“I would never have thought I would have to experience the necessity of triage again in my life,” an older colleague who remembers well the grim events of the Second World War said to me recently. Hardly anyone, including myself, could have imagined even a few weeks ago that we would experience the need for triage to be practised in our part of the world. Yet it is now commonplace in medical facilities in the North of Italy and Alsace, and hospitals in Austria, Germany and elsewhere are preparing to have to implement it as well. What follows is a reflection on the challenges that the practice of triage, which has its origins in emergency medicine in war-time, present from a medical-ethical perspective as well as conceptually.
Triage is the process of allocating resources in such a way that as many patients as possible can be treated as efficiently as possible in situations where there is an unexpectedly high number of patients and where medical resources are so limited that it is not possible for all patients to be treated appropriately. Criteria need to be established for the just distribution of the available medical resources in this exceptional emergency situation. This means prioritising and rationing the medical resources available by deciding whose treatment should be prioritised and whose treatment should not.
The term itself comes from the French trier, meaning to sort or to classify and was developed in medicine as practised originally in warzones and later in the context of responding to catastrophes. Concretely, it enabled decisions to be made about which wounded soldiers or those injured in catastrophes should be assisted first before a detailed diagnosis of the type and severity of their injuries could be undertaken. However, in the meantime, the term has become established in medicine in the general sense mentioned above, even if the conditions under which triage takes place, for example in the context of the Covid-19 crisis, differ from that of a war or acute disaster situation.
The Covid-19 crisis is not a war situation, as I will explain below. Further, it is only partially comparable with an acute disaster situation because the Covid-19 crisis has been foreseeable at least for several weeks and therefore preparatory steps to avoid triage situations arising were, and still are, possible.
It is therefore vital that every effort is made immediately to increase medical capability. It is not only about the provision of resources for intensive care medicine, but also about the most prudent and financially responsible application of medical resources outside of intensive care medicine that can be deployed to treat Covid-19 patients in this emergency situation.
It is also important that all people working in the healthcare sector, especially those who come into direct contact with patients – such as doctors, nurses, triage teams – are protected as much as possible from infection by personal protection equipment. This is not only for personal reasons, that is, to protect their own health, but also to ensure that the healthcare system can continue to function even in a time of crisis and that the sick get the care they need.
From an immunological point of view, urgent measures must also be taken to interrupt the chain of infection as effectively as possible. Ideally, this includes mass testing. Individuals who are infected should not be identified and isolated only when they develop symptoms of the disease, but even earlier. In fact, and more importantly, those individuals who are infected yet asymptomatic must be identified and isolated. It is also the personal responsibility of every single citizen to follow strictly measures to prevent infections such as hygiene, keeping physical distance, etc.
In the event that triage becomes inevitable it must be based on clearly defined criteria and must not be at the personal discretion of the doctors or the team tasked with carrying out the triage. In this way the personal burden of having to make triage decisions should be eased. It will also be eased by ensuring that such decisions are taken by a team, preferably consisting of at least two intensive care physicians, a nurse and possibly other specialist staff.
The criteria must be communicated openly and transparently and those required to implement them should have an opportunity to discuss them. This is necessary in order to achieve the broadest possible shared consensus, on the one hand, and to convey to (potential) patients and their relatives a sense of confidence, on the other. Both aspects are required in order to guarantee trust in the health care system which can only function in this exceptional situation if there is trust and solidarity.
Finally, it must be ensured that if a triage situation becomes inevitable, fundamental medical-ethical and moral dimensions are observed and followed. This means in the first instance that decisions in relation to patient care continue to be taken based on medical criteria, taking into account the wishes of patients and their current clinical condition. The usual prognostically relevant scores should be applied. In a triage situation, the clinical determination of comorbidities and the general clinical condition of the patient (in the sense of clinical frailty) plays a role insofar as these are relevant for the prognosis. The patient’s age can also play a role in the prognosis and in determining risk of mortality.
However, I consider it essential that these aspects, namely, comorbidities, frailty, age etc. do not in themselves constitute criteria for excluding patients from treatment in the sense of generalised criteria for maximising efficient use of resources. The principle of justice cannot be set aside and neither can the need for the most individualised assessment of a patient’s prognosis that is possible to determine in the circumstances. The decision to treat patients differently must be justified on medical grounds such as urgency and the prospect of a successful outcome.
It seems to me to be ethically legitimate to presume that comorbidity, frailty or older age adversely affect therapeutic outcomes only in the circumstances where it is no longer possible to determine the urgency and prospect of success of intensive care treatment, likelihood of survival, etc. in several patients admitted at the same time. This will be due solely to time pressure in such exceptional situations. I would consider any other approach in a healthcare system that must be committed to the dignity and well-being of each individual patient to be a first step down a slippery slope towards utilitarianism. Discrimination on the grounds of age or against specific social groups and categories of patients must be avoided.
Exceptional circumstances might determine that the best possible treatment with the most likely successful outcome cannot be provided to individual patients. This may be because the treatment needed by other patients or the limitations of the healthcare system as a whole must be taken into account. In such situations the fundamental principle of natural justice pertains.
Another problem in triage situations is whether it is permissible to discontinue the intensive medical treatment of a patient with a poor prognosis in order to treat a patient with a more favourable prognosis. I consider – again in accordance with the principle of justice – that in a triage situation the continuation of intensive medical treatment of a patient with a poor prognosis, with the consequence that a patient with a more favourable prognosis would remain untreated or would have intensive medical treatment delayed, needs a stronger justification than in comparable situations outside of triage conditions. The actual proportionality of intensive medical treatment of a patient with unfavourable prognosis in such concrete cases requires not only the evaluation of the individual patient’s progress in treatment, but must also consider the equal rights other patients have to receive intensive medical treatment according to their medical needs and prognosis.
To conclude, I would like to deal with the issue of comparing the COVID-19 crisis to a war. This is not just about the use of the concept of triage, which – as already shown – was originally used in war-time medicine. It is striking that in many instances discussions and political debates refer to us being “at war”; that doctors and nurses are “on the front line”; that “war-like conditions” exist in hospitals; also, that appropriate measures can be seen as a “bazooka” against the Covid-19 crisis, etc. I share the concern expressed by Berlin Mayor Michael Müller, among others. He criticized the use of “drastic war vocabulary” as “reckless, dangerous and irresponsible” because it “unnecessarily increases and stirs up fears”. In any case, such rhetoric doesn’t help to counter the sense of extreme threat and helplessness many people are currently feeling or help them to feel any more secure. It should also be noted that war rhetoric and people’s anxieties can also easily be manipulated in order to justify legal measures and to enact regulations that restrict or override basic democratic rights at least temporarily.
However, given that legal measures restricting people’s democratic rights are currently being enacted in many countries I believe that not only careful attention should be paid to the language we use and its impact, but also to the following aspects:
- That the procedures being enacted are adhered to meticulously in accordance with the rule of law; that decision-makers do not exceed their competencies; that the separation of powers under the rule of law is respected and that democracy is protected – taking into account also possible long-term consequences of measures and procedures restricting people’s democratic rights.
- That proportionality is maintained between the general safety and protection of groups of people at risk, on the one hand, and the restriction of freedoms, on the other. This is in order to avoid putting at risk the acceptance of these measures by society over time and/or solidarity with the risk groups needing protection;
- That there is reliable regular and transparent communication of information in regard to the measures being taken and the political decisions being enacted to deal with Covid-19. This is in order to counteract a climate of panic and uncertainty and as an effective measure against the spread of rumours, half-truths and ‘fake news’.
(English translation by Eamonn Conway, Limerick, Ireland; original publication in German on April 1, 2020, at https://www.feinschwarz.net/covid-19-und-triage-medizinethisch/).