Israel drawing up triage options if coronavirus overwhelms health system

But in the draft of a paper on ethics by the Israel Medical Association, age will not be a factor in deciding who should receive care

By Ido Efrati, HAARETZ  | Mar. 20, 2020

The Israel Medical Association is drawing up a list of principles for treating serious coronavirus cases if the health system becomes overloaded as has happened in Italy and other countries in recent weeks – though age will not be a factor.

A position paper by the association’s ethics board, a draft of which has been obtained by Haaretz, discusses the dilemmas that may arise.

If intensive care units are overly taxed and there is a shortage of ventilators, doctors will have to consider a patient’s chances of recovery.

The paper, “Ventilation and Intensive Care in Stormy Corona Times,” is intended for “extraordinary conditions of a huge imbalance between needs and available resources,” the ethics board said.

The guidelines are based on a previous paper on handling a mass-casualty event. As Dr. Tami Karni, the head of the association’s ethics board, put it, “If during routine times doctors operate according to the principle of providing the best of care to each and every patient, in the current situation this principle is replaced by one where you provide the best possible medical care to as many casualties as possible and not the best to all of them.

“When there is a terrible flood of cases we want to save as many lives as possible. When the existing resources can’t answer everyone’s needs, we will want to save as many patients who have a chance to survive and we will be forced not to ‘waste’ any very expensive resources on those who can’t be saved.”

In the Lombardy region in northern Italy, the epicenter of that country’s outbreak, the health system has been overwhelmed for weeks. Medical staff thus are prioritizing difficult cases based on age and extent of need – thus giving priority to younger patients.

According to the draft of the Israeli paper, “Based on data from the first two weeks in Italy, about a tenth of infected patients require intensive care via invasive or noninvasive ventilators.”

In the paper, age is not a consideration. “We have decided that a physician can’t be a party to a decision about budgeting resources based on nonmedical criteria such as age, gender, religion, race or economic or social status,” Karni said.

Doctors are instructed to consider only medical criteria in the sorting of patients.

“Budgeting is a complicated and very delicate choice,” the paper says. “An exaggerated rise in available intensive care beds does not ensure proper treatment for all patients on ventilators.”

Karni added: “The dilemma in deciding how to distribute resources is very complex and doesn’t only depend on ventilating machines and other medical devices. There’s a limit to the personnel and their training – even if you have some of the technical means, you can’t provide the best care to everyone.”

She said that “even if we choose the first come, first served option, it hurts the patient who arrives later, so the principle that must guide the choice of serious patients is always weighed with flexibility within the range of your resources and the patient’s condition.”