Who lives? Who dies? Who decides?

From 2008 – a classic post:

WHO DECIDES?

Suppose there were a medical disaster such as a flu pandemic (which doctors expect sooner or later) where medical services are stretched beyond the limit. In that situation who lives and who dies and who decides?

Now an influential group of U.S. doctors have drafted a specific list of recommendations for which patients would not be treated. They include the very elderly, seriously hurt trauma victims, severely burned patients and those with severe dementia.

These guidelines are an attempt to make sure that scarce resources – including ventilators, medicines, and doctors and nurses — are used in a uniform, objective way.

The U.S. report urges hospitals to designate a triage team with the Godlike task of deciding who willand who won’t get lifesaving care. Those out of luck are the following:

  • People older than 85.
  • Those with severe trauma, which could include critical injuries from car crashes and shootings.
  • Severely burned patients older than 60.
  • Those with severe mental impairments, which could include advanced Alzheimer’s disease.
  • Those with a severe chronic disease, such as advanced heart failure, lung disease or poorly controlled diabetes.
  • Should your 85-year old grandmother get no life saving care?
  • Should your 60-year-old severely burned father get no lifesaving care?
  • Should your husband who has severe emphasyma receive no life saving care?
  • Should there be a national debate on how scarce medical resources are used in a disaster?

17 Comments »

  1. 1
    Paul Costopoulos Says:

    This only officialises what has been going on for several years in our chronically short staffed and overcrowded hospitals and clinics. To my knowledge it has been done, although not on such a large scale or spectrum, for over 20 years. Of course the above stated policy would apply in case of a severe pandemic or disaster. In war theaters doctors, paramedics and even civilians have long been faced with those choices.
    When it goes on far away nobody notices, when it hits close to you than you start wondering what if? Don’t you!
    I may sound cynical but these guidelines do not come as a shock to me but they will relieve health professionals of a lot of guilt.

  2. 2
    neilmckentyweblog2 Says:

    Paul: –

    I fear you are right. A group of doctors in Canada say that health costs are rising so rapidly that the authorities should ration them. But by what criteria? I believe we should have a national debate on this issue.

    Thanks for your comment. Always appreciated.

  3. 3
    Cornelius T. Zen Says:

    Good morrow, all!
    It’s called triage. Work on those who are most likely to survive the procedure. Medical resources of all descriptions have always been limited, even scarce, mostly because the vast majority of the current population has no immediate need. It comes as no surprise. As for shock…welcome to reality. Like gravity and entropy, those are the facts of life. But then, I digress…CTzen

  4. 4
    Chimera Says:

    What CTZen said, and more.

    For everyone about to climb, blubbering, on the “save my grampa” bandwagon just because you happen to love him above everyone else, stop with the tug on the emotional heartstrings, already. When you do that, you demand the impossible.

    If doctors really had a “godlike task,” they wouldn’t have to pick and choose whom to save; they could save everyone. What they have is a very human task of awesome proportions, and in the case of a disaster, limited resources and utter chaos in which to work.

    Doctors work with objectivity, and so should we all, in times of disaster. If we can’t do that, we should at least get out of the way of those who can. [And for those who notice things like this, I really hate the onus of the word, “should,” but sometimes there is no other way to say it.]

    If you have a hundred injured people and two doctors, does anyone think the doctors are gonna work on patients with the best cheering section or the ones with the best chance to survive, recover, and then pitch in and help in their turn?

    I rarely offer serious advice, but here’s an exception: prepare yourself to be one of the ones either pitching in to help despite your own injuries, or one of the ones being set aside because you are too severely injured to make an effective and useful recovery. Once you’ve made up your mind to do that, the rest will happen as it happens. It will, anyway, but at least you’ll be emotionally and psychologically better prepared.

  5. 5
    Paul Costopoulos Says:

    You are right Chimera. I would hate to be another Golubchuck. And I have seen to it in my last will and testament that includes a “living will”.

  6. 6
    neilmckentyweblog2 Says:

    Cornelius and Chimera,

    The scenario you paint is bleak indeed. I grew up in a society where the philosophers said the hallmark of a great society was the way it treated its most vulnerable and defenseless citizens. In our new society will will cut them loose. Necessary, perhaps, but how hard=boiled, if not evil. Didn’t Hitler try that?

  7. 7
    Paul Costopoulos Says:

    Neil, Hitler did it systematically. What we are talking about here are extreme circumstances when extreme measures are required. Still we must draw the line at therapeutic harrassment in the name of science and research or religion. We must also draw the line when the person has no more quality of life and no hope for a cure barring a miracle. A very good case is the late Mr Golubchuck whose family went to extreme lenghts to keep him alive despite all odds. He died last week looking like a still, all tubes and machines.

  8. 8
    neilmckentyweblog2 Says:

    Paul: —

    “Neil, Hitler did it systematically.” But isn’t that what Corneilius and Chimera are advocating – that we systematically abandon the most vulnerable. And isn’t that what Hitler did – with the Jews, the mentally retarded, gays and gypsies. I expect that’s not the kind of society either your or I want to live in.

  9. 9
    Paul Costopoulos Says:

    Neil, I don’t think either CTZ or Chimera meant to be that extreme. Certainly systematic eradication of the vulnerable is not what I have in mind. As I wrote, in extreme, and I stress extreme, conditions tough decisions have to be made. Other than that humanity must prevail.
    Mind you in the far north, when they could no longer pull their weight and became a danger to the tribe, the elders would walk away and allow themselves to die of cold exposure, but, again, those were extreme circumstances and a matter of survival for the clan. It is no longer done.

  10. 10
    Cate McB Says:

    The issue here is not just who on the list should get life saving care but who should get that care if they get whatever killer flu comes around. In this context, those on the list are those who from an empirical standpoint, are the least likely to benefit from the life saving care for all kinds of reasons including the ways they are already physically compromised. In the ICU where I work, they are already the least likely to survive even a moderately severe pneumonia, not to mention a killer flu in the context of a pandemic.

    I hate to sound pessimistic, but in the case of a pandemic from my vantage point within the health care system in Ontario, I wonder how we will be able to care adequately for those who empirically have the very best chances. We will do our very best and what will be will be. Until that day, I concentrate on what I really want to do in this life. After that, if some pandemic gets me, c’est la vie. I’ve already had TB and Hep. B and know what treatment involved in those situations for me as an otherwise healthy person.

  11. 11
    neilmckentyweblog2 Says:

    Cate:-

    It is always good for us to have a comment from a professional in the field.
    Do I hear you saying that medical services will be strained to care for those who have the very best chances, let alone those who are weakened to begin with?

  12. 12
    Barbara Says:

    What I believe is meant is that, in extreme circumstances, one would do one’s best to give aid and comfort to all. However, if there was, say a limited amount of vaccine to administer during a pandemic, decisions have to be made. Do you give the same inadequate amount to all and cross your fingers or do you give the vaccine to those who stand the best chance of surviving? It is not a matter of killing off the weakest (Hitler did not just abandon the Jews, gypsies and gays, he exterminated them like cockroaches), it is attempting to save as many as you can. I believe that was what I was taught in ethics.

  13. 13
    neilmckentyweblog2 Says:

    Barbara:

    Are we talking here about the lesser of two evils?

  14. 14
    Cate McB Says:

    Neil,
    Yes, I am saying that medical services will be strained to care for those who have the very best chances, let alone those who are weakened to begin with. That is the case now, without a flu pandemic.

  15. 15
    Barbara Says:

    I am not sure where it fits in technically.

  16. 16
    Cornelius T. Zen Says:

    Good morrow, all! Has it not occurred to anyone that medical resources are already strained? The news is full of horror stories of waiting lines, of vital surgeries delayed or cancelled, because of limited resources. Not enough beds, not enough nurses, not enough blood, not enough…name it, it’s scarce. Medical costs are soaring, more and more of our government budgets are being dedicated to health, and hospitals are still turning people away, or making them wait for hours, days, weeks, months.
    On one hand, Canada advertises for doctors, fully accredited in their own countries, to come to Canada. Then, it tells them, “you can’t be a doctor here, you are not accredited in our medical system.” How brilliant is that, eh? Now, imagine how much worse it is in the United States, where millions have no medical insurance coverage, and cannot afford care at all.
    I am wondering exactly who it is who benefits from this system. It would not be working (I use the term loosely, as you can imagine) this way, unless somebody wanted it to work this way.
    On the other hand, I may be assuming malice, whereas stupidity may be an adequate explanation. But then, I digress…CTZen

  17. 17
    Chimera Says:

    “But isn’t that what Corneilius and Chimera are advocating – that we systematically abandon the most vulnerable.”

    Speaking only for myself, I advocate no such thing. And Neil, you really need to take another look at your original premise before you go off half-cocked and try to compare a natural disaster to Hitler!

    Put yourself in the position of a doctor, rather than that of a victim of this disaster. You have a hundred people who are clamoring for your skills, and they are all sick or injured to some degree, some more than others. Can you honestly say you’d spend all your skills and energy and resources on a couple of people who will die no matter what you do for them? Or will you focus your energies on those who can recover, and maybe make the dying a little more comfortable on their way out.

    Imagine that you have one dose of disinfectant and one roll of bandage. Will you use it for the man who has a bleeding head wound, but can recover? Or will you throw it away on the man with the supurating belly wound, who will die no matter what you do for him? You are the doctor. You have to choose.

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2 Comments »

  1. 1
    Vin Smith Says:

    …This is too heart-wrenching a job for me to ever do. I would gladly act as a chaplain, however. Making such decisions can only be done–in my opinion–by medical people versed in triage. They have the expertise.

  2. 2
    catharine Says:

    Thank you, Vin, for your inciteful message. Catharine


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