The May 2008 article in Chest journal DEFINITIVE CARE FOR THE CRITICALLY ILL DURING A DISASTER
(available at http://www.chestjournal.org/content/vol133/5_suppl/)
and ALLOCATION OF VENTILATORS IN A PUBLIC HEALTH DISASTER published in Disaster Medicine and Public Health Preparedness Vol 2/No1, recommends that health care workers do not receive any preferential treatment in a pandemic. Many other planning documents recommend the same. I have a great deal of respect for these documents and the people that wrote them. The authors of these documents are trying to make plans that will save as many lives as possible during a pandemic using the limited resources that they expect will be available to the health care system. They try as much as possible to stay within traditional ethical guidelines, but insist that the principle of doing the greatest good for the greatest number of people is the primary principle and this should override values based on the traditional ways of delivering health care.
The principal rationales for not providing health care workers with preferential access to ventilators are these:
- Fundamental ethical principles demand that there is no discrimination in access except for survivability criteria. Discrimination based on age and health status is acceptable because this allows the triage team to identify which individuals are more likely to have an increase in survivability by having access to the limited supply of health care.
- It is unlikely that a health care worker that is given preferential ventilator access during a pandemic will recover in sufficient time to be able to come back to work and help others before the pandemic is over.
- The triage protocols demand that certain persons be given authority to decide who gets access to medical treatments in limited supply. The public must trust that these persons will make decisions based on the pre-established rules and sound ethical principles. If the public believes that the decision makers are giving preferential access to people that they personally know, it may undermine this trust.
Discussion of Point #1
I believe that the principle of non-discrimination except for areas where it improves overall survivability is very valid and should be pursued. Where the argument for not favoring health care workers may fail is that it considers the availability of healthcare in a pandemic to be a zero sum game; that whatever is available at the beginning of a pandemic is all that will be available. They state this explicitly when they say that whatever is used to help health care workers will not be available to help the general public. This is may not be entirely true, as I will outline in point 2.
Discussion of Point #2
Now it may be so that once stricken, the health care worker as an individual may not be able to contribute a positive benefit to the pandemic care effort, but it is wrong to look at health care workers strictly as individuals. Health care is a team effort. The work that must be done by health care workers during a pandemic is not the routine of the non-pandemic. Society will demand that health care workers place themselves (and possibly their families through indirect exposure) at greater personal risk than the general public, and will demand that they work under more severe and hazardous working conditions and longer hours than they normally do.
It is essential that health care workers are motivated to not only work under these conditions, but to provide the most and best quality work they can. Staffing level is one of the key issues identified as a major limiting factor in being able to provide the maximum care to save as many people as possible in a pandemic. One way to get staff to work more would be to impose stringent laws and use force to draft anyone able to provide health care to work whether they want to or not. This would not be good way to get maximum efficiency from all workers and most plans do not recommend it. The workers must be motivated to provide the very high level of performance expected from them during a pandemic.
The health care worker component of a pandemic shortage is not a zero sum game. Some conditions will encourage healthcare workers to go to greater lengths to provide the most that they possibly can, and other conditions will cause them to retreat from working into a place of self preservation. It is not as straightforward either as being that worse conditions cause more people to retreat. Many people will work very hard in poor working conditions and even in situations of great risk if they feel their cause is just. Military organizations understand this, and place a great value on maintaining morale, group cohesion and supplying a valid reason for soldiers to contribute their maximum effort.
The US military is known as being one of the finest fighting organizations in the world. They do not rely only on just having the best equipment, but also focus on getting the maximum that they can from their people. One of the ways they do this is by saving every captured or injured soldier that they can. The principle is best stated in the Ranger Creed of “No Man Left Behind”. (See http://www.yaleherald.com/article.php?Article=532 for a discussion of this.) Each soldier is willing to risk his life to save his fellow soldier, even in the face of extreme odds, because he knows that the other would do the same for him. This cohesion and dedication then translates into a high degree of effectiveness for the many other things a soldier is asked to do.
Now look at two scenarios, handled in different ways and what could be the possible outcomes. Both scenarios start the same way. A pandemic strikes; workers are worried for their safety, but feel a sense of duty and commitment to work. Most show up for work, but are not sure about volunteering for extra work. Some are distrustful that their employers are doing everything they can to protect them and stay away from work. They talk about this a lot at breaks. One of the nurses gets sick and needs a ventilator. The other staff believes she got sick from caring for a pandemic patient.
In the first scenario the nurse is refused a ventilator so that it can be given to another person. The other staff worries that they too may get sick and believe that not enough will be done for them. More staff now stays home from work. The hospital can now care for less patients than they could before due to staff shortage.
In the second scenario the nurse is put on a ventilator. Other workers volunteer extra hours to make sure she is well looked after. Some workers that initially stayed home now also come to work. They have greater trust that they will be looked after if they get sick and also wish to be available if any more of their coworkers get sick and need help. The hospital can now care for more patients than they could before.
It is interesting that the second scenario works even if the nurse does not survive. It is the fact that they were able to try to save her that is important.
Discussion of Point #3
The public may accept that health care workers will go to great lengths to care for their own. We accept this from other groups that put themselves in danger in order to protect us. Two examples are police and firefighters. When they go to great lengths to save one of their own, or in the case of police to obtain justice for the death of one of their own, the public does not complain that they are now providing a lower level of service to the rest of us. We accept this, and even demand it. When it was found out by the public that many injured Iraqi war veterans were poorly treated the public demanded that conditions improve. The same happened for many police and firefighters injured in 9/11. The public respects the risks that people place themselves in for the public good and demand that they receive the best care possible when they are hurt in the line of duty.
I would like to believe that I would do everything I can to help in a pandemic crisis regardless of risk to myself, and I think most people feel this way. I just can’t be sure that everyone will actually act so magnanimously when a crisis actually occurs. A lot can be learned from studying staff reactions during the SARS crisis in Toronto when some people felt that the hospitals involved did not provide adequate information and protection to staff working with SARS patients. I understand that the critical care system is a public trust and that the health care workers cannot arbitrarily use these resources preferentially for themselves. The triage plans that have been published take a much more pragmatic approach to the allocation of scarce resources such as ventilators in a crisis such as a pandemic. These plans are willing to forgo systems that are currently used such as first come, first served, in favor of allocation systems that will save the most people possible. Perhaps they should study how staff will actually behave in a pandemic system, and adjust the plans accordingly if it could in fact save more total lives.
Maybe this is the place for the Pandemic Ventilator. Maybe if healthcare workers volunteer extra hours to look after their own in a pandemic and even build their own ventilators…