Daniel Sokol: Where are the ICU triage protocols?

It is no secret that intensive care unit (ICU) capacity may be overwhelmed if the pandemic worsens. Why then is there so little published guidance on ICU triage from the UK government and NHS Trusts?  

The Royal College of Physicians’ ethical guidance on covid-19, published on 2nd April 2020, stated that “any guidance should be accountable, inclusive, transparent, reasonable and responsive.”

The British Medical Association’s ethical guidance, published the next day, emphasised the need for decisions to be made “openly, transparently, by appropriate bodies and with full public participation”. Yet, where are the protocols setting out the triage criteria? 

Frustrated by this lacuna, I decided on Friday 3rd April 2020 to produce a practical document for frontline clinicians.  With the help of intensivists, lawyers, and ethicists, I produced a document, complete with decision-making flowchart. It took two days. It is not beyond the wit of the government or NHS management to create a similar protocol. 

In the last two weeks, I have received calls from doctors seeking help in developing local triage protocols.  People are clearly working on this problem, but their output, by and large, is nowhere to be seen.

A possible explanation for the silence is a reluctance from the top brass in government and in the NHS to publish documents that may clash with the rhetoric of increasing ICU capacity. The official message is that with continued communal efforts the NHS can be protected, ICU need not be overwhelmed, and tragic choices will be avoided. Publishing a document that contemplates an NHS in chaos and tragic choices aplenty sits awkwardly with that message.  

There may also be fears of causing public panic, in the way that doctors of yesteryear would not utter the word “cancer” to patients for fear of causing distress. As ICUs may never be overwhelmed, this distress might prove quite unnecessary.

Another possible reason is fear of legal challenge. The National Institute for Health and Care Excellence (NICE) was threatened with judicial review upon publishing its covid-19 guideline for clinical care last month, causing it to amend its advice due to concerns about unlawful discrimination against people with long-term conditions such as autism and learning disabilities. Legal challenges and complaints about triage protocols have also been made in the United States by disability groups.   

My attempt at producing a protocol has made it clear that none will please everyone.  

However, these concerns should not be barriers to sharing protocols. The public is surely aware of the possibility of difficult choices in the future. The press is full of articles on ICU triage. If the public is in fact blind to this possibility, then better for it to have its eyes open now than during the crisis. At this stage, there is still time for the public involvement encouraged by the Royal College of Physicians and British Medical Association.   

Any protocols of any practical use will be vulnerable to judicial review. Even with the input of legal experts, the threat of legal challenge and complaints is ever present. But, again, it is preferable to hear those challenges now, when changes can still be made at little cost, than later when lives may be lost unjustly.

The reluctance to be open about these life-and-death protocols is understandable but misplaced.  They should not be secret or unwritten, but open and subject to public scrutiny. They should be disclosed now.

Daniel Sokol is a medical ethicist and barrister. His ICU triage protocol is available here: http://medicalethicist.net/wp-content/uploads/2016/06/v5-Sokol-ICU-Triage-April-2020.pdf

Twitter @danielsokol9

Competing interests: None declared.