Which Patients With COVID-19 Should Get Scarce ICU Beds: Survey

Which Patients With COVID-19 Should Get Scarce ICU Beds: Survey

NEW YORK (Reuters Health) – A new survey finds most Americans are in favor of allotting “the last ICU bed” to the patient with the highest probability of surviving COVID-19.

Responses from 2,000 respondents from the nationally representative YouGov internet panel also show that, for the most part, people were not swayed by the age of the patient, according to a report in the Emergency Medicine Journal.

“I was surprised,” senior author Dr. Dale Whittington of the University of North Carolina at Chapel Hill told Reuters Health by email. “I expected that most people would be more willing to give the last ICU bed to younger or middle-aged adults than to the elderly, but this wasn’t really the case. Although there were some differences among groups of the public, on average the U.S. public does not want an elderly patient with COVID-19 to be denied ICU care if a physician believes they are the patient with the highest probability of survival.”

But Dr. Douglas White, a critical-care physician and chair of ethics in critical-care medicine at the University of Pittsburgh, Pennsylvania, who was not involved in the survey, said the findings should be “taken with a major grain of salt – and interpreted with extreme caution.”

He told Reuters Health by email that “it’s not clear that a brief poll like this one truly reflects the informed preferences of the public, because there was no opportunity for the public to think through the implications and consequences of each option they were presented. For example, there is now good evidence that triage according solely to survival probability would disadvantage Black patients and widen health inequities during the pandemic. If that information had been shared with respondents, it is likely that it would have influenced their opinions.”

For their survey, Dr. Whittington and his colleagues turned to the YouGov internet panel of U.S. households. YouGov maintains an online panel of several million respondents. For the current study, YouGov drew a random sample of respondents that matched the demographic characteristics of the nation.

The researchers interviewed the respondents between August 28 and September 4 of 2020. Respondents were provided with a simple explanation of what survival probability means and then were asked to choose which of three hypothetical patients with COVID-19 should receive an ICU bed if only one were available.

The patients differed from one another in four ways: age, gender, presence or absence of Alzheimer’s or a similar mental disability, and the probability of survival if given an ICU bed. The researchers also told respondents that all three patients were “almost certain to die” without an ICU bed.

The researchers designed the experiment so that the values of the four attributes of the three hypothetical patients varied and each respondent would get four “choice tasks.”

The most important attribute to the respondents was probability of survival (odds ratio, 5.5; 95% CI, 4.41 to 6.91).

Still, the age group of the respondent affected how much the age of the patient mattered. Those under 30 were more likely to choose young and old patients and less likely to choose patients between 40 and 60. For respondents aged 30 to 49, their preference for saving the patient declined modestly in a linear fashion with increasing age of the patient.

Dr. Whittington does have a caveat to the study, however.

“We didn’t ask respondents to compare giving the last ICU bed to a child with COVID-19 or an elderly adult with COVID-19,” Dr. Whittington said. “So, the US public may want to give the last ICU bed to child instead of an elderly patient, even if the elderly patient has a higher probability of survival.”

Dr. White also emphasized that giving more information to respondents might have affected the results. “In fact, other researchers have found that the public is less inclined to simply triage by patients’ survival probabilities when they are told that doing so would disproportionately deny resources to historically marginalized groups,” he explained.

“Somewhat tellingly, (the survey) data also showed that Black and Hispanic respondents were less supportive of using survival probabilities in triage, which may reflect knowledge that this triage strategy would unfairly disadvantage them,” Dr. White said.

He added that the findings also “provide another reminder that there is a significant societal bias against persons with cognitive disabilities. Respondents were less inclined to allocate the scarce ICU resource to a patient with a cognitive disability than one without a cognitive disability. This is a troubling finding and one that – if put into policy – would violate existing antidiscrimination laws in the U.S.”

“Importantly, this finding is an example of the limits of public preferences in policy making. There are some considerations that should not be incorporated into triage considerations even if a significant majority of the public prefers that it be used. This study suggests that there should be special efforts in triage to prevent implicit bias against persons with disabilities from influencing triage decisions,” concluded Dr. White.

SOURCE: https://bit.ly/33mncCX Emergency Medicine Journal, online January 3, 2022.

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