TOTD 2020-3-25: Who Decides Who Dies?

We have no idea how well things will go. There is hope and facts that it looks like things will be okay but there is also facts that things could turn bad. If the hospitals are overrun with people who need critical care. At that time someone will have to decide who gets that help and who doesn’t.  I have some questions to get at some rational for those decisions.

What is the main criteria for giving the rationed resources? Need? Money? Prospects for recovery?

Should there be bright line things that put people off the list for receiving these things? Ex. No one above a certain age. No one with a terminal illness.

Who should be on these “death panels”? Doctors? Community leaders?  Sock puppets?

Would you be willing to give up “your place in line” to help another person?

This reminds of the lifeboat problem. Who dies so others may live?

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27 thoughts on “TOTD 2020-3-25: Who Decides Who Dies?”

  1. I feel for the people who may have to make these decisions. Sometimes one does not get to make good choices but less bad ones. One in a sense plays God by deciding who gets the lifesaving medicines and treatments. I hear this has already happened in Italy. Could you make these decisions?

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  2. Trinity Waters:
    They could recruit Sarah Palin.

    Seriously, there is no answer.  Those in the moment do whatever.

    I thought of Sarah too.

    I think some serious thought has to be given so those decisions can be made as best as possible.

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  3. If it comes to the point of triage, the doctors on the ground will be the ones making the decision. It’s the same as in combat; the medic attached to the unit has the ultimate say when it’s time to triage. Gruesome stuff.

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  4. Robert A. McReynolds:
    If it comes to the point of triage, the doctors on the ground will be the ones making the decision. It’s the same as in combat; the medic attached to the unit has the ultimate say when it’s time to triage. Gruesome stuff.

    I need to be making friends now.

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  5. Does anyone with medical training know how triage is decided on? Are the ideas fairly uniform or entirely subjective to the doctors in charge?

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  6. What a tough decision if you only have 20 ventilators and you need thirty! People asking for help that you can’t give. Would one ever disconnect a ventilator to give that lifesaving to someone with a better chance? Or “They had their turn.” so it is time for someone else to have a chance.

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  7. 10 Cents:
    I think some serious thought has to be given so those decisions can be made as best as possible.

    You will be gratified to learn that some serious thought has been given.  I searched for [medical ethics disaster] and came up with this (WMA Statement on Medical Ethics in the Event of Disasters) among many other links, from which I excerpt a particularly juicy passage:

    8. Furthermore, the WMA recommends the following ethical principles and procedures with regard to the physician’s role in disaster situations:

    8.1 A system of triage may be necessary to determine treatment priorities. Despite triage often leading to some of the most seriously injured receiving only symptom control such as analgesia, such systems are ethical provided they adhere to normative standards. Demonstrating care and compassion despite the need to allocate limited resources is an essential aspect of triage.

    Ideally, triage should be entrusted to authorized, experienced physicians or to physician teams, assisted by a competent staff. Since cases may evolve and thus change category, it is essential that the official in charge of the triage regularly assesses the situation.

    8.2 The following statements apply to treatment beyond emergency care:

    8.2.1 It is ethical for a physician not to persist, at all costs, in treating individuals “beyond emergency care”, thereby wasting scarce resources needed else-where. The decision not to treat an injured person on account of priorities dictated by the disaster situation cannot be considered an ethical or medical failure to come to the assistance of a person in mortal danger. It is justified when it is intended to save the maximum number of individuals. However, the physician must show such patients compassion and respect for their dignity, for example by separating them from others and administering appropriate pain relief and sedatives, and if possible ask somebody to stay with the patient and not to leave him/her alone.

    8.2.2 The physician must act according to the needs of patients and the resources available. He/she should attempt to set an order of priorities for treatment that will save the greatest number of lives and restrict morbidity to a minimum.

    Now Heaven only knows what sort of leftist aperture the WMA is — I haven’t checked — but the whole statement (which is of the “we hereby re-affirm the following” variety) is good reading, and not too long.

    Somebody (Civil Westman?) recently mentioned QUALY (quality-adjusted life-years), which is a grown-up approach to guidance in one aspect of making decisions such as these.  This is a feature of the train of thought unfortunately crystallized by the incompetent bumbling of Obama when he told that girl that “maybe grandma just gets the painkiller” or similar, when he thought he could make the sale for an entire philosophy of care.  His strategy in communicating was hubris, which reflects the overall mindset of those attempting to socialize healthcare for an ostensibly free people, but the tools he spilled all over the stage come from a well-managed toolbox.

    What Obama should have done at that point was pass to professionals — instead he thought he could run the ball to the end zone, and he got stuffed.  Part of a doctor’s toolkit is a bedside manner, which is sometimes conducted in the waiting room, and mushmouth ain’t got it.

    Such thought as is required has indeed been given.  The most approachable version is the straightforward three-category triage (literally, dividing into three) wherein an overwhelming pulse of patients are categorized, Goldilocks-style, as one of only three priorities:

    • those who are too sick to be helped with resources available
    • those who are not sick enough to be helped with resources available
    • those who can be helped with resources available

    Note that the resources available also get a vote; it is not an objective assessment of sickness, but a totally subjective assessment of sickness weighed against resources available.  Note that this is explicitly different from the same decision when a system is not overwhelmed — that is, when the front-door standards of care can be honored.  This is hard-nosed decision-making in the face of acute (that is here and now) shortages, and those who provide care for a living do a lot of training on this, and absorb policy from on high, and make decisions in the moment, and wrestle with issues day in and day out that are utterly transparent to most of us until grandma gets sick during an outbreak.

    War is Hell, but it’s no field-expedient care center — not like I’m qualified to make that distinction, but perhaps those from whom I’ve heard it won’t mind me making it here.  I’m glad I don’t have to tell grandma the obvious truth, with which I agree — when resources dictate.

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  8. If he got tested, he has already received special treatment.  From here on out, follow-up care will be standard treatment.  “Standard” for royalty under the (giggle) NHS.

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  9. Haakon Dahl:
    If he got tested, he has already received special treatment.  From here on out, follow-up care will be standard treatment.  “Standard” for royalty under the (giggle) NHS.

    Good points, Commoner.

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  10. The State of NY has already established a protocol back in 2015.   In the aftermath of the 2005 avian flu and 2009 H1N1 epidemic, it became clear that in the event of a serious influenza pandemic there would not be enough ventilators.   Instead of buying more, NY established a task force to design protocols for rationing the existing supply.    Why not buy more?  The document provides this answer:

    ” In a severe public health emergency on the scale of the 1918 influenza pandemic, however, these ventilators would not be sufficient to meet the demand. Even if the vast number of ventilators needed were purchased, a sufficient number of trained staff would not be available to operate them. If the most severe forecast becomes a reality, New York State and the rest of the country will need to allocate ventilators”

    The entire report is available here:

    https://www.health.ny.gov/regulations/task_force/reports_publications/docs/ventilator_guidelines.pdf

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  11. Ed K:
    The State of NY has already established a protocol back in 2015.   In the aftermath of the 2005 avian flu and 2009 H1N1 epidemic, it became clear that in the event of a serious influenza pandemic there would not be enough ventilators.   Instead of buying more, NY established a task force to design protocols for rationing the existing supply.    Why not buy more?  The document provides this answer:

    ” In a severe public health emergency on the scale of the 1918 influenza pandemic, however, these ventilators would not be sufficient to meet the demand. Even if the vast number of ventilators needed were purchased, a sufficient number of trained staff would not be available to operate them. If the most severe forecast becomes a reality, New York State and the rest of the country will need to allocate ventilators”

    The entire report is available here:

    https://www.health.ny.gov/regulations/task_force/reports_publications/docs/ventilator_guidelines.pdf

    Thank you.  I have thought about there might be a need to gear up training for times of crisis. Some specific skills might not take too long to master and could be indispensable when nothing is the alternative.

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  12. 10 Cents:
    I feel for the people who may have to make these decisions. Sometimes one does not get to make good choices but less bad ones. One in a sense plays God by deciding who gets the lifesaving medicines and treatments. I hear this has already happened in Italy. Could you make these decisions?

    From the Jerusalem Post, two days ago:

    Israeli M.D. Gai Peleg, who is currently working to save lives in Parma, Italy, told Channel 12 that things are only getting worse as the number of patients keeps growing.

    As his department receives coronavirus patients who are terminally ill, the focus is to allow patients to meet loved ones and communicate with them during their last moments despite the quarantine regulations. Other reports claim that, as the number of dead increases, some families find themselves unable to secure a proper burial for their loved ones.

    Peleg said that, from what he sees and hears in the hospital, the instructions are not to offer access to artificial respiratory machines to patients over 60, as such machines are limited in number.

    https://www.jpost.com/International/Israeli-doctor-in-Italy-We-no-longer-help-those-over-60-621856

    Yikes.

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  13. Haakon Dahl:
    Somebody (Civil Westman?) recently mentioned QUALY (quality-adjusted life-years), which is a grown-up approach to guidance in one aspect of making decisions such as these.

    It was Civil Westman (@ateransere) and here’s the link.

    This is the grown-up approach but the nation is running short on grownups lately in preference to crying soccer moms. Here’s hoping the grownups carry the day.

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  14. On the SS Earth how many lifeboats are there for critical care? I am sure it depends on the nation with poorer nations left with few.
    Here is the list of hospital beds per 1000 for countries.
    https://en.m.wikipedia.org/wiki/List_of_countries_by_hospital_beds

    On the list this is some of the numbers.
    2017 Numbers per 1000 people

    1. Japan 13.05

    2. South Korea 12.27

    14. Hong Kong (2015) 5.4

    17. Switzerland 4.53

    26. Italy 3.18

    29. Spain 2.97

    32. USA (2016) 2.77

    35. UK 2.54

    36. Canada 2.52

    40. Mexico 1.38

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  15. Here is the question I think should be asked to every open border supporter.

    In a pinch, will illegal immigrants get care and citizens not get care?

    I think it illustrates the problem of illegal immigration.  Of course everyone should get treated, but what does it mean to be a citizen if citizenship isn’t even a variable in a life or death decision?

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