Well, if you state and I quote, “these guidelines (beyond providing SOFA scores and making objections through an appeals process, I imagine) and that they are headed by CCM physicians.” then I would request you to please open any of the guidelines and read word to word. because you are fighting a battle that is based on misinformation and self made assumptions. Also I know American medical education system is one patient driven, patient driven treatment plans but the current situation is not for one patient. In Pandemic! there is no training on how to deal with patient surge! and not a patient surge when ther is road traffic accident, this is exponential surge with each patients with high severity of illness. so Get the grip of gravitas of the pandemic situation, and take time and read these guideline. I will attach a link too. so that there is no room for assumptions.
Lets take this in a compendium way.
- what kind of critical care delivery model is your health system/ hospital follow/adopted?
I can answer for the one I work for: Closed ICU with Critical care director and day time bedside intensivist + 24/7 Tele-Intensivist Model.
So in functioning of the ICU( operational as well as clinical decision making - CCM plays a majot rolein every aspect of all hospital related decisions. And ICU is part of hospital) I don’t know what what kind of place do you work for that your concerned are that your opinions and ability of decision making will be overruled by some non physician people? and you would have to go to appeals. If that the situation where you are working then I don’t know what kind of assurance you want to me to provide you.
- Imagine a scenario where ICU bed capacity is 20. Patients in ICU admitted are 22, and you have a pool of patients( 100 patients) in step down that require ICU admissions. Suddenly one bed get vacant. and so from those hundred which patient will you give that one bed. Then which one patient would you give that bed. the one who will survive with that ICU bed if he ius in the ICU for 30 days or the one that will survive and get discharged in 1 day? or would you give that bed to a health care colleague who has acquire this infection, or a stroke case who is in golden period for treatment, or a pregnant women with complications. so if you have read the guidelines it mentions and coberes in depth decision flowcharts with only one criteria to judge and that is clinical criteria, no emotions.
Here your clinical ability to save one individual patient is not important, when the pandemic has given you opportunity to do a greater good for the larger community of patients with limited hospital resources… There are modules that you can read, practice in such triage situations, You no longer work for patient driven diagnostic treatment plan, In Pandemics the driving force is how many people will survive in the limited recourse like ICU bed, ventilator and most important ICU intensivist. In a pandemic situation do you want to just treat one patient because your acumen, and ability proves that you will treat that patient for X amount of days.
Identifying the vulnerable group is no ‘rocket science’ and therefore we must strive to utilize our efforts and direct our resources that would have a positive and beneficial outcome. It is no point on barking a tree where there is very little yield expected in return. We must therefore be well informed and well prepared to combat this deadly virus
I will repeat that we all pray that this situation doesn’t escalate till triage for recourse allocation. but we still have to prepare.
Reading material: Triage for resource allocations:
Utley M, Pagel C, Peters MJ, et al. Does triage to critical care during a pandemic necessarily result in more survivors? Crit Care Med 2011;39:179–83. doi:10.1097/CCM.0b013e3181fa3c3b
Christian MD, Sprung CL, King MA, et al. Triage: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest 2014;146:e61S–74S. doi:10.1378/chest.14-0736
Vergano M, Bertolini G, Giannini A. . Clinical Ethics Recommendations for the Allocation of Intensive Care Treatments in exceptional, resource-limited circumstances - Version n. 1. Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI); 16th Mar 2020, 2020
Agency for Healthcare Research and Quality . AHRQ Publication No. 05-0043; Rockville, MD: 2005. Altered standards of care in mass casualty events. Prepared by Health Systems Research Inc. under Contract No. 290-04-0010.
AMA code of medical ethics: guidance in a pandemic. Available: https://www.ama-assn.org/delivering-care/public-health/ama-code-medical-ethics-guidance-pandemic
Emanuel EJ, Persad G, Upshur R, et al . Fair allocation of scarce medical resources in the time of Covid-19. N Engl J Med 2020. doi:doi:10.1056/NEJMsb2005114. [Epub ahead of print: 23 Mar 2020].pmid:http://www.ncbi.nlm.nih.gov/pubmed/32202722