Sunday, September 20, 2009

What should we call Triage?

Every health care plan has triage of some sort. If nothing else, there are limits of time and risk so that accepting one treatment plan will take time that can not be spent on something else.

But most have limits that cut in before there are risks that people are unwilling to take or limits on just what sort of treatment people choose. Insurance won't cover experimental treatment. Some policies have lifetime treatment caps. Most electives are outside of coverage. That is triage.

The first time I encountered triage was when a guy ran a red light and hit me. We ended up in the same ER and they took care of him first. Triage is applying limited resources in order of need and effectiveness. It is often not pretty and often not fair.

Health plans have triage There are limits to the time and money available. People tend to want three things. First, they want more than they are paying for, second, they often want treatment past what other people would judge to be the point of diminishing returns and third, they often want treatment so they can avoid being compliant in observing their own health.

At times, triage comes together harshly. In WWII, antibiotics went first to treat venereal diseases, and then what was left over went to treat those injured in combat. Generally, combat infections resulted in death. V.D. got you treatment. But the treated went back to war, those rotting from combat wounds would have gone home (and, you could treat 20 cases of V.D. for the same antibiotics that one infected wound would take).

Often, triage also seems arbitrary. Decisions made seem to be random, often decided by cultural matters. Sometimes the decisions are mechanical, made in advance by formulas (Oregon's hierarchy list for example).

So, what do you call triage? In some ways it decides who gets an extra chance at life and who dies now. It also decides who gets treatment for non-compliance and who gets optional benefits (e.g. dialysis for for kidney problems brought on by not controlling sugar intake, AZT for AIDS, abortions, Viagra, or cosmetic surgery -- you name it, it might be on someone's list).

In addition, at some point, medical care is no longer done for someone, it is done to someone. Who decides that point? Some people would pay a million dollars to live an extra hour in pain rather than die an hour earlier in peace, especially if it is someone else's money.

It is disingenuous to claim that triage and plans for triage do not exist. It is a lie to deny that. However, it is questionable to characterize such plans as "death panels." Perhaps, perhaps not. But denying that triage exists is not only a lie, it is a harmful lie, because it stops communication about the real issue.

Given that perhaps half of Medicare money goes to mostly futile expenditures in the last ninety days of life, given the growing expense of non-compliance, given all of these other issues, we need a rational discussion on triage. Avoiding it by claiming that it is not happening or can be avoided serves no one. Until we can have an open and honest discussion on triage, we will be in denial, with all the increasing failures that causes.

What will be the answer we get? I don't know. What is the right answer? I don't know. But we can't find either the right answer or any answer if we don't have an honest discussion.

1 comment:

Anonymous said...

I support the idea that triage is an individual judgment - and in my opinion collective judgments are stifling.