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Crisis Level ICU Triage Is About Saving Lives.

We described a system to assist physicians in making complex and morally difficult decisions triaging scarce critical care resources in times of extreme distress of their healthcare systems in our article (1), recently published in Critical Care Medicine. Our article is accompanied by an editorial with inaccurate and troubling assertions (2). Zivot (2) sees the role of the triage officer as an executioner instead of a rescuer. He blames the rescuer of rationing when trying to reduce the harm caused by an overwhelming pandemic and/or previous hospital or government decisions and lack of preparedness. Avoiding the need for triage should be the highest priority for governments and those coordinating the response to coronavirus disease 2019 (COVID-19) (3). Being unable to offer care when the resource does not exist is not killing. There is a fundamental and obvious difference between triaging patients with a greater likelihood of surviving to save more patients than directly killing them. Triaging patients is part of standard critical care practice with examples of prioritization for organ transplantation and extracorporeal membrane oxygenation. The poor outcomes observed in many disasters are often the result of inaction and poor implementation of the necessary measures required to prevent or mitigate the impact of disasters (4). We address one aspect of implementation of necessary measures to mitigate the potentially disastrous impact of the COVID-19 pandemic. Every element of our algorithm (performance score, ASA score, and organ failures) has a correlation with mortality. As they predict mortality, if appropriately used to triage patients, they will save lives overall. The suggestion by Zivot (2) for the first-come first-serve system is a form of lottery to assure that people are treated equally, but in fact saves less people. Our algorithm uses exclusion and inclusion criteria and four different priorities to triage patients. It is only when there is a tie that saving the most life-years is used. Using most life-years allows for the saving of more lives because of acute and chronic illness and has nothing to do with the elderly consuming life they no longer deserve. We clearly state that what is important is physiologic and not chronological age (1). We are not allowing older individuals to die because of their age, but rather, we are using objective medical criteria to define survivability, anyone of any age who has a lesser likelihood to survive. Giving preference to the young is widely acknowledged as not necessarily being equivalent to age discrimination based on the “fair innings” or “life cycle” approach (5). Life support decisions are complex and demand extensive medical, logistical, and systems knowledge. Prioritizing and triaging life-supporting systems especially during pandemics when some patients who might ordinarily be saved cannot be saved is stressful and creates substantial moral distress (6). Our policy does not propose that clinicians refuse to treat patients because of moral distress, as suggested by Zivot (2). We recommend objective protocols to assist the implementation of triage decisions and thereby decrease the provider’s moral distress. Charles L. Sprung, MD1