Ventilator Triaging Policies During the COVID-19 Pandemic

Matheny Antommaria AH, Gibb TS, McGuire AL, et al.
Ventilator Triage Policies During the COVID-19 Pandemic at U.S. Hospitals Associated With Members of the Association of Bioethics Program Directors. Ann Intern Med 2020;173:188-194.

The following are key points to remember from this article on ventilator triage policies during the coronavirus disease 2019 (COVID-19) pandemic at US hospitals associated with members of the Association of Bioethics Program Directors:

  1. The authors surveyed the Association of Bioethics Program Directors, advisors to hospital governing leadership in over 70 institutions throughout North America, asking:
    • Whether a ventilator triage policy had been implemented in the wake of the COVID-19 pandemic,
    • What criteria would be used in such a policy, and
    • Which individuals are or would be involved in creating or activating the policy, or in adjudicating individual decisions.
  2. A majority of institutions did not have a ventilator triage policy in place at the time of the survey. With a 92% response rate, over half (54%) of the respondents reported no ventilator triage policy in their institution, and 10% reported inability to publicly share their policy. Findings from the 26 unique available policies were thus reported.
  3. There were certain common features in the available policies. Among the 26 available policies, the most frequently cited triage criteria were:
    • Benefit (96%, indicating those having the greatest chance of surviving with use of the ventilator), and
    • Need (54%, indicating those who would likely not survive without the ventilator).
  4. Determination of benefit and need were based on the Sequential Organ Failure Assessment (SOFA) or the Modified SOFA (MSOFA) scores (80%) or specific diagnoses (e.g., cardiac arrest or extensive burns).
  5. The most frequently cited ethical values guiding the policies were justice (88%), transparency (77%), and stewardship (62%).
  6. There was substantial heterogeneity between all of the ventilator triage policies in a number of areas. Important apparent disagreement in criteria was observed in the following:
    • Age, with younger patients given greater priority given otherwise similar triage scores, was cited as a clinical criterion in 50%, but few specified age thresholds.
    • Anticipated resource consumption, a factor conferring lesser priority, was cited in 38%.
    • Prioritization of the health care worker patients was indicated in 38%, but inconsistent rationale were provided to support this decision.
    • Role of the treating physician, with 50% indicating that those providing direct patient care should not be included in the triage decision making.
    • Policy activation, with 38% requiring governmental authority and 30% giving no indication of who would have the authority to activate an existing policy.
    • Although most policies list criteria deemed ethically irrelevant, such as race or insurance status, only two policies (7.7%) mandated blinding of the decision makers to such information.
  7. These findings raise concern about the potential for bias in the triaging process, and call for the adoption of explicit criteria to minimize the risk of unfairness in the allocation of a limited, life-saving resource.

Clinical Topics: Arrhythmias and Clinical EP, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias

Keywords: Bioethics, Coronavirus, COVID-19, Critical Care, Heart Arrest, Insurance Coverage, Organ Dysfunction Scores, Patient Care, Policy Making, Resource Allocation, Secondary Prevention, severe acute respiratory syndrome coronavirus 2, Social Justice, Triage, Ventilators, Mechanical

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