which circumstances can change by the minute and patients of such varying conditions will be brought for treatment and care.

Some patients would benefit from short-term application of the ventilator; others would require long term use --- something impossible in the present circumstances. Furthermore, appropriate reassessments of patients on a periodic basis would be required in the event that a patient shows evidence of being able to benefit from limited medical resources. The hospital would need to determine, by established criteria such as those listed below, whether the patient shows evidence of being able to benefit from the use of the ventilator within a reasonable time frame. If evidence of improvement does not occur, the ventilator could be discontinued.

The crisis in Haiti has brought to light the importance of having policies in place to manage crisis situations. A clear policy would help physicians recognize the need to make careful judgments about who would best be helped by short-term use of the ventilator, and who would require more support than could be given. Policies also diminish the likelihood of arbitrary decisions being made which might appear as favoritism to some over others. We have provided, below, a set of criteria that could be used to guide such a policy. In all cases, when a decision has been made that a patient will not benefit from limited resources, appropriate palliative care should be provided.

Thankfully, more supplies, including another ventilator, will soon arrive at Sacre Coeur Hospital. The National Catholic Bioethics Center has been asked to remain on call for further ethics consultations from Haiti. We hope that the Center can assist the suffering people of that devastated nation and their care-givers by bringing the highly developed moral tradition and compassion of the Catholic Church to bear in these heart-breaking situations.

To see the ethical crieria developed by the NCBC you can visit their website.