Israeli Triage Commission
The coronavirus disease 2019 (COVID-19) pandemic created the need for triaging scarce life-saving resources, raising medical, ethical, social, legal, and religious dilemmas. In Israel, a Joint Commission of the Israel National Bioethics Council, the Ethics Bureau of the Israel Medical Association, and the Israeli Ministry of Health was appointed by the Director General of the Ministry of Health to develop national guidelines for triaging severely ill patients if the health-care system was overwhelmed. The Commission was composed of senior experts in medicine, ethics, law, sociology, Jewish law, Christianity, and Islam. The document produced by the Commission provides an overview of general principles, pragmatic medical criteria, and a practical triage protocol. Guiding principles included supreme value of life, equality of all individuals, transparency, consistency, equity in access, fair distribution, greatest good to the greatest number, palliation, preserving societal humanity and compassion, and promoting public trust. The guidelines furnish objective, functional clinical criteria and decision-making mechanisms and prohibit discrimination based on race, religion, sex, nationality or citizenship, sexual orientation, socioeconomic status, age, or disability. The Israeli National policy is the only national policy for the COVID-19 pandemic developed by a governmental agency.
Triage Guidelines and Protocol
Triage guidelines apply only after the health-care system is overwhelmed and the Ministry of Health declares an emergency state. The triage protocol is simple and easy to understand, uses multidimensional assessment measures, and enables quick decisions. The Commission discussed several algorithms with different scoring systems to triage ICU beds and ventilators, choosing the best predictors of short-term survival and enabling the quickest decisions. Working with an international expert group that developed a triage protocol1 helped provide additional assessments and consistency adapting the protocol to Israel.
The first triage decision (ie, inclusion and exclusion criteria) is the same used under normal circumstances. Only individuals too ill to benefit or those likely to recover without scarce resources are excluded. Thus, everyone has the same opportunity to receive scarce resources as during “normal” conditions. This should allay societal fears about individuals not triaged because they are considered “unworthy” of being saved.2 The measures chosen for prioritization included functional ability (Eastern Cooperative Oncology Group performance score), comorbidities (American Society of Anesthesiologists score), number of organ systems failing, and overall estimation of short-term survival. The Sequential Organ Failure Assessment score was not chosen because it requires additional assessments, it was unhelpful when applied to epidemic data, and most COVID-19 patients only have single organ failure.1 If more patients than resources have the same priority, further triage should be based on lives saved and then on “first come, first served.” The triage algorithm applies equally to all ICU or ventilator candidates with and without COVID-19. Patients’ advance directives should be sought and honored. All patients must receive palliative care. This triage protocol was endorsed by the Israeli Critical Care Society.
Objective protocols are recommended to facilitate triage decisions, enhancing fairness and consistency and reducing provider moral distress.1 The general principles of the Israeli guidelines are similar to those in various countries, but some differences reflect the local sociocultural and regulatory landscape.
Despite the fact that some countries have used age to triage patients during the pandemic,3 the Commission noted that chronological age is not a legitimate stand-alone criterion for triaging scarce resources and should only be considered as part of the combination of risk factors. Furthermore, all else being equal, the goal is to maximize the number of lives saved rather than life-years saved by considering only the chances of the individual’s short-term survival.
Although some protocols prioritize health-care professionals for receiving care,4 the Commission recommended that unless absolutely necessary to overcome staff shortages, health-care professionals should not be given upfront priority even if infected while treating COVID-19. When there is, however, parity for medical priority between two patients, health-care professionals will receive priority. These rules explicitly apply to all workers directly involved with COVID-19 patients (ie, including cleaning staff, patient transporters, and so forth).
Many protocols recommend that triage decisions be made by institutional committees separate from the triaging physician.4 The Israeli Commission judged such separation as unworkable. The Commission recommended appointing two senior physicians to jointly decide on triage, and appointing a special ad hoc institutional triage committee for consultations.
Triage protocols generally call for periodic reassessment of decisions to optimize the use of scarce resources. Limiting the treatment of a patient whose condition is deteriorating despite ICU treatment or ventilator therapy can free scarce resources to patients more likely to benefit. Withdrawing ventilation is currently illegal in Israel, and the Commission was split on the issue of recommending legal changes allowing ventilation withdrawal.
Because there are geographical disparities in availability of medical resources, the Commission recommended that the State ensure the nationwide fair distribution of available ICU beds, ventilators, and skilled personnel according to population density and the expected/actual demand.
When the Commission’s report was first publicized, several organizations for people with disabilities protested against the inclusion of a functional performance score in the triage algorithm. This was viewed as discriminatory against people with disabilities. Commission chairpersons met with representatives of these organizations and amended the document to explicitly prohibit discrimination based on disability status per se. Specifically, the document focuses on individual assessment of the likelihood for short-term survival and prohibits decisions based on groups of people, such as the elderly or individuals with disabilities.5 (See English translation of the document.6) Because performance status in critically ill7 and other patients is a significant predictor of in-hospital mortality and is widely used in medicine, the Commission concluded that it was an important measurement for triage, and that its elimination would reduce the predictive power of the triage algorithm and exacerbate inequity.
Conclusion
The Israeli consensus document and pragmatic triage protocol offer a societal and medical roadmap for allocating scarce resources. They reflect both universal principles and local sensitivities. The current summary of the process and decisions (Table 1 ) of the Israeli Joint Commission provides strategies and approaches for policymakers in different countries to develop policies (Table 2 ) for this pandemic, the next coronavirus wave, or other disasters, to correct previous policies and to develop objective, transparent, equitable, and consistent national triage policies.
Table 1.
The Israeli Commission on Prioritization of Scarce Medical Resources: Decisions and Reasoning for Selected Issues
| Issue | Decision | Reasoning |
|---|---|---|
| A. General Principles | ||
| Greatest good for greatest number | Saving the most lives (not the most life-years) | Maximal societal benefit (utilitarian), sanctity of life, equality |
| Equity | Same criteria for all patients | Fairness, public confidence |
| Transparency | Public disclosure | Public confidence |
| B. Prioritization criteria | ||
| Medical criteria | Consistency Nonmedical criteria lead to inequality, bias, and discrimination, and benefit is not maximized | |
| Short-term survival | Prediction of short-term survival is much more accurate than prediction of long-term survival Using long-term survival would significantly bias against older individuals and people with disabilities |
|
| Tie-breaking | First come, first served | Fairness, transparency |
| C. Specific patient features | ||
| Age | Not a stand-alone criterion, only as part of combined risk assessment | Sociocultural respect for the elderly |
| Disability | Not a stand-alone criterion, only as part of combined risk assessment of short-term survival | Equality and lack of discrimination Functional status can be used for prioritization only if it affects short-term survival |
| Health-care workers | No prioritization upfront | Equality, public confidence |
| Prioritize only if needed to address staff shortages and then only as a tie-breaker | Recognition of risk and of service (for all workers with patient contact, not only health professionals) | |
| Palliative care | Especially for patients not admitted to ICU or ventilated | Beneficence |
| D. Implementation | ||
| Initiation of policy implementation | Overwhelmed medical system | Emergency triage is acceptable only in crisis situations |
| Formal declaration of an emergency situation by the Ministry of Health | Formal announcement is critical for public trust | |
| Local triage decisions | Two senior physicians, institutional triage committee available for consultation, not mandatory | Mandating requirement of an institutional committee is unworkable in the local setting during emergencies |
| National triage decisions | Establish a national triage committee, available for amendments | Triage situations not covered by current policies may arise |
Table 2.
Developing National Triage Policy
Governmental, professional, and public involvement
|
Commission composition
|
Guideline development process
|
Guideline document
|
Acknowledgments
Other contributions: We thank all members of the Commission: Commission Co-Chairs: Avraham Steinberg, MD, Ephrat Levy-Lahad, MD, Tami Karni, MD, MHA; Medical Subcommittee: Charles Sprung, MD, JD, FCCP (Chair), Jonathan Halevy, MD, Yaron Niv, MD, Ofer Merin, MD, MHA, Pesach Schwartzman, MD, Moshe Sonnenblick, MD, Adi Nimrod, MD, Israel Strous, MD, MHA; Philosophical-Ethical-Social Subcommittee: Noam Zohar, PhD (Chair), David Heyd, PhD, Yael HaShiloni-Dolev, PhD, Ruth Landau, PhD, Efrat Ram-Tiktin PhD; Legal Subcommittee: Gil Siegal, SJD, MD (chair), Salim Jubran, LLB, Shai Lavi, Talia Agmon, LLB; Halachic/Religious Subcommittee: Avraham Steinberg, MD (Chair), Eyal Krim, Yigal Shafran, PhD, Mordechai Halperin, MD, LLB, Avraham Manela, Muhammad Abu-Abeid, Etienne Lepicard, MD, PhD. We thank Nurit Dessau, MBA, for research assistance, and Rafi Twizer and Deganit Lahav for administrative assistance.
Footnotes
FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.
References
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