Below is a case study about a flu pandemic. In this case you will see that a meeting was held of various health officials trying to decide what approaches would be useful to contain the cycle of infection. Imagine that you are one of those officials and you are assigned to make a presentation to the group with suggestions about how to proceed. You will have to justify/argue for your approach.

For our Special Topics class, your assignment is to write about what you will suggest to the group. Try to address some of the social, scientific, and ethical issues involved in containing a pandemic and dealing with too many patients and too few resources.

This assignment must be at least 4 written pages using 12-point Times New Roman font, double spaced. Please submit it to me via email by Sunday, February 16. Use any additional sources that would be helpful. The assignment will be graded on the seriousness you bring to the questions, the thoroughness of your recommendations, and grammar, spelling, and punctuation.

The Case

An outbreak of a novel influenza virus has progressed to the point that the World Health Organization has declared a pandemic. In the pandemic’s first wave, hospital capacities were sufficient to handle the influx of pandemic influenza patients, whose morbidity and mortality rates mirrored rates for seasonal influenza. However, despite a vaccination campaign and other measures, such as ensuring surge capacity, rates of morbidity and mortality associated with the virus have increased drastically during the pandemic’s second wave.

The resulting increased number of patients needing hospital beds has overwhelmed even the surge capacity of the Critical Care Units (CCUs) of a metropolitan city’s tertiary care hospitals. To meet this challenge, a teleconference has been scheduled between several members of the hospitals’ administration, the CCU directors from each hospital, and public health officials involved in leading the jurisdiction’s pandemic response. As a public health official who played a central role in developing the pandemic plan for your jurisdiction, you have been included on the call to provide guidance for the pandemic response.

During the meeting, a number of CCU directors report that their physicians and nurses are concerned about the type of patients being admitted into the CCU. Some of the directors see a trend that they suggest is ultimately undermining the efficiency of the pandemic response. They argue that, as the severity of the pandemic continues to increase, their triage criteria should be modified so as to use CCU resources to save the most lives possible. They worry that admitting those who present with the most need is preventing treatment of those who will benefit most from CCU admission. “So long as our triage scheme saves the most lives, it is ethically justifiable” a number of them declare.

The group takes up the proposal of a CCU director to triage according to Sequential Organ Failure Assessment (SOFA) scores—which are derived using a tool that determines a patient’s organ function and failure rate to predict outcomes. Were the pandemic’s severity to increase, the group suggests that, in addition to the CCU director’s proposal to use SOFA criteria, even more inclusion, exclusion, and priority criteria could be added with the goal of saving as many lives as possible. They’ve proposed exclusion criteria for CCU admittance that include patients with a poor prognosis, patients with other known health issues, and some mention of age cut-offs, to name a few.

Others involved in the teleconference question whether this is the right approach to take. They argue that, by aiming to save the most lives possible, those who may benefit less from CCU admission, like older adults or individuals with disabilities, will be unfairly affected. They say, “we should not just aim to save lives, but rather save lives fairly.” As you and your public health colleagues are leading the pandemic response, the hospital administrators and CCU directors look to you for a recommendation or decision about how to proceed.

Some Discussion Questions (there are many more)

1.

Ensuring that the CCU has surge capacity is a common strategy to accommodate an influx of patients who have been infected with pandemic influenza.

  • Does surge capability require alternative critical care triage criteria?

 

(b) If the population’s health needs exceed contingency arrangements, should alternative critical care triage criteria be used?

 

(c) How should these decisions be made?

 

(d) What principles, values, or processes should influence these decisions?

 

2.

What considerations might exist during a pandemic that do not exist in everyday critical care and critical care triage that do or do not support the modification of triage criteria? If pandemic critical care triage requires a unique conceptual framework, what principles ought to be valued in such a framework (e.g. need, equality, utility, efficiency)?

 

3.

Would the severity of a pandemic ever warrant the use of a utilitarian scheme for critical care triage, given that the public generally finds it unpalatable and carrying out such a plan could require coercion? How could an adverse public reaction to coercive or covert measures be mitigated?

 

4.

In a pandemic, the most seriously ill patients with the lowest probability of being saved might be left untreated because their care would require too many resources with little prospect of recovery. This illustrates a conflict between the common good and the best interests of individual patients. What other conflicts might arise when triaging in a pandemic?

5.

Triage can be used to maximize the number of lives saved with available resources. Should we aim to maximize the number of lives or, alternatively, the number of life years saved? This can also give rise to questions about the quality of those lives and years lived. Is it ever appropriate to make allocation decisions based on quality of life or life years?

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