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Ethical triage, where vulnerability means increased risk, not certain death

Much has been written and reported globally about heart-rending decisions made by health professionals in the face of a COVID-19 surge on who will receive intensive care treatment and who will miss out.

The Health Issues Centre (HIC), a peak consumer health advocacy group, has been concerned that “conspicuously missing” from the ethical discussions around such decisions has been the voices of consumers, “those who will be most impacted by bedside decisions made in emergency rooms”.

HIC last week hosted an online consumer forum of experts and  representatives from at risk groups to discuss the ethical issues now arising. Its communications consultant Heather Potter reports below on the discussions that emerged from the COVID-19 Ethical Triage Forum.


Heather Potter writes:

Experts presenting at an online forum to discuss ethical triage during the COVID-19 crisis have sought to reassure at risk consumers that the disease is not a death sentence.  

Hosted by Health Issues Centre on April 2, the event was intended to give community representatives of vulnerable groups such as the elderly, people with disabilities and those with comorbidities an opportunity to feed into the discussion about triage decision-making.

More than 200 people participated, many representing groups that fear they may be the first to miss out on scarce resource allocation if hospitals become overwhelmed. Also participating were representatives from state government and health services, universities and researchers. 

Health Issues Centre CEO Danny Vadasz

Opening the discussion, Health Issues Centre CEO Danny Vadasz said the event was critically important to ensuring that consumer voices were part of the discussion which, unsurprisingly, had to date been dominated by clinicians, academics, researchers and policy advisors and yet to air the concerns and perspectives of vulnerable groups.

“This may be the only opportunity for vulnerable communities to influence these life and death decisions,” Vadasz said, acknowledging the enormity of the challenge facing the forum. 

“As the reality of rationing intensive care resources looms as a probable scenario, the question of how triage decisions will be made is no longer a dystopian hypothetical,” he said. 

“Today is going to be the most difficult thought experiment you have ever engaged in. I don’t know how far we can get toward achieving a useful result. But we owe it to the vulnerable and the disadvantaged in our society, who are most likely to bear the impact of COVID-19, to give it a red-hot go.”  

His sentiment was echoed by leading ethicist Dr Paul Komesaroff, from the Faculty of Medicine, Nursing and Health Sciences at Monash University, who said:

“If we have values worth defending, this is the time we need to fight for them,” he said. 

“We will be judged by future generations on how we respond to the present crisis. We need to keep our ethical nerve.” 

Dr Paul Komesaroff

Confrontation and reasons for hope

Professor Charlie Corke, President of the College of Intensive Care of Australia and New Zealand, talked to the forum about the confronting experience faced by the very small proportion of patients who would develop serious symptoms and be admitted to intensive care units – and those tasked with caring for them.  

“What we do to patients with this personal protective equipment on, when everyone is terrified of you, doesn’t want to touch you, doesn’t want to go near you, has to wear all this stuff – it’s pretty dehumanising,” he said.  

“It’s hard to have humanity in all this. And isolation on your own is frightening. 

“Everything we have to face will be very confronting. Committees to back up (triage) decisions may be very helpful, but the evidence is that committees don’t do particularly better than doctors … these decisions are not easy.”  

Professor Corke said the experiences of hard-hit locations like the US showed that even the most vulnerable patients could experience quite mild symptoms and recover, giving reason to be optimistic. 

We know that this disease is worse with increasing age and increasing co-morbidities and increasing frailty but it’s not all bad,” he said, having earlier sought to calm fears expressed at the forum about the fate of those with a lung disease. “It’s not a death sentence,” he told them, “we do have treatment options”.  

Professor Charlie Corke

Professor Corke discussed the profile of a number of patients diagnosed with COVID-19 in long-term care in Washington State in the US: of the 101 patients, their mean age was 83, 94 of them had chronic underlying conditions and there was a one third mortality amongst them.  

“But I was impressed not by the one third mortality but the two thirds who didn’t die; and a lot of them had very mild symptoms, he said.

“So I think we can all take away that there is the opportunity with this disease to be lucky and (dying is) not an inevitability.”

Need for a clinical mindshift

Cathy Mead, board member and former president of Council on the Ageing (COTA) Victoria, was a voice for older Australians on the panel. She said managing the crisis would require a mind-shift from clinicians. 

 “We are in the process of adding to duty of care the duty to manage scarce resources and that’s a shift that clinicians are going to have to make,” she said.  

 “And we make the shift by saying ‘all patients are eligible for care’ and then we consider how to prioritise that care. 

 “There should be no social criteria for exclusion from treatment but there may be some social criteria for inclusion and priorities. For example, we might want to give priority to healthcare workers. We might want to give priority to Indigenous people.”

Cathy Mead

Health Issues Centre Board Chair and consumer expert Sophy Athan said consulting the community was a vital part of developing an effective response to a major health crisis and she hoped the forum’s discussion would inform future planning and preparedness. But she expressed her frustration that there was so little evidence of progress over the past decade.

 “There’s been discussion over the last ten years that we are anticipating a pandemic … so we have had sufficient warning. My question is, could we have prepared a little bit better?” she said.  

“This is the beginning of potentially some further health crises that could be emerging in the future. We need to not only engage in the conversation but we actually need to have these policies in place for the future.”  

Who should make triage decisions?

Professor Vasi Naganathan, academic at the University of Sydney and expert geriatrician shared research he had been involved in that studied how Australian and New Zealand residents felt triage decisions should be made in the event of a flu pandemic.  

 The research showed consumers had a clear preference for doctors to make triage decisions – informed by present circumstances – with guidelines from health departments as a close second.  

Professor Vasi Naganathar

Professor Naganathan also raised the issue of whether assessment tools would assist clinicians in making decisions at the pointy end of care.

“Age does come into it because older people are more likely to have health problems, multiple diseases and frailty. So do you use a tool for frailty? Do you use a tool to determine how sick someone is?,” he said.  

 “The problem with all tools is they tell you what a group will do. They’re not particularly accurate for the individual and a lot of people forget that.

“One of the concerns that geriatricians have is that the tools that are used for older people will be used for people with disability … and it’s important to not think about people with disability in the same way as older people with comorbidity and frailty.  

“But there is an appetite for using tools because people feel that it provides some clear guidance for what people should do.” 

Following the plenary session, attendees divided into smaller online breakout groups to discuss issues and formulate key principles or recommendations. Health Issues Centre is now reviewing and collating these and will publish a communique reflecting the most common sentiments. 

You can watch a video of the plenary session here and follow the Twitter discussions via the #HICcovidforum hashtag.

Feedback and questions from the session are also being collated and full responses will be published on the Health Issues Centre website, with links from our social media pages.

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