States ponder worst-case scenario H1N1 decisions

Federal officials maintain that the chances of U.S. intensive-care units being overwhelmed by flu patients in the coming weeks are remote, but what if they are wrong? States are beginning to struggle over triage guidelines in the event of a worst-case flu pandemic. "In recent years, officials in a host of states and localities, as well as the federal Veterans Health Administration, have been quietly addressing one of medicine’s most troubling questions: Who should get a chance to survive when the number of severely ill people far exceeds the resources needed to treat them all?," Sheri Fink of ProPublica reports.

Triage guidelines in some states instruct doctors to refuse ventilators or admission to hospitals to patients with "Do Not Resuscitate" orders, the elderly, those requiring dialysis, or those with severe neurological impairment, while others apply triage guidelines to mental institutions, nursing homes, prisons and facilities for the "handicapped" before the general public. Most triage plans were created for mass casualty events, not disease outbreaks, Fink reports. "Exclusion criteria," which bar certain categories of patients from standard hospital treatments in a severe health disaster, and "minimum qualifications for survival," which instruct doctors to remove essential treatments from patients who are not improving within a certain time frame, in state plans have sparked controversy.

Dr. Frederick Burkle Jr. outlined these features in a post-9/11 journal article suggesting triage plans in a large-scale bioterrorist event. Now some are arguing against one-size-fits-all approaches to triage. Some state pandemic plans call for hospitals to remove patients from ventilators if they are not improving after two to five days, Fink reports, but studies show that people severely ill with H1N1 flu generally need a week to two weeks on ventilators to recover. State and federal officials say formal rationing is the last in a series of steps designed to stretch scarce resources and protect the public, but even Burke doesn't think current plans fit the possibility of a flu pandemic. He tells Fink: "I have said to my wife, 'I think I developed a monster here.'" (Read more)