Attending Doctor Should Decide Life or Death-No One Else!

By Deane Waldman, MD MBA - 10/04/20

Elected officials such as New York and Atlanta mayors as well as clinical physicians, viz., in Maryland and Colorado, are projecting there will be more patients who need life-saving CoViD-19 services than there are facilities--ICU beds and ventilators--available. Such an imbalance between the needs of critically ill patients and healthcare capabilities requires triage, deciding who gets care and who waits.

Who should do the triage? Who should make the life or death decision?

Triage of the sick or injured started on the battlefield probably during Napoleon's 1799 siege of the ancient city of Acre in northern Israel. Many of his troops became ill from poor sanitation and inadequate food. The soldiers were separated or "triaged" into those fit to fight and those who were not.

The word triage comes from the French trier, meaning to separate out or to categorize. What Napoleon did is called primary triage: those who were unfit and could not be rapidly restored to fighting condition were left to die.

Between 1800 and the 1930s, a soldier injured on the battlefield was taken to medical facilities usually a long distance, necessitating a long time between injury and care. Those who had less immediately life-threating injuries survived to reach medical care and those with more severe injuries died in transport. In essence, the triage doctor was time.

During the second World War, the time between injury and care was dramatically shortened by placing hospitals right next to battlefields. A large number were saved who would have died in transport. Even so, there were only a small number of doctors and a larger number of injured combatants. Doctors and nurses observed the wounded entering the battlefield hospital and triaged them according to who was the sickest. Those most likely to die came first, except for those with injuries the triage officer considered unsurvivable.

Triage was done on a case-by-case basis performed by a care provider on the scene. With the current talk about a limited number of ventilators or insufficient drug supply for those sick with CoViD-19, there is concern about how to triage critically ill patients.

Who should be your triage officer?

Who should make the triage decision: state or federal politicians, a hospital committee, an administrative physician, or the doctor on the scene?

According to NBC News, "Amid growing fears that the United States could face a shortage of ventilators for coronavirus patients, [Maryland] state officials and hospitals [emphasis added] are quietly preparing to make excruciating decisions about how they would ration lifesaving care."

A Boston Globe headline read, "New gut-wrenching state guidelines [emphasis added] issued on rationing equipment, ICU beds" for critical CoViD-19 patients.

Dr. David Marcozzi, director of the coronavirus response for the University of Maryland Medical System, said the state [emphasis added] should create "crisis standards of care."

Triage--choosing life or death--for a patient is the ultimate medical decision. Legally as well as ethically, neither the state nor a hospital can triage. The only person who can or should triage patients is the attending physician, a licensed practitioner on the scene who accepts responsibility for that patient and is held accountable for that patient's welfare.

An Italian physician put it succinctly as, "It is a fact that we will have to choose [whom to treat] and this choice will be entrusted to individual operators on the ground."

Personal or population medicine

Clinical doctors make decisions for individual patients one at a time. Doctors practice personal medicine--retail in a sense--not population medicine, not wholesale.

Crisis standards of care are intended to "prioritize survival of the group over survival of an individual patient during disasters," such as the current pandemic.

As an emergency physician in Denver said, "Normally, we operate with the individual patient's best interest at heart." But during this pandemic, "You're looking for the most good for the greatest number - it really is a shift."

No! This is a shift we cannot and must not make. The physician staring at ten CoViD-19 patients in respiratory failure and only eight ventilators is responsible for those ten patients, not the other 600,148 residents of Denver, CO.

Morally and legally, doctors practice personal medicine, not population care.

Guidance is orders

Undoubtedly, the argument will be advanced that these official guidelines, standards, or advisories for triaging patients are merely guidance, suggestions, and advice. This argument is disingenuous or certainly unrealistic.

Every practicing clinician knows these pronouncements are effectively orders. They are commandments written in stone brought down from Mount Sinai (state capitols or Washington). You deviate from them at the risk of your license, hospital privileges, even criminal penalties.

Using crisis standards or guidelines, bureaucrats are practicing medicine on patients. That is both improper and immoral.

Conclusion

We must protect the direct fiduciary connection between doctors and individual patients. There should be no other person or group making these Solomon-like life or death decisions. The only person who should triage you is the doctor on the scene.