Over 170 participants in Covid-19 forum
Over 170 people have participated in an online forum hosted by Health Issues Centre to discuss ethical triage during the Covid-19 Crisis.
The event was held on April 2 to give community representatives of vulnerable groups such as the elderly, people with disabilities and those with co-morbidities an opportunity to feed into the discussion about triage decision-making.
Many of these groups fear they may be the first to miss out on scarce resource allocation if hospitals become overwhelmed.
CEO of Health Issues Centre, Danny Vadasz acknowledged the enormity of the challenge facing the group.
“Today is going to be the most difficult thought experiment you have ever engaged in,” he said.
“I don’t know how far we can get toward achieving a useful result. But we owe it to the vulnerable and the disadvantaged in our society, who are most likely to bear the impact of COVID-19, to give it a red-hot go.”
We will answer to future generations
This sentiment was echoed by leading ethicist Dr Paul Komesaroff, who delivered a stinging charge.
“If we have values worth defending, this is the time we need to fight for them,” he said.
“We will be judged by future generations on how we respond to the present crisis. We need to keep our ethical nerve.”
Mr Vadasz said the event was critically important to ensuring that consumer voices were part of the conversation.
“Unsurprisingly, the discussion to date has been dominated by clinicians, academics, researchers and policy advisors but the concerns and perspectives of vulnerable groups have yet to be aired,” he said.
“This may be the only opportunity for vulnerable communities to influence these life and death decisions.”
Leading intensive care specialist, Professor Charlie Corke, spoke sobering detail about the experiences of frontline staff who may be called on to make triage decisions – and what it’s like to be a patient in such circumstances.
“What we do to patients with this personal, protective equipment on when everyone is terrified of you, doesn’t want to touch you doesn’t want to go near you, has to wear all this stuff – it’s pretty dehumanising,” he said.
“It’s hard to have humanity in all this. And isolation on your own is frightening.
“Everything we have to face will be very confronting. Committees to back up (triage) decisions may be very helpful, but the evidence is that committees don’t do particularly better than doctors … these decisions are not easy.”
Covid-19 not a death sentence
Professor Corke suggested that there was reason to be optimistic.
“We know that this disease is worse with increasing age and increasing co-morbidities and increasing frailty but it’s not all bad,” he said.
“The evidence from recent infection in Washington state in a number of long-term care facilities – the mean age of patients who were infected was 83 years, 94 of them had chronic underlying conditions and there was a one third mortality amongst them.
“But I was impressed not by the one third mortality but the two thirds who didn’t die; and a lot of them had very mild symptoms. So I think we can all take away that there is the opportunity with this disease to be lucky and (dying is) not an inevitability.”
A shift in mentality
Cathy Mead, board member and former president of Council on the Ageing (COTA) Victoria, said managing the crisis would require a mind-shift from clinicians.
“We are in the process of adding to the duty of care the duty to manage scarce resources and that’s a shift that clinicians are going to have to make,” she said.
“And we make the shift by saying ‘all patients are eligible for care’ and then we consider how to prioritise that care.
“There should be no social criteria for exclusion from treatment but there may be some social criteria for inclusion and priorities. For example, we might want to give priority to healthcare workers. We might want to give priority to indigenous people.”
We saw it coming
Health Issues Centre Board Chair and consumer expert Sophy Athan said consulting the community was a vital part of developing an effective response to a major health crisis and she hoped this discussion would inform future planning and preparedness.
“We need to not only engage in the conversation but we actually need to have these policies in place for the future,” she said.
“There’s been discussion over the last ten years that we are anticipating a pandemic … so we have had sufficient warning. My question is, could we have prepared a little bit better? This is the beginning of potentially some further health crises that could be emerging in the future. Maybe there are lessons to be taken from that.”
Professor Vasi Naganathan, academic at the University of Sydney and expert geriatrician shared some oddly prophetic research he had been involved in that studied how Australian and New Zealand residents felt triage decisions should be made in the event of a flu pandemic.
The research showed consumers had a clear preference for doctors to make triage decisions – informed by present circumstances – with guidelines from health departments as a close second.
Clearer guidance
Professor Naganathan also raised the issue of whether assessment tools would assist clinicians in making decisions at the pointy end of care.
“Age does come into it because older people are more likely to have health problems, multiple diseases and frailty. So do you use a tool for frailty? Do you use a tool to determine how sick someone is?,” he said.
“The problem with all tools is they tell you what a group will do. They’re not particularly accurate for the individual and a lot of people forget that. One of the concerns that geriatricians have is that the tools that are used for older people will be used for people with disability … and it’s important to not think about people with disability in the same way as older people with comorbidity and frailty.
“But there is an appetite for using tools because people feel that it provides some clear guidance for what people should do.”
Concerns of the vulnerable
A key concern raised by consumer participants in the group was a widely-held fear that for people with lung conditions, Covid-19 is all but fatal.
Professor Naganathan was quick to address this.
“It’s factually incorrect to say if you have a chronic lung condition and you get Covid you are going to die,” he said. “You have a slightly increased risk.”
Professor Charlie Corke agreed, saying, “I completely agree that if you have a lung disease, it’s not a death sentence. We do have treatment options.”
Next steps
Following the plenary session, attendees then divided into around a dozen breakout groups to discuss the issues and formulate key principles or recommendations. Health Issues Centre is now reviewing and collating these and will publish a communique reflecting the most common sentiments, within the next few days.
The Health Issues Centre team will publish a video of the plenary session in the coming days. Feedback and questions from the session are also being collated and full responses will be published on the Health Issues Centre website, with links from our social media pages.
