Worst case: rethinking tertiary triage protocols in pandemics and other health emergencies

Demand for critical care resources could vastly outstrip supply in an influenza pandemic or other health emergency, which has led expert groups to propose altered standards for triage and resource allocation. A pilot study by Christian and colleagues applied the Ontario, Canada draft critical care triage protocol to an actual retrospective cohort of intensive care unit patients. The findings are troubling. Patients who would have been triaged to expectant and designated for withdrawal of intensive care unit care and ventilator support in fact had substantial survival rates. Triage officers often disagreed and lacked confidence in their categorization decisions. These findings suggest that rationing paradigms which include categorical exclusion criteria and withdrawal of lifesaving resources should be reconsidered, and public input sought on nonclinical aspects.