Tag: triage

Bioethics Blogs

Harvey and Irma: Bioethics in Natural Disasters

by Craig Klugman, Ph.D.

This is a time of disaster. Last week Hurricane Harvey devastated Southeast Texas, a place where I did my doctoral studies. This week we are awaiting Hurricane Irma, the strongest hurricane to head toward South Florida in 25 years. My family lays in the path of that coming storm. I first became interested in natural disaster in 1989 when my college campus was jolted by a 7.1 earthquake in Northern California.

Bioethics has a role in responding to and preparing for these natural disasters. Most every state, large city and county, and most hospitals have been working on crisis standards of care plans. In 2009 and again in 2012, the Institute of Medicine recommended governments to undertake such planning. Many of us working in bioethics have been involved in these efforts. More specifically, we have been involved with developing ethical frameworks for decision-making, policy-making, and operations during emergency planning.

I worked with Texas during its planning for pandemic flu and for the last 3 years have been part of the ethics subcommittee of Illinois’ workgroup, most recently as chair. Similar groups have produced excellent reports in many places such as Delaware, North Carolina, Michigan, Minnesota, Tennessee, Texas and Toronto. They offer guidance and justification for a varied set of guiding principles and ethical frameworks. All of them hold certain core ideals in common.

First, all of the reports agree that transparency and open communication is essential. Planning needs to involve not only government officials, but also community members.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Jewish Guide to Practical Medical Decision Making

Check out
this new 368-page
book
 from Rabbi Jason Weiner: Jewish Guide to Practical
Medical Decision Making.


Due to rapid advances in the medical field, existing books on Jewish medical
ethics are quickly becoming outdated. 
Jewish
Guide to Practical Medical Decision Making
 seeks to remedy that by
presenting the most contemporary medical information and rabbinic rulings in an
accessible, user-friendly manner. 


Rabbi Weiner addresses a broad range of medical circumstances such as surrogacy
and egg donation, assisted suicide, and end-of-life decision making. Based on
his extensive training and practical familiarity inside a major hospital, Rabbi
Weiner provides clear and concise guidance to facilitate complex
decision-making for the most common medical dilemmas that arise in contemporary
society.


1. Facilitating Shared Decision-Making 

A. Understanding Terminology: Key Concepts to Facilitate
Collaborative Decision-Making

B. Truth-Telling: When Painful Medical Information Should
and Should Not Be Revealed 

C. Mental Illness: Determining Capacity and Proper Treatment
in Accordance with Jewish Law  


2. How Much Treatment? 

A. Risk and Self-Endangerment: Determining the
Appropriateness of Attempting Various Levels of Dangerous Medical Procedures

B. Making Decisions on Behalf of an Incapacitated Patient

C. Pediatrics: Jewish Law and Determining a Child’s Consent
and Treatment 

D. Palliative Care and Hospice in Jewish Law and Thought


3. Prayer  

A. Is Prayer Ever Futile? On the Efficacy of Prayer for
the Terminally Ill 

B. Viduy: Confessional Prayers Prior to Death


4.  At the End of Life

A. Advance Directives and POLST Forms  

B. End-of-Life Decision-Making: DNR, Comfort Measures,
Nutrition/Hydration, and Defining “Terminal” in accordance with Jewish Law

C. Withholding vs. Withdrawing: Deactivating a
Ventilator and Cessation of Dialysis and Cardiac Defibrillators at the End of
Life

D. Case

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

New Section: Law & Bioethics

New Section: Law & Bioethics — Voices in Bioethics

New Section: Law & Bioethics

Apr 19

Apr 19 New Section: Law & Bioethics

Politicize my Bioethics: Compensation for egg cells

Nov 11 Politicize my Bioethics: Compensation for egg cells

Call For Stories

Mar 23 Call For Stories

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Call For Stories

Call For Stories — Voices in Bioethics

Call For Stories

Mar 23

Mar 23 Call For Stories

Celebrity Medicine: Ben Stiller’s Prostate Edition

Dec 7 Celebrity Medicine: Ben Stiller’s Prostate Edition

New Section: Law & Bioethics

Apr 19 New Section: Law & Bioethics

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics News

Terrorism and triage

Imagine that you are a doctor responding to an emergency in Israel. A terrorist has attacked people in a shopping mall with a knife, stabbing some old women and children. A policeman has shot and seriously wounded the terrorist. Whom should you treat first?

This is a classical triage situation in which the worst are to be treated first. The conventional view is that doctors must be “colour-blind” in treating victims. If the terrorist is the worst injured, he should be treated first.

In an article in the Journal of Medical Ethics, two Israeli doctors question this. Value-neutrality can lead to injustice, they contend, even if “ the virtuous euphoria that accompanies the subjective neutrality-maintenance effort” seems ethically pure.

In any case, “value-neutrality” is a myth, they claim. Deciding which organ to treat is a neutral decision; deciding which person to treat always involves the invocation of values. In fact, a strict “no exceptions” rule could easily be “a manifestation of conservative stagnation, induced by fear of change, or even masked political-correctness.”

In their analysis they argue that on three counts, victims deserve to be treated first:

• “Terrorists do not deserve the right of higher priority in the terror-triage dilemma (retributive justice).

• “The higher societal merit of the victims makes them eligible for higher priority (distributive justice).

• “The terrorist, who intentionally caused the victims’ injury, should be of lower priority than the victims (corrective justice).

In a commentary on this controversial view, Michael Ardagh, of Christchurch Hospital, in New Zealand, disagreed with the Israelis’ analysis.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

BioethicsTV: Mass Casualties & Triage

by Craig Klugman, Ph.D.

Chicago Med (Season 2; Episode 14). Over the last few years I have been working in the area of crisis standards of care. In fact, just today I presented the conclusion of 3 years of work on an ethics white paper to the state of Illinois crisis standards of care task force leadership. Serendipitously, tonight’s episode of Chicago Med dealt with a limited mass casualty situation: A multiple car pile-up on a freeway brings a large number of patients to the hospital. However, there is a major snowstorm and there is no chance of additional personnel or supplies coming to the hospital. How do they deal? First, they moved all able-bodied patients in the ED to the waiting room. Second, they canceled all non-emergency surgeries and reassigned staff to the ED. Both are good moves and follow what most crisis guidelines to prepare for the influx of crisis patient.

One of the patients brought to the ED suffered third degree burns over 90% of his body when his car caught on fire. Dr. Latham declares the patient to be “black tag.” In a mass casualty incidence, triage comes into play to determine which patients to treat and in what order. There are those who seem okay, those who need treatment but can wait, those who need treatment quickly and have a good chance of survival, and those who require massive resources in their intervention and have a low likelihood of survival. Patients are sorted into these categories and given tags with the color of their group.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Triage and the Israel-Palestine Conflict: A Case of Medical Tourism

by Sarah Kiskadden-Bechtel

Medical tourism widens the sphere of available medical care beyond a single country’s borders. Patients who voluntarily leave their home country to seek treatment in other countries typically do so out of perceived medical necessity; these procedureswhich are often poorly covered by insurancerange from mandatory heart surgery, to kidney or other organ transplants. In conflict-laden countries like Israel, organ donation rates “are among the lowest in the developed world, about one-third the rate in Western Europe,”[1] giving rise to advertisements for transplants due to inherent shortage.[2] Although rabbis offer different opinions about whether organ transplantation should be permissible under Jewish law, Israeli citizens have been known to venture as far as South Africa to undergo illegal kidney transplants.[3] Clearly, there is palpable incentive for Israeli citizens to receive organ transplants; questions remain, however, regarding whether and how these organs are being obtained, and what should be done as a result.

There is some evidence that Israeli soldiers have harvested organs from captured Palestinians. In November of 2015, the Palestinian Representative to the UN Dr. Riyad Mansour wrote an open letter to the UN Secretary General Ban-Ki Moon claiming that, under Israeli occupation in East Jerusalem, Palestinians killed and seized by Israeli soldiers were being returned with “missing corneas and other organs.”[4] As a counterpoint, Israel’s UN Ambassador Danny Danon dismissed these claims ascribing them to “anti-Semitic motives.”[5] If there is any truth to Mansour’s claims, there is little clarity about which organs were missing, or whether the individuals in question were peaceful citizens or more militant aggressors.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

ICU Admission, Discharge, and Triage Guidelines: A Framework to Enhance Clinical Operations, Development of Institutional Policies, and Further Research

A SCCM task force has just published, in the September 2016 Critical Care Medicine, updated guidelines for ICU admission, discharge, and triage.  

In addition to those three topics, the guidelines also include six pages on “Nonbeneficial treatment (futile care) in the ICU.” The authors make good basic points in terminology, prevalence, prognostic scoring, CPR, brain death, ethics consults, and palliative care.

Specific recommendations include:

  • We suggest employing the term “nonbeneficial treatment” whenever clinicians consider further care “futile”
  • We suggest avoiding the current quantitative definitions of nonbeneficial treatment because of the lack of consensus on a single definition
  • We suggest against the routine use of the currently available severity-of-illness scores for identifying nonbeneficial treatments in specific patients
  • We suggest that the information provided by healthcare professionals be quantitative to reduce disagreement between the prognostic information delivered to the patients’ surrogates and their understanding and acceptance of the message
  • We suggest developing clear ICU and institutional nonbeneficial treatment policies through consensus of all the parties involved (physicians, nurses, administrators, lawyers, ethicists, and family representatives)
  • We suggest that prudent clinical judgment, in conjunction with the latest American Heart Association guidelines and specific local and hospital policies, be followed in deciding when to withhold or terminate cardiopulmonary resuscitation
  • We suggest that life-supportive therapies be removed in cases of patients declared dead by neurological criteria in accordance with local law (including potential legal restrictions associated with the patient’s religious beliefs), hospital policies, and standard medical practice and after appropriate organ donation considerations
  • We suggest the early involvement of ethicists (within 24 hr of identifying potential or actual conflict) to aid in conflicts associated with nonbeneficial treatment
  • Although palliative medicine consultations have been previously associated with reduction in critical care resources, the most recent evidence does not support a recommendation, emphasizing the need for additional high-quality research on this subject
  • We suggest following the SCCM Ethics Committee’s 1997 general recommendations for determining when treatments are nonbeneficial and for resolving end-of-life conflicts regarding withholding or withdrawing life support.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Pediatric Triage in a Severe Pandemic: Maximizing Survival by Establishing Triage Thresholds

A new study in the September 2016 issue of Critical Care Medicine develops and validate an algorithm to guide selection of patients for pediatric critical care admission during a severe pandemic when Crisis Standards of Care are implemented.

The authors found that triage resulted in: 1) more children receiving ICU care, 2) greater survival of those admitted to the PICU, and 3) greater survival among all casualties compared with first come, first served.

Because ICUs are often full even without a severe pandemic, we might consider adopting similar triage protocols for daily practice.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics News

Playing God

 

Via Radiolab: “When people are dying and you can only save some, how do you choose? Maybe you save the youngest. Or the sickest. Maybe you even just put all the names in a hat and pick at random. Would your answer change if a sick person was standing right in front of you?”

 

In this episode of Radiolab, they follow New York Times reporter Sheri Fink as she searches for the answer. “In a warzone, a hurricane, a church basement, and an earthquake, the question remains the same. What happens, what should happen, when humans are forced to play god?”

 

Produced by Simon Adler and Annie McEwen. Reported by Sheri Fink. 

 

You can find more about our collaborative public engagement effort in Maryland at: www.nytimes.com/triage

 

In the book that inspired this episode you can find more about what transpired at Memorial Hospital during Hurricane Katrina, Sheri Fink’s exhaustively reported Five Days at Memorial

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.