COVID-Surge Triage Simulations Help Clinicians Make Life and Death Decisions

By Ronnie Cohen

April 26, 2022

(Reuters Health) - What happens when a region runs out of ventilators or intensive-care hospital beds during a COVID-19 surge?

Clinicians say that triage plans for distribution of scarce resources help them to navigate crises but don't lessen their struggle with implementing the plans, a new study finds.

Researchers enlisted 41 physicians, nurses and ethicists in the state of Washington for 12 multi-institutional triage simulations. The teams were tasked with grading patients' chances of surviving long enough to be discharged from the hospital.

Blinded to the identities of the patients, the clinicians grappled with the clinical uncertainties and ethical challenges of deciding who would get limited resources needed to live, the qualitative analysis found.

"Despite our attempts to very carefully define the role of the triage team, the clinicians still encountered clinical and ethical questions," lead author Dr. Catherine R. Butler told Reuters Health in a phone interview. "Our hope was to minimize the amount of reasoning that had to be made on the fly."

"What this - and the whole pandemic - has taught us is that there's ways to prepare," she said. "But it's always going to be a challenge."

Dr. Butler, a nephrologist at the University of Washington, in Seattle, and her team drafted the triage simulations based on hospital census data during a surge in COVID-19 cases. Participating clinicians and ethicists broke into teams with at least two clinicians and an ethicist. Each team met three times - for a 60-minute orientation, a 90-minute triage simulation and a 30-minute debriefing - over Zoom from December 2020 until February 2021.

Researchers silently observed the team dynamics and decision-making, and they conducted post-simulation interviews with a sample of participants.

The qualitative study in JAMA Network Open includes quotations from the interviews, many of which capture the conflict team members felt about having to turn away people in need.

The exercise was intended to divorce clinicians, who could not look at the faces of the patients or their loved ones, from their emotions. That proved impossible.

"We could just have a computer do this work," one emergency physician said, "but we have chosen to specifically not to. And I think the reason is because of that human connection."

"One of the ways I'm going to be able to sleep at night is by knowing that I wrestled with it," said another emergency physician. "It helps me feel like we're really honoring the patient in a way that can't be honored when you just adhere to an algorithm...that struggle and that investment makes the process more humane and more palatable."

Dr. Butler expected physicians and nurses would have an easier time separating the clinical from the emotional than they did.

"Some of the clinicians saw this as bringing not just their clinical skills but their sense of compassion to this operation," she said. "They were still grappling with it and still being human beings. I was surprised. I didn't anticipate that."

Dr. Daniel Sulmasy, director of the Kennedy Institute of Ethics at Georgetown University in Washington, D.C., was not involved with the research. He fully expected the struggle.

The study "illuminates basically how hard this really is," he said in a phone interview. "Maybe it doesn't take a study to prove that. In some ways, some of the best studies prove what we intuitively know, and I think this gives some flesh to that."

The study showed, Dr. Sulmasy said, "It's hard to do this psychologically; it's hard to do it statistically. There's a lot of uncertainty."

"Fortunately, it was based on simulations," he said. "Nobody had to actually do these things."

Still, the study showed, clinicians appreciated being able to discuss the questions and make decisions in groups.

"It should not be an individual decision," one emergency physician said. "It's just too weighty. But when you hear everyone else talk it out, there's a comfort in that. There's a comfort when the team gets to relative consensus. There's a relief."

Several team members said the study served as important practice and preparation for a real-world triage scenario. Clinicians also appreciated ethicists' input in clarifying thinking and exposing value conflicts.

Ethicists recognized the difficulty clinicians had disengaging emotionally. "As much as we'd like to think it's all based on numbers," one ethicist said, "it's still a very human enterprise."

SOURCE: JAMA Network Open, online April 18, 2022.