Clinicians grapple with decisions in crisis-care simulation
If resource shortages became dire, triage team members would have to deprioritize some patients from getting life-sustaining care

Date:
April 18, 2022
Source:
University of Washington School of Medicine/UW Medicine
Summary:
A new analysis conveys the moral distress that triage team members
experienced while participating in a simulated crisis-care event
in which they had to decide which patients would and would not be
prioritized to receive life-sustaining resources.



FULL STORY ==========================================================================
The COVID-19 pandemic has led healthcare organizations to draft plans
for critical patient care in the event of shortages of resources such as ventilators. Invoking "crisis-care" standards at a hospital would prompt
the deployment of a triage team -- three or four seasoned clinicians
and a medical ethicist responsible to determine which patients have the
best chance of survival and prioritizing these people to receive scarce resources while deprioritizing others.


==========================================================================
If this task sounds tragic, you're in good company: A new analysis
conveys the moral distress that triage team members experienced while participating in a simulated crisis-care event in which they had to
decide which patients would and would not be prioritized to receive life-sustaining resources.

The paper was published April 18 in JAMA Network Open.

"This was a setting to try to operationalize a process for making
life-and- death patient decisions in a way that most medical professionals
have never faced before," said the paper's lead author, Dr. Catherine
Butler. She is an assistant professor of medicine (nephrology) at the University of Washington School of Medicine.

The qualitative analysis was based on interviews conducted from December
2020 to February 2021 with 41 triage-team members from hospitals in
Washington state. They had participated in 12 patient simulations and
their feedback informed the WA state Department of Health's guidebook
for critical care in response to potential extreme resource scarcity
during the pandemic.

The intention of the guidebook, Butler said, is to provide plans based
on empirical evidence and community deliberation that would standardize
the triage process, improve fairness, and reduce the emotional toil
involved in the grave deliberations for which triage team members might
be unprepared.



==========================================================================
The goal of the state's prep work was to clarify operational, clinical
and ethical issues and develop a standardized framework before invoking crisis-care standards. That way, triage teams would simply get a
limited set of data about patients, make a prognostic determination and objectively prioritize care, she said.

Triage-team members were solely asked to grade patients' chances of
surviving until hospital discharge. The decisions were based on far less information than would be the case in usual clinical care. Triage team
members, for instance, did not know personal information, such as race and gender, that might introduce bias into a decision to continue care. They
did not know how many other patients were competing for a scarce resource.

Triage-team members completed the task but, as the process unfolded,
they voiced uncertainty and misgivings about operational and ethical
aspects of their role. The analysis included quotes from participant
interviews (see comments in inset).

Participants also expressed tension between feelings of duty to
individuals and the bigger-picture responsibility to allocate resources
fairly, Butler said.

"Balancing your patient's priorities versus priorities of others is
quite hard for clinicians. You want to advocate for your patient, but
with crisis care you have to wear a different hat, one that looks across
all patients and prioritizes fair distribution of scarce resources at
a population level," she said.

Some triage-team members said the simulation presented parallels to their
work in busy emergency departments or in resource-limited countries,
where decisions are frequently based on providing care for as many
people as possible with limited supplies or staff. For these doctors,
the nature of the task was not entirely unfamiliar.

Still, Butler said, "our findings acknowledge that people in this
triage-team role will probably struggle with this difficult task,
no matter how much experience they have." In fact, some triage team
members felt that struggling with such a consequential decision was part
of their duty to respect the patients involved, she said.

"No one wants this [triage-team] job; it's not why anyone chose a career
in medicine. But we did hear from multiple participants that having a
more concrete idea of what is entailed in a simulation made them more
confident about being in these roles if they had to." This paper is
the last in a series of three in which Butler and colleagues studied
the development of plans for crisis-care circumstances.

* The first paper described a consensus-building process among
members of
the emergency preparedness community to decide on a set of patient
information items needed for the triage team's decisions.

* The second paper reported on the accuracy and consistency of
triage team
meetings including their ability to predict patients' prognoses
using this limited data set.


========================================================================== Story Source: Materials provided by University_of_Washington_School_of_Medicine/UW_Medicine.

Note: Content may be edited for style and length.


========================================================================== Journal References:
1. Catherine R. Butler, Laura B. Webster, Douglas S. Diekema, Megan
M. Gray,
Vicki L. Sakata, Mark R. Tonelli, Kelly C. Vranas. Perspectives of
Triage Team Members Participating in Statewide Triage Simulations
for Scarce Resource Allocation During the COVID-19 Pandemic in
Washington State.

JAMA Network Open, 2022; 5 (4): e227639 DOI: 10.1001/
jamanetworkopen.2022.7639
2. Megan M. Gray, Catherine R. Butler, Laura B. Webster, Mark
R. Tonelli,
Vicki L. Sakata, Douglas S. Diekema. Patient Information Items
Needed to Guide the Allocation of Scarce Life-Sustaining Resources:
A Delphi Study of Multidisciplinary Experts. Disaster Medicine
and Public Health Preparedness, 2022; 1 DOI: 10.1017/dmp.2021.351
3. Catherine R. Butler, Laura B. Webster, Vicki L. Sakata, Mark
R. Tonelli,
Douglas S. Diekema, Megan M. Gray. Functionality of Scarce
Healthcare Resource Triage Teams During the COVID-19 Pandemic: A
Multi-Institutional Simulation Study. Critical Care Explorations,
2022; 4 (1): e0627 DOI: 10.1097/CCE.0000000000000627 ==========================================================================

Link to news story: https://www.sciencedaily.com/releases/2022/04/220418120411.htm

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