What do "triage" and "informed consent" really mean in practice?
In essence, there are three morally justifiable reasons for denial of ICU admission (2). The first is medical futility, based on the principle of beneficence. The referred patient is judged by the responsible ICU doctor to have a clinical condition that cannot benefit from ICU admission and care, therefore rendering ICU admission futile or of no value. Patients for whom ICU admission is considered futile are usually those who are considered to be too ill (e.g. a patient who has extensive metastatic carcinoma and has now suffered a prolonged asystolic cardiac arrest). Although not commonly described in these terms, ICU admission can also be considered futile (in terms of benefit) for those who are too well (e.g. a patient who has now recovered consciousness from a simple idiopathic generalised seizure). If it is decided by the clinician that ICU is of no benefit to the patient, either because the patient is too sick or too well, the clinician has a responsibility to deny ICU admission.
The second is patient preference, based on the principle of autonomy. The referred patient is judged by the gatekeeper to have a condition that may benefit from ICU admission, but ICU care may be unacceptably burdensome for the patient. After appropriate communication with the patient and/ or family, the patient's wishes regarding forgoing ICU admission should be respected, even when such decision may shorten his/her life.
The third is triage, based on the principle of justice. The referred patient is judged to have a condition that may benefit from ICU admission, but a limitation of resources means that not all of these patients can be offered admission. Although the term 'triage' has been used to describe different aspects of the decision to admit or decline ICU admission (3-5), it is preferable to restrict the use of the term to the definition provided in authoritative texts. Triage means 'choosing' or 'sorting' from among a group of patients who could all benefit from ICU care, to prioritise which individuals should be admitted. Triage is thus entirely the result of the need to ration resources (6,7). Therefore, a triage decision is made by necessity and not made in the interests of the individual patient (8), in contrast to decisions of futility and patient preference. While triage is often based on admitting those most likely to derive the greatest benefit (9), this is not the only criterion that has been proposed (10). A summary of the proposed decision making framework is shown in Figure 1.
Why is such detailed definition important? It is because each reason for refusal (futility, patient choice and triage) has different practical implications. Refusal on the basis of triage indicates insufficient resources to admit all who may benefit from an ICU admission, with the implication that resources should be increased. Equating patients refused on the basis of triage to refusal for any reason (3,5) or to patients who would be expected to benefit but were not admitted (1) does not allow us to determine the extent of resource limitation.
Refusal on the basis of futility (too sick or too well to benefit) implies that the patients would be refused regardless of whether resources were available or not. The decision that admission would be futile will always depend on clinical judgement, but clinicians have a duty to systematically audit these decisions from time to time. Dr Howe's data suggests that we may often be wrong in these judgements. Of those refused because they were "too sick to benefit" from ICU care, 30% survived, even without ICU care. It is not clear how the decision of "too sick to benefit" was made or by whom, but at face value, these survival results would not meet previously proposed criteria for futility (11,12). The decision regarding likelihood of benefit is a clinical judgement and therefore prone to error (8). The group of patients who were refused ICU admission due to futility but survived needs very detailed assessment to ensure that future decisions do properly identify those who are in fact "too sick to benefit". Our comments should not be seen as a criticism of the clinical care and decision making of Dr Howe's team. The ability to identify 'futile' cases is exceedingly difficult and conceptually controversial (11-13). Strategies and protocols to improve decision-making on ICU admission are of pivotal importance. The results of a study conducted in our unit several years ago resulted in not dissimilar results. This caused us an equal measure of concern and necessitated a reassessment of admission procedures. Most of our admission refusals previously labelled as futile (4) are now included in the triage category and this information forms the basis for robust requests to appropriate decision makers for additional resources.
The largest category of admission refusals in Dr Howe's study was in the "too well to benefit" group. Surprisingly, almost 10% of these patients died without ICU care and this number again acts as a reminder of our inability as clinicians to make perfectly accurate clinical judgments. These decisions should also be reviewed on a case by case basis to ensure that they were in fact "too well" for ICU to provide any benefit, and to exclude the possibility that some were in fact excluded because of pressure to conserve resources or factors that may introduce ethical or prejudicial bias (8). Dr Howe has reported on an important part of this process by his scrutiny of possible differential admission rates by racial group.
[FIGURE 1 OMITTED]
The above observations demonstrate why clearly identifying the reason for refusing ICU admission has important implications because the strategy required to improve our management of patients referred for ICU admission is directly related to the type of refusal category. In addition patients, families and society are entitled to the truth about critical health decisions that are enforced on them. It is very different telling a patient or his or her family that the ICU admission is being declined because the patient will not benefit from such treatment, from informing them that although the patient may benefit, the resource will be reserved for someone else who will benefit more. Despite potential difficulties, we strongly believe doctors have a duty to inform patients, families, society and politicians truthfully about the factors that drive critical health decisions. Only when this happens can there be an informed and reasoned approach to resource allocation (14).
Finally, for patients and/or families to be able to exercise their autonomy and make an informed decision to accept or refuse ICU admission, one essential requirement is that they should receive sufficiently detailed information about the benefits and burdens of ICU care.
The paper in this issue of the Journal by Honeybul et al (15) is a stark reminder of the technical requirements necessary for our patients to make informed decisions. Their findings clearly show us the potentially disastrous effects of failing in our efforts (15). Their choice to test the procedure decompressive craniectomy is relevant as the likelihood and nature of unfavourable outcomes have severe practical implications for the quality of life of surviving patients and families. In a simulated setting they demonstrated clearly that good quality numerical information relating to outcomes meaningfully influenced the decision for surgical intervention, expressed through agreeing to 'informed' consent. It could be strongly argued that the initial study 'patients' (actually anaesthetists) who did not receive this information were not fully informed and therefore were denied the possibility of proper and shared decision making as part of the informed consent process (16-17).
What can we learn from this paper? The lessons are many, but perhaps the most important one is the absolute need for doctors providing information to their patients to be fully informed themselves and up to date with relevant, detailed numerical information relating to the outcome of the interventions they perform.
A second important lesson is the realisation that very often such detailed outcome information is not available, or comes from populations and settings that do not resemble our own. This study therefore also highlights the need for much more effort to be devoted to relevant large-scale studies documenting patient outcomes. The development of scoring systems to determine accurate outcomes for our patients is particularly attractive, but remains a challenge. It may be best, when possible, to measure our own outcomes in our own institutions. However, few of us achieve this. A recent systematic review failed to identify even a single study that quantitatively assessed the effects of providing a surgeon's performance data to patients considering elective surgery (18).
Although the provision of relevant, high quality numerical data is strongly advocated as an essential component of informed consent, Honeybul et al (15) investigated the provision of such data in a relatively complicated format to medical professionals. Patients may not understand such information provided in this way as part of a consent process in a real clinical setting. One study has demonstrated that only about half of all adults without higher education were able to convert 1% to the number of patients in 1000, and less than one in four adults were able to convert 1 in 1000 to a percentage (19). Another study demonstrated that 16% of individuals incorrectly answered simple questions about risk size, such as which represents the larger risk when comparing 1%, 5%, or 10%20. It is therefore critical to communicate information in a form that our patients can understand. Several suggestions have been made as to how this could be achieved. It may be beneficial to put risk into context such as placing the patient's risk of developing complications in context of well-known medical conditions or nonmedical occurrences (21). Data in the form of absolute risk may sound less threatening than relative risk data and may be more easily understood (19). It may be also useful to give written information or use illustrations, in addition to providing verbal information (22).
The definition and description of triage and interpretation of informed consent provided above appear to sufficiently describe some of our ethically related decisions and responsibilities in ICU. Some may disagree with the interpretations provided and alternative proposals may be better. For example some may prefer the term "bed rationing" to the more traditional term "triage", or "shared decision making" to the traditional term "informed consent". We would not argue vigorously for the use of any particular term, but reaching a clear consensus about the precise meanings of these terms is a duty of our profession if we are to consistently provide our patients with honest explanations, clear guidance and trustworthy advice.
(1.) Howe C. Observational study of admission and triage decisions for patients referred to a regional intensive care unit. Anaesth Intensive Care 2011; 39:650-658.
(2.) Beauchamp TL, Childress JF. Method and moral justification. In: Principles of Biomedical Ethics, 5th ed. New York: Oxford University Press 2001. p. 384-413.
(3.) Sprung CL, Geber D, Eidelman LA, Baras M, Pizov R, Nimrod A et al. Evaluation of triage decisions for intensive care admission. Crit Care Med 1999; 27:1073-1079.
(4.) Joynt GM, Gomersall CD, Tan P, Lee A, Cheng CA, Wong EL. Prospective evaluation of patients refused admission to an intensive care unit: triage, futility and outcome. Intensive Care Med 2001; 27:1459-1465.
(5.) Shum HP, Chan KC, Lau CW, Leung AK, Chan KW, Yan WW. Triage decisions and outcomes for patients with Triage Priority 3 on the Society of Critical Care Medicine scale. Crit Care Resusc 2010; 12:42-49.
(6.) Gatter RA Jr, Moskop JC. From futility to triage. J Med Philos 1995; 20:191-205.
(7.) Iserson KV, Moskop JC. Triage in medicine, part I: Concept, history, and types. Ann Emerg Med 2007; 49:275-281.
(8.) Truog RD, Brock DW, Cook DJ, Danis M, Luce JM, Rubenfeld GD et al. Rationing in the intensive care unit. Crit Care Med 2006; 34:958-963.
(9.) Consensus statement on the triage of critically ill patients. Society of Critical Care Medicine Ethics Committee.
(10.) Fair allocation of intensive care unit resources. American Thoracic Society.
(11.) Schneiderman LJ, Jecker NS, Jonsen AR. Medical futility: its meaning and ethical implications. Ann Intern Med 1990; 112:949-954.
(12.) Schneiderman LJ, Jecker NS, Jonsen AR. Medical futility: response to critiques. Ann Intern Med 1996; 125:669-674.
(13.) Burns JP, Truog RD. Futility: a concept in evolution. Chest 2007; 132:1987-1993.
(14.) Daniels N. Accountability for reasonableness. BMJ 2000; 321:1300-1301.
(15.) Honeybul S, O'Hanlon S, Ho KM, Gillett G. The influence of objective prognostic information on the likelihood of informed consent for decompressive craniectomy: a study of Australian anaesthetists. Anaesth Intensive Care 2011; 39:659-665.
(16.) Whitney SN, McGuire AL, McCullough LB. A typology of shared decision making, informed consent, and simple consent. Ann Intern Med 2004; 140:54-59.
(17.) Australian Government. National Health and Research Council. General guidelines for medical practitioners on providing information to patients. Canberra NHMRC 1993. From http://www.nhmrc.gov.au/publications/synopses/e57syn.htm. Accessed May 2011.
(18.) Henderson A, Henderson S. Provision of a surgeon's performance data for people considering elective surgery. Cochrane Database Syst Rev 2010; CD006327.
(19.) Schwartz LM, Woloshin S, Black WC, Welch HG. The role of numeracy in understanding the benefit of screening mammography. Ann Intern Med 1997; 127:966-972.
(20.) Lipkus IM, Samsa G, Rimer BK. General performance on a numeracy scale among highly educated samples. Med Decis Making 2001; 21:37-44.
(21.) Elmore JG, Ganschow PS, Geller BM. Communication between patients and providers and informed decision making. J Natl Cancer Inst Monogr 2010; 2010:204-209.
(22.) Krumholz HM. Informed consent to promote patient-centered care. JAMA 2010; 303:1190-1191.
C. D. Gomersall
The Chinese University of Hong Kong,
Shatin, Hong Kong
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|Author:||Joynt, G.M.; Gomersall, C.D.|
|Publication:||Anaesthesia and Intensive Care|
|Date:||Jul 1, 2011|
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