Which factors should be included in triage? An online survey of the attitudes of the UK general public to pandemic triage dilemmas

  1. Dominic Wilkinson
  2. Hazem Zohny
  3. Andreas Kappes
  4. Walter Sinnott-Armstrong
  5. Julian Savulescu

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Abstract

As cases of COVID-19 infections surge, concerns have renewed about intensive care units (ICUs) being overwhelmed and the need for specific triage protocols over winter. This study aimed to help inform triage guidance by exploring the views of lay people about factors to include in triage decisions.

Design, setting and participants

Online survey between 29th of May and 22nd of June 2020 based on hypothetical triage dilemmas. Participants recruited from existing market research panels, representative of the UK general population. Scenarios were presented in which a single ventilator is available, and two patients require ICU admission and ventilation. Patients differed in one of: chance of survival, life expectancy, age, expected length of treatment, disability and degree of frailty. Respondents were given the option of choosing one patient to treat or tossing a coin to decide.

Results

Seven hundred and sixty-three participated. A majority of respondents prioritised patients who would have a higher chance of survival (72%–93%), longer life expectancy (78%–83%), required shorter duration of treatment (88%–94%), were younger (71%–79%) or had a lesser degree of frailty (60%–69%, all p<0.001). Where there was a small difference between two patients, a larger proportion elected to toss a coin to decide which patient to treat. A majority (58%–86%) were prepared to withdraw treatment from a patient in intensive care who had a lower chance of survival than another patient currently presenting with COVID-19. Respondents also indicated a willingness to give higher priority to healthcare workers and to patients with young children.

Conclusion

Members of the UK general public potentially support a broadly utilitarian approach to ICU triage in the face of overwhelming need. Survey respondents endorsed the relevance of patient factors currently included in triage guidance, but also factors not currently included. They supported the permissibility of reallocating treatment in a pandemic.

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  1. Version published to 10.1136/bmjopen-2020-045593
  2. ScreenIT

    SciScore for 10.1101/2020.10.06.20207662: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board StatementIRB: A sample size of 500 or higher was estimated to provide power of .95 to detect even small differences in preferences with-in subjects between the different scenarios.[28] The experiment was approved by the University of Oxford Central University Research Ethics Committee [R69537/RE001].
    RandomizationScenario blocks were presented in random order, and the order of scenarios within each block was also randomized.
    Blindingnot detected.
    Power AnalysisA sample size of 500 or higher was estimated to provide power of .95 to detect even small differences in preferences with-in subjects between the different scenarios.[28] The experiment was approved by the University of Oxford Central University Research Ethics Committee [R69537/RE001].
    Sex as a biological variablenot detected.

    Table 2: Resources

    No key resources detected.

    Results from OddPub: Thank you for sharing your data.

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Limitations: As with any online survey, there are challenges in generalizing to the wider community. In this case, while those who participated were part of pre-existing marketing research panels, they were representative of the UK general population for gender, age, income, education and employment. The scenarios presented to participants in this survey are necessarily unrealistic. They were designed to control for single variables. This means that responses only indicate which factors participants would take into consideration, but not how much relative weight respondents would give to different factors. We had added a control scenario where participants were asked to allocate treatment between patients from different racial backgrounds (who were specified to have a similar chance of survival). This indicated (as anticipated) that a majority of respondents would give each patient an equal chance of receiving treatment. However, as the pandemic unfolded, reports of racial disparities in infection and mortality rates increased.[41] This may have led some respondents to prioritise those of Black Caribbean ancestry, since they appear to be left worse off by the pandemic or to deprioritize such patients because of a belief (contrary to the details provided) that their outcome would be worse. Interpretation: The results of this survey suggest that members of the UK general public would support a broadly utilitarian approach to triage in the face of overwhelming need.[15,16] A maj...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    About SciScore

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  3. Version published to 10.1101/2020.10.06.20207662v1 on medRxiv