Certain hospitals are including information on their critical care triage policies in admission packets to explain how care or supplies will be allocated if rationing becomes necessary. People want to know what it means for them in particular.
“There will be big enough concepts and words used that require interpretation in the immediate situation,” says Paul T. Menzel, PhD, professor of philosophy emeritus at Pacific Lutheran University in Tacoma, WA. Hospitals are obligated to explain how decisions would be made. “It’s wrong to hide them ... but how to make them transparent, and how aggressively, is another matter,” says Menzel, an affiliate professor at the University of Washington department of bioethics and humanities.
Some clinicians feel ethically obligated to inform everyone up front of the possibility. Others think it is better to do so only if and when it becomes necessary. “There are real ethical nuances there,” Menzel observes. “This is a real ethical dilemma.”
Menzel sees a strong parallel with another controversial practice. Clinicians struggle with how to tell patients about voluntarily stopping eating and drinking as a way to hasten death. “In certain situations, that can be a very viable and even comfortable and appropriate option,” Menzel suggests.
Yet if clinicians bring it up too early, people may fear the clinician is pushing them to end their life. “This can happen if it’s brought up in the wrong context, or the wrong way, to someone who hasn’t asked about it specifically,” Menzel notes. In one such case, the patient was adamantly opposed when the clinician first brought it up.1 “When problems and pain persisted, the clinician bravely decided to broach it again,” Menzel explains.
This time, the patient immediately decided the option was the right choice. “It was accomplished successfully. But it wouldn’t have happened if the clinician hadn’t taken the risk of bringing it up again,” Menzel recalls.
In other cases, clinicians have held off on raising the issue. When they finally do talk about the issue, it becomes apparent the patient would have greatly benefited from knowing about the option earlier.
Clinicians face a similar dilemma when informing people of how decisions would be made if care is rationed. In both situations, says Menzel, “there is the risk of too much information, too soon — or the risk of too little, too late.”
Patients and families do have the right to the information. “People ought to know what’s going on,” Menzel argues.
Putting the information in an admission packet may be insufficient. This puts the burden on the patient or family to ask about the option. “A more aggressive stance would be to raise the issue, and say, ‘Right now, it’s not applicable to you. But if you want to talk about this at any point, please ask,’” Menzel says.
Ethicists cannot respond to every alarmed patient and family member about what critical care triage means for them. Instead, ethicists can support clinicians to confidently and capably answer tough questions. “Ethicists should communicate clearly to clinicians that this is very tough work. You are not always going to make the right decision,” Menzel says.
That is a good place to begin, since none of the guidelines offer definitive answers. “They are tough to write, there are always tradeoffs, and there are dilemmas harbored in just about every priority claim stated,” Menzel says.
Most people would agree that someone with the best prospect of success should go ahead of somebody with worse chances. “But even that is challengeable, not only in terms of philosophy but also in the minds of very ordinary people who do understand the dilemma,” Menzel says.
It is not enough for clinicians to clearly communicate the guidelines to patients. Clinicians need more than that from ethics, Menzel stresses. He suggests ethicists give clinicians a fuller picture by saying something like: “The best thinking we’ve put into it at this facility has generated these guidelines. Nobody should think they are the ultimate moral truth. They are just the best we can come up with.”
“There are complex dilemmas involved in this, and you can’t paper them over,” Menzel acknowledges.
Making triage processes transparent, an ethical obligation for providers and hospitals, has proven quite challenging. “We are obligated to educate the public about scarce resources and the principles of population-based ethics of healthcare delivery under crisis standards of care,” says Kathleen Akgün, MD, MS, associate professor of medicine at VA Connecticut Healthcare System and Yale University School of Medicine.
These principles are contrary to ethical obligations during regular times, which prioritize patients’ autonomy. This is a complicated message to convey. “We have been working on how best to telegraph these issues to the public without causing alarm,” says Akgün, co-chair of the clinical ethics committee and director of the medical intensive care unit at VA Connecticut.
Ethicists are developing a frequently asked questions pamphlet to be given to patients and surrogate decision-makers at hospital admission. “We remain concerned over whether this would be enough preparation when the time comes,” Akgün says.
Clinicians may struggle to comprehend all the ethical nuances of critical care triage guidelines. Many feel ill-prepared to explain all the details to distraught family members.
“Some are working 12-hour shifts for weeks on end. There are often calls to ethicists about patients who seem to be failing, and the question is what to do,” says Janet L. Dolgin, PhD, JD, co-director of the Hofstra University Bioethics Center in Hempstead, NY.
No matter how much guidance is in place, ethical challenges remain for everyone. “Anything you do is in an arena in which ethics are being shifted and re-examined,” Dolgin explains. “The possibility of feeling satisfied and sanguine does not exist.”
How the critical care triage policies are communicated publicly is an important question, among many others that organizations will need to examine through an ethical lens. “We will have to rethink some of the foundational principles of bioethics,” Dolgin predicts. “It’s not possible to rely on autonomy in a context where many lives are going to be lost.”
Some hospitals will find it necessary to revise triage policies. If so, efforts should be made to obtain public input, Menzel says. That can be accomplished by including members of the community on policy-forming committees, or by holding public forums with prominent people in attendance.
“This is especially important if the situation in the region is one where there really is a prospect of having to ration, or there’s evident public worry about it,” Menzel says.
- Quill TE, Menzel PT, Pope TM, et al, eds. Voluntarily Stopping Eating and Drinking: A Compassionate, Widely Available Option for Hastening Death (forthcoming, Oxford University Press).