The last bed dilemma burns out COVID-19 triage: A viewpoint from Medical and Law students

Abbreviations

ICU

intensive care unit

PPE

personal protective equipment

WHO

World Health Organization.

COVID-19′S footprint

As of March 11th, 2020, COVID-19 has been declared a global pandemic. On April 10th, Italy and USA reached respectively 143,626 and 425,889 total confirmed cases with a death toll of 18,281 and 14,665 [1]. Between February 20th and March 18th, the COVID-19 Lombardy ICU Network managed 1300 affected patients with acute respiratory failure demanding ICU admissions. Of those, 99% needed respiratory support [2]. Data that show how overwhelmed the healthcare system is, thus requiring the implementation of triage protocols to properly allocate the medical resources.

Triage in theory

As its etymology suggests, trier means the culling, the sorting and allocation of patients, treatments or resources, historically attempted by a plethora of methods. In brief, clustered in egalitarian and utilitarian triages. Behind the former lies a “first come, first served” philosophy that is regardless of their clinical picture, every individual is treated according to their time of arrival. While it definitely encompasses ethics and the fulfilment of the WHO's idea of the fundamental right to health, the concept of such a patient-centred care is doomed to overwhelm the healthcare system when a pandemic arises: thus, the change toward a community-centred care [3].

Unavoidably, in a potential resource scarcity, the community welfare refers sacrifices and choices to the medical staff pursuant to the utilitarian method whose aim is to achieve the greatest good for the greatest number of casualties. First patented by Baron Larrey on the battlefield, this form of triage was modelled to the odds of recovery of the (soldier) patient and hence dubbed “combat triage”. Currently, it is being implemented in several COVID-19 wards, either in compliance with algorithm-based guidelines or according to distributive justice, as underlined by the Società Italiana di Anestesia Analgesia Rianimazione e Terapia Intensiva [4] that advices to base the decision to withhold or withdraw life-sustaining treatments on the evaluation of criteria such as age, comorbidities and functional status of the critically ill patients.

Triage in clinical practice

Whatever the method implemented, healthcare personnel still faces everyday a tough dilemma: to treat or to let go?

A dilemma between the patient who gets to be admitted to ICU and so given a chance to win the battle against COVID-19 and the patient that has to be discharged. And, the solution is not always clear. According to the first protocol, when dealing with the life-threatening case of a 68-year-old man, obese, hypertensive and smoker, the physician has no choice but to allocate the last ICU bed, fully aware that an hour later the same bed could have been used to cure a younger patient, without any comorbidity and a higher life expectancy. On the other hand, an utilitarian triage might still show its flaws, in common with a sort of Ancient Sparta, where newborns deemed unfit to survive were left to themselves on Mount Taigeto, easy prey for rains and beasts. Suffice it to see the Italian clinical case of an ex swimming champion on a waiting list for a kidney transplant who, having contracted the coronavirus, was ultimately denied the ventilator, which went to a younger positive patient with more possibilities of survival [5].

What if the physician empirically disagrees with the protocol since his work experience taught him to believe that for that specific patient something more could be done than what the written guidelines suggest?

In each hypothesis, the weight of the decision is once again on the physicians’ shoulders. Although, as put by Dr. Robert L. Klitzman, director of the masters of bioethics programs at Columbia University, “We are on the battlefield. We are in the trenches and in the middle of a war and we have not trained our medical staff to deal with military battlefield medicine and ethics” [5].

Direct consequence of working on such a front line might be the rife upsurge of medical burnout.

Medical staff burnout

The issue was already under the lens before the pandemic spread: lengthy shifts, work overload, high pressure and sleep deprivation, to name a few, were de facto drying up the healthcare personnel, leading the Medical Community to further investigate. Now, in addition to the ‘ordinary’ stressors, physicians have to face COVID-19.

Shanafelt et al.’s research [6] has deepened the understanding of the frontline healthcare professionals’ burnout sources: what they fear is to not have access to the appropriate personal protective equipment (PPE) against contact and droplets, thus being more likely exposed to the virus at work, increasing the chances of taking the infection home to their family. And, the isolation continues in the hospital, where physicians and nurses face more than the sole pandemic. The number of medical staff affected by the virus is higher than in general population (15% vs 7%), with the grim outcome of longer and more tiring shifts for those still in the frontline.

Their current work conditions not only hint to burnout, but also appear to be teetering on the edges of a violation of human rights, namely “the right to rest and leisure, including reasonable limitation of working hours” (Article 24) and “the right to a standard of living adequate for the health and well-being of himself and of his family” (Article 25), set forth in the Universal Declaration of Human Rights. Nonetheless healthcare professionals, being fully aware of how unprecedented this crisis is, are demanding nothing more than to be put in a safe position to save as many lives as possible.

Commune naufragium omnibus solacium

A safe position means proper PPE but also, on a broader scheme, the reassurance that their “doing the utmost” will be enough even when they cannot save everyone.

Although medical team's mental health [7] will in any case require attention in the aftermath of the outbreak, a means of alleviating the toll might consist in a structured triage. Of the two processes proposed, what is the most suitable one, if any? Selecting who gets treated according to a random entry order might relieve the physicians of the burden of rationing care, albeit leaving them in a state of total impotence. At the opposite end, handing them the last judgment might deteriorate their empathetic distress fatigue, whereas strictly adhering to guidelines would, on one hand, derive its justification from outcome predictors but, on the other, turn physicians into mere appendages of the machine. Ultimately the COVID-19 ward burnout may find a palliative cure in the implementation of set out guidelines; nevertheless, it still seems pivotal to not unduly separate the doctor from his patient. In the event, the physician reasonably doubts about a patient, whose prognosis is negative according to the algorithm, but questionable to the physician's clinical eye, he should be able to call a meeting with at least two more colleagues to figure out the course of actions. In our view, this solution would suitably respond to two essential problems: a patient otherwise discarded by the guidelines might be given a chance to survive based on physician clinical experience whereas, if nonetheless the meeting withheld the bed, the physician would relieve his stress, sharing, to the greatest extent possible, the burden with the team. Because alone, “Nam neque nos agere hoc patriai tempore iniquo/possumus aequo animo […]/in rebus communi desse saluti” [8].

Disclosure of interest

the authors declare that they have no competing interest.