Triage in the time of COVID: if you need hospital treatment, what will you get?

There is good and bad news about the potential for Sydney and Melbourne hospitals to be overwhelmed in October, and again after we open up.

Let’s start with the good. Estimated rates of the voluntarily unvaccinated have gone into decline. The latest survey from the Melbourne Institute has only 12% of Australians saying they won’t get vaccinated. When combined with those who remain unsure, the figures suggest that Australia can achieve at least 85% of the population fully vaccinated once supply issues have been resolved.

The bad news is that because of ongoing vaccine supply issues, Sydney and Melbourne — in addition to being locked down for months and months — are predicted to hit peak caseloads in their hospitals in October. Peaks that may also resurface when 80% of the population is double-vaxxed and Australia stops using lockdowns to suppress COVID-19 and opens up for good. Healthcare providers fear this could overwhelm the hospital system and, because of an undersupply of ICU beds and ventilators, force competition for care.

Such competition is a nightmare for patients — and clinicians too. Imagine being an intensivist on call for a COVID-streaming hospital and you get a call from the junior doctor on shift saying there is just one ICU bed and two patients in the ED who need it. There are no other beds in the city that can take the patient, and the decision needs to be made quickly so the person chosen has a chance to survive.

No individual health practitioner should have to make such a choice by themselves or according to their own value system. In Alberta, Canada, where the hospital system is currently overwhelmed, public debate about how such decisions should be made has led to a public-facing document about how ICU beds would be allocated when resources became scarce.

In Australia, we have had no such conversation despite clinicians begging for it, and for the processes, protocols and decision tools that will allow for such decisions to be made consultatively, consistently and in ways the community agrees is fair.

Lacking this, I think it’s critical the community weighs in. Because while we don’t know exactly how COVID-streaming hospitals will prioritise — or triage — care, we do have some clues. These include disclosures from academics who were given privileged access to COVID protocols developed by individual hospitals, and guidelines issued by the Australian and New Zealand Intensive Care Society (ANZICS).

Emergency care is always prioritised. In pre-COVID times, the usual standard of care would be delivered within set time periods according the acuity of a patient’s presentation, with patients needing more urgent care (like those suffering a stroke) getting seen before those with a sprained ankle.

Triage in a time of COVID is designed to help clinicians decide which critically ill patient — whether they are acutely ill from COVID or having a heart attack — will get the ICU bed or ventilator which will mean the difference between life and death.

The ANZICS guidance tells intensivist clinicians to allocate treatment to patients most likely to benefit from it. That is, to patients more likely to recover from their acute illness and leave hospital if they get treated. Their chances of living a good and long life should be considered as well.

So if you have co-morbidities or are older than others in line for the bed, you could miss out and be sent for palliation. Some hospitals require consideration of other criteria that could reduce a person’s chance of surviving longer term with a reasonable quality of life. Like being obese or being dependant on alcohol. And if push really comes to shove, the intensivists think it’s ok to use the following criteria to decide who gets treatment: patients who are members of socially deprived and disadvantaged groups, have caring responsibilities, are younger or are healthcare workers or their family members.

Thinking about rationing care is painful for doctors and patients alike. It flies in the face of our ethical values and legal principles that say we all are equal and have equal rights, including to life.

But while it’s right to criticise governments who had eighteen months to prepare for this moment but failed to ensure adequate surge capacity was there, that’s not going to change the difficult decisions our healthcare providers are currently being forced to make and will continue to make in the coming weeks and months.

Saying it’s cruel and heartless to suggest additional or alternative criteria on which allocation choices should be made (like vaccination status) or unethical to raise the discussion at all doesn’t make the dilemmas our healthcare providers face go away.

It just means they face them alone.