INTRODUCTION
Our tradition in medicine, dating back to the Hippocratic oath in the fifth century BC,1 has emphasized the importance of putting our patient first, avoiding choices that might harm them, and not considering issues unrelated to that particular patient’s health as we make our medical decisions. Public health considerations involving risks to providers and other patients have not normally been factored into the decision. Furthermore, what we have known to be best for the patient in the past, has not involved calculating the risk of contracting a potentially fatal infectious disease while merely walking into the hospital.
Recently, however, the unprecedented and now-familiar events related to the COVID-19 pandemic have affected communities all over the globe,2,3,4 including South Florida. By the time of this writing, Newsweek reported, based on U.S Center for Disease Control and Prevention (CDC) data, that coronavirus had surpassed heart disease and cancer as the number one killer of Americans on a daily basis.5
On March 14, US Surgeon General Jerome Adams recommended in a tweet that hospitals stop all elective procedures amid the COVID-19 outbreak.6 The same day our two hospitals’ administrations issued an electronic communication asking surgeons to cancel all elective surgeries at our facilities. On March 20 the Governor of Florida issued a formal ban on elective surgery7. Permissible procedures included “removal of cancerous tumors, transplants, limb-threatening vascular surgeries, trauma-related procedures, and dental care related to the relief of pain and management of infection.”7 In practice, in oncologic surgery, it was left to each institution to determine what was urgent, and which patients would be best served by receiving surgery, despite increased risk to the patient, providers, and other patients during the pandemic.
Our approach, as we addressed surgical triage, was to consider each patient’s risk of complications related to receiving surgery in the midst of the pandemic and deciding if that risk ”tipped the scales” towards delaying care or planning an alternative treatment. Though data was scarce, experience in China and Italy indicated that the risk of either directly developing a coronavirus infection, or of ending up with a complication requiring care in the midst of a situation of inadequate medical resources, might outweigh the benefit of receiving cancer surgery earlier in certain cases.3,4,8
The greatest paradigm shift that occurs in times of crisis, however, is the concept that the good of society, and the health of the caregivers and other patients, may have some weight in the equation, even as clinicians continue to make our patients’ well-being our primary goal. Considering these additional factors is the part that we may find most difficult to adjust to. Furthermore, as we approach so called “surge” conditions in any disaster, and resources approach the point of being overwhelmed, these factors may become more important, and even approach or surpass those of the patients themselves.9,10
In times of crisis, it is clearly recognized that standards of medical care may have to be altered. In an almost clairvoyant publication, intensivist and disaster management expert Michael Christian, MD, published an essay entitled “Triage” in October 2019,9, just before anyone imagined the events that were about to unfold in Wuhan, China. He defines triage as “allocating scarce resources in order to do the greatest good for the greatest number”. He emphasizes that appropriately performed triage, while difficult, can save large numbers of lives, by preserving resources for ”salvageable” patients. One must add to this equation the need to protect caregivers so they can attend to other patients. There is an extensive literature on appropriate crisis triage, based on experience during warfare 11,12,13 and natural disasters.14,15 This was most recently seen in our own country with the crisis in New Orleans in the aftermath of Hurricane Katrina, when physicians in hospitals had to triage civilian patients in a manner normally seen only in the midst of battle.14,15
While we can extrapolate from triage and management models developed for times of war or natural disaster, this global pandemic is a different entity entirely, affecting almost the entire planet at once.2,3,4 It involves an ascension to a peak volume and then a descension, rather than a single disaster date as would occur with a natural disaster or act of war, and it is affecting Asia, Europe, Africa, and the Americas within months of each other.2,3 The SARS-CoV-1 epidemic of 2001-2004,16 the H1N1 influenza epidemic of 2009-2010,17 the Middle Eastern Respiratory Syndrome (MERS) of 2012,18 and the West African Ebola epidemic19 of 2013-14, were much more geographically confined. Perhaps for this reason, there are no published reports of a need for cancer patient triage during such epidemics. H1N1 Influenza, in particular, was known to be virulent in patients with hematological malignancies 17, especially if undergoing treatment, but we found no reports that access to health care was threatened, requiring triage of solid cancers. There were limited anecdotal reports of health access issues during the Ebola crisis in West Africa; they hinted at some of the issues we currently face.20,21,22
The ethics of triage and management in situations of crisis including pandemics have been extensively discussed, modeled and prepared for, and it is widely accepted that the rules need to be adjusted to each new situation.9 Biddison et al.,10, in a consensus statement in the critical care literature, identify 23 ethical guidelines for crisis situations. The importance of communication with patients and families and the possibility of consulting ethicists is emphasized. Moreover, they comment: “We suggest critical care resources be allocated based on specific triage criteria, irrespective of whether the need for resources is related to the current disaster/pandemic or an unrelated critical illness or injury. “
Our purpose here is to provide a practical working example of how one large head and neck oncology group sought to ensure that patients requiring head and neck surgery received appropriate triage during the pandemic, and were neither put at increased risk of a poor outcome from their tumor nor from Covid-19 infection.