It's not an accident that patients often describe clinical care as cold, calculated, and unfeeling. However, the clinic is where doctors and nurses must make critical decisions under pressure. This includes which patients will be seen first and what type of care they receive. Triage is when resources such as oxygen, staff, oxygen and time are limited. The Dallas Morning News reported last week that several Texas hospitals were looking at major changes in how they do this. It begs the question: Is it sensible to consider the vaccination status of Covid patients? Given the ICUs being overcrowded with Covid-19 patients, and the shortage of nurses and beds, should clinicians care for vaccinated patients before or differently from those who are not vaccinated?
This hasn't happened yet, and it probably won't. This idea was inspired by a memo from North Texas Mass Critical Care Task Force, which is a regional group of doctors, nurses and other stakeholders. They developed procedures that hospitals can follow in times of crisis like a pandemic. The memo's authors rushed to clarify that they were not trying to push a new policy but just trying to communicate their thoughts. People are tired, angry, and exhausted. One of the most pressing questions is: If we were to make a triage decision about a patient's vaccine status, can we consider that? Robert Fine, a physician who was also co-chaired the team that wrote the memo on vaccine status. Fine claims that no decisions were made. We asked the task force to share our concerns with their ethics and triage committees, as well as your clinical care physicians, so that we can continue this conversation.
Fine mentioned that Fine was referring to the "Come on, we all thought it school of talking points" memo. This is a great thing! This would have been a worrying change to say the very least. No matter who the decision makers were, emergency rooms have to provide care for all patients. A hospital care guideline outlines the treatment that patients will receive after they are admitted. Texas does not have any statewide guidelines regarding critical care or triage. This means that local organizations are responsible for providing the best care. However, difficult times such as those caused by low vaccination rates or the Delta variant of the disease require a reexamination. The fourth wave of Covid hospitalizations is different from the previous ones because nearly everyone who is seriously ill is also not vaccinated. More than 12,800 people in Texas are hospitalized because of Covid-19. Between 93 and 98% of these patients are not vaccinated. It is tempting to put the blame for this outbreak on people who have not had their shots. This is what has been bubbling up: this anger, this frustrations, this fear and this worry. Each day we were witnessing the climb of the curve. Fine claims that it is now the steepest it has ever been. The task force leaders and I decided that these numbers were not good. These are the questions that keep coming up.
Yes. You get it, right? I feel great empathy for doctors and nurses. It's a horrible situation. They are working hard, but they're under tremendous stress. Patients and their families often lash back at them, which is why they don't appreciate it, says Bernard Lo. Lo is the director emeritus at UC San Francisco's Program in Medical Ethics and the author of Resolving Ethical Dilemmas: A Guide For Clinicians. It is difficult to care for people who think they could have done more.
Fine and Lo both readily admit that this is not the way triage should work. This is a complex medical and ethical issue. However, the simplest version of the matter is that the most effort is given to those most likely to survive. It's difficult to know what to do in advance. In areas most affected by the pandemic the triage process has been complicated because the disease affects different groups of people. To prevent clinicians from allowing their biases to influence treatment, triage guidelines exist to ensure that the treatment is fair and ethical in all ways. Worse, triage is not necessary if you have unlimited resources. Clinics with less funding have to do more triage, and are also more likely to see those most affected by the disease, due to their location and population served.
