Pandemic doctors' dilemma

It's a scary thought, but not far-fetched. During Katrina, medical personnel were forced to make decisions without any guidance but their own (and I'd argue, did a fairly good job).

During this latest flu season, resources were taxed. We turned day rooms into patient rooms, had "virtual beds" in hallways...

No one in the public is going to be happy about this.

I agree with you that turning this into a lifeboat scenario, rather than trying to change the underlying problems, is important, but there will be times that, no matter how many lifeboats we build, they won't be enough.

Tough stuff.

Clout will rule the day. The Mayor's son, the Doctor's sister, these will be the chosen few.

Security will have to be at maximum strength so that grieving father with the Glock on his hip doesn't make room on the list for his wife. Sound apocalyptic??? Perhaps, but without pre-identified pandemic flu treatment areas (schools, auditoriums, etc.) the hospital system will collapse.

We aren't building bigger better lifeboats. The lifeboats we have are going into "bypass mode" (read full) on normal weekend nights. Come pandemic time it will also be pandemonium time.

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It is past time for this subject to be openly discussed. And as Revere stated above, this is only a partial list of who lives and who dies. Do we take old and dying people already using the vents off of them? What about premature infants? Do we take the smallest off to allow an otherwise healthy infant a chance at beating the disease? As vents are already used at capacity, someone will indeed have to play God. Some of the decisions will be made for us, first come first served is a good example. But, I suspect as Gil has already stated, a great many of those who will be given the gift of care, will be those who have the monetary or political clout to demand a bed and get one. Unless the single mom is a Senator, I don't think she will make the cut.

Most people don't have the luxury of self-quarantining for months. And even fewer who do have the means, will not be able to maintain isolation until a vax is available. Hopefully, the next time we run into a pandemic of epic proportions, we will be better prepared than Defoe describes in his book. Let's hope we only see a CFR of less than 5% otherwise.......

Free full text access to the triage documents can be found at
http://www.chestjournal.org/content/vol133/5_suppl/

bc: Many thanks. Have been looking for it.

In my mind revere, after the initial shock and realization of a pandemic, everyone will try to do the right thing. And there will be many good ordinary people who realize on their own that they must truly give up their lives so another can live.

As far as a violation of federal law prohibiting discrimination by age or disability or income, well come on now, in the midst of a pandemic that will have to be worked out afterwords, that is if any one is still willing to pursue such utter nonsense.
Sometimes the "rules" have to be broken.

What about premature infants? Do we take the smallest off to allow an otherwise healthy infant a chance at beating the disease?

I think this example in particular highlights the difference CFR would make. If the CFR doesn't drop, and I mean precipitously, the smallest uninfected micro-premie might have a better chance at survival than an infected "otherwise healthy" infant. (And "otherwise healthy" in this context makes me think, "other than that, how did you enjoy the play, Mrs. Lincoln?")

Furthermore, even if the CFR was 1 or 2%, even for infants, doesn't putting someone on a ventilator imply their lung capacity is already seriously compromised? IOW, they have a particularly bad case? Even with a low CFR, the micro-premie might still have the better chance.

Of course, then there's the question of, if the premature infant needs the ventilator for months, and other patients a week or so each.

Just some thoughts (haven't read all 5 articles yet):

1. These guidelines have received a lot of press/blog coverage but the controversy to me seems somewhat misplaced. On the one hand, some editorials and comments have inveighed against the unfairness of 'abandoning' the elderly, etc. On the other hand, some blogs and commentators talked about how the public just 'doesn't get it' when it comes to the reality of what might happen during a pandemic. But this sort of decision making happens already happens everyday to some degree with organ transplants, difficulty accessing care by the uninsured, etc.. Last week, an article in the Wall Street Journal talked about how some hospitals are actually denying chemotherapy to patients unless they are first paid for care upfront(http://www.wsbt.com/ news/health/18353979.html)! Another article discussed the use of medical marijuana (even with a doctor's approval) as a disqualifying factor in patient eligibility for organ transplants.(http://seattlepi.nwsource.com/ local/361630_marijuana03.html?source=mypi). Patients already are denied care because they lack insurance/wealth or lead what some may view as questionable lifestyles. This is wrong under 'normal' circumstances and would be no less disturbing during a pandemic. The only difference is that more people would be affected by these types of value judgments and some of the criteria used for making these judgments might be somewhat altered during that time. (Or maybe not that altered when you get right down to it).

2. Right now, the overall case fatality rate for H5N1 appears to be much higher among those ages 10-40, rather than the very young or elderly (See http://www.who.int/wer/ 2007/wer8206.pdf). So that 85-year old discussed above may actually have a much greater chance of survival than, say, a 40 year old critical care nurse. It's also worth noting that the case-fatality rates vary greatly among men and women; for instance, the case fatality rate for women aged 20-29 is almost 20 percent higher than that of males in that age group (in other age brackets, men seem to die at much higher rates than women). Are we going to make gender (or ethnicity for that matter) a factor in decision making as well as age if that impacts survival? Why is it (apparently) 'ok' to take into account a person's age or a person's mental status (e.g., severe dementia) -- even when being older may actually improve survival -- but presumably would not be acceptable to anyone under any circumstances to take into account gender or ethnicity if these factors were to impact patient survival? While these sorts of triage schemes superficially appear logical and evidence-based, I sometimes think what they really do is codify and condone our existing biases and judgments.

We may need this kind of "incentive" for people to really think about community mitigation (aka NPI, aka "school closure and all the rest").

We can't afford to have too many people falling ill at the same time.

See most recent discussion (even argument) here: http://newfluwiki2.com/showDiary.do?diaryId=2416

And, of course, CFR=1% means hospitalisation rate is higher than 1%. How much higher? As higher as possible, if not-too-severe cases are hospitalised "just in case".

It will be messy.

Thing is: will it be unnecessarily messy?

Yes.

msb: I think the main point here is that this is an opportunity for discussion of the topic (lugon makes the same point). Your comments assume that it is the chance of survival that should be the criterion rather than the "worth" of the person to society. That is a position that some but not all would agree with. Those in the comment thread who say it is irrelevant because in an emergency people will do what they want to do are only partly correct IMO. Yes, many "rules" will go out the door but structures and ways of thinking put in place after due deliberation before the emergency will also affect things. They may not determine outcomes but they will affect them. And the discussion is important not just for pandemic planning but also for the kind of rationing and triage that already exists, a point you make. This issue has given you an opportunity to make that point. So all in all, I think it is a good thing this has come up.

Or folks, you can do it as it should be and that is first come first served.......

The McDonalds approach to handling this particular pandemic is what will end up being done, likely at gunpoint at least here in the states. Until a state of emergency comes into being and a declaration allowing those protocols to go into effect (wont take long) they have to follow the law. Thats what a state of emergency, or declaration of martial law will do give them the out to enforce those protocols. Temporarily. After a short bit of time they wont work.

Wont matter though. The Senators wife will be already heading out the door medically speaking, along with just about everyone one the list above. The 65 year old doctor statistically should make it, but be nearly invalid for several weeks or months (The chinese truck driver took six months). The 40 year old might make it... but the numbers are not in her favor.

The numbers suck across the board. The 17 year old is toast and the 90 year old should just be at home and just waiting for the inevitable. I dont want to discard anyone at all but the realities are, ventilators, supplies and what have you just dont work on this stuff. No equipment works. Nor does the mass dose Tamiflu. Relenza might but has anyone seen that being stockpiled? Revere's statin drugs also might but it again leads to a distribution nightmare. Everyone is worried about healthcare if it happens? Statistically what outcome? I havent seen anything but a few walk out of this. They are able to care for most of them now using extreme measures and produce about 1 out of 4 for a favorable outcome, but extreme measures cost money, supplies and physical efforts on the part of the doctors/nurses/hospitals. Wont have that luxury for panflu. They'll be making rounds of several hundreds if not thousands of patients a day and the HCW numbers will be dropping steadily with each day we are in it. Then what? Cant put that ventilator in without an order, and you have to have someone to do it. How many docs have done it recently?

Then there is the gunpoint. Theirs and ours. This gets down to what I have spoken about before. Is healthcare a right or a service? The implication that the Senators wife might get care is fine, but what do you do if someone comes in packing firepower to take the ventilator away from her? The military will be pulled out to maintain order but these are all people who would for the better part be sick themselves w/wo vaccine distribution. Hey, everyone is going to get it at some state and stage. Complete and utter chaos is going to rein supreme. So to me the guidelines and updates to them are based upon the fact that order is maintained and that is something that will not be there for at least the first two months. Couple it up with the previously posted infrastructure collapses especially in the populations centers in the North of the US and other countries, I cant see that their protocols mean squat. What is this for, post pandemic litigation?

For my way of thinking all of this medical preparation stuff is pure pie in the sky. We dont need to spend a trillion dollars on beefing up healthcare, we need to spend a billion or two and develop a vaccine that works. Works in this case would be acceptable if it just keeps you alive and in moderately good condition. Nothing yet has proven that. The supplies alone to support the patients above would be out of date or used up so fast that it wouldnt come close to being able to take care of even one of the above people because it will have been used up long before they get there.

Costs? Remember it cost 50,000 bucks USD two years ago to keep one Chinese guy alive for a month. Use that number on a population of 300 million or even a third of it and see what you come up with. The average daily cost of a hospital stay was $697 per day in the US.

http://query.nytimes.com/gst/fullpage.html?res=940DE5DA1438F936A15756C0…)

Would this be average? I doubt it. But for grins the 697 x 100 million citizens and staying for 14 days is $975,800,000,000.00. Sorry folks but its just not going to happen. What do you do when the hospitals turn around and just say no? They cant turn people away you say? Wanna bet? Those private hospitals can and will because they will not be able to afford it. This will become something like a Hurricane Andrew or Oakland fire. The insurance companies will start getting the bills in, find that they are insolvent and then the system collapses. It would happen if it were UHC too. You are never get close to that ventilator so its a moot point.

Government takeover and forced labor by HCW's, Uh-huh. Who says so? Going into one of those places would be like taking a Sunday drive in to Hell. Sure there will be pockets that are able to hold up, most wont and then a whole new set of protocols will come into effect. That will be the protocol of reality. I asked three of my doc's if they would go and they to two men and woman said only as long as their own health wouldnt be jeopardized and as long as there were supplies and workable facilities.

So I am skeptical about the above. Its nice to produce what we is for all intents and purposes a medical rule of engagement. But this is going to last about 10 seconds after the last ventilator is used. Once in and on, they are going to find themselves in it up to their necks for all services.

Anyone want to write a nastygram to Siti Supari?

puskom.publik@yahoo.co.id

Much over looked is keeping it simple. Yes, it's great this has finally come up for discussion however, humans have a tendency to complicate matters.
Cover the basics please and then when necessary use sound judgement in having to make the hard decisions.

lugon hit the nail on the head basically. Thing is: will it be unnecessarily messy? Yes.

Lea: OK. Keep it simple. Such as . . .

Im glad this topic finally came into the public realm. Maybe it will get people to actually think about the fact that a pandemic is coming. Might wake the ostriches up and get some of them prepping...or at least talking.

My family has come up with its own protocols. After much discussion, we concluded that a hospital is absolutely the LAST place any of us would want to be. Therefore:

1 - We will SIP as long and as completely as we can. Anyone who enters the compound does so with the understanding that they will NOT be taken to the hospital, no matter what. We will also likely be the last of the last to get vaccinated, if a successful vaccine is ever developed. We dont want to be standing in line with a bunch of other people who may already be infected, and we dont trust any plans being made by either the Feds or the PHD.

2 - We will do whatever we can medically to protect and maintain each other, but if anyone gets sick or injured, they will either die at home or get better.

3 - We will make sure that we have enough jerry cans of diesel fuel put aside to run the tractor and backhoe. We will bury anyone who dies on our own property and will not surrender any bodies until the pandemic is completely over. Maybe not then either.

4 - Anyone still standing is responsible for taking care of the others. If no one is still standing, it probably wont matter much.

revere/Revere: Cover the basics, just as was done in this AP release. Come up with a plan, as was done according to this AP release, draft it, revise it, finalize it. Distribute it and then let it go.

It most likely will come down to personal decisions anyway. In the end no one will want to be forced to make any decisions when it comes to choosing who lives and who dies, really.
My greatest "hope" would be enough pain medicines that will be given freely to those who are going to die.
Along with companionship, no one truly wants to die alone.

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msb: Glad you mentioned the medical marijuana patient, it's a travesty indeed.
Hepatitis C Patient Denied Transplant Based on State and Doctor Approved Medi-Pot Use - Seattle, WA:
University of Washington Medical Center (UWMC) officials have denied a 56-year-old hepatitis C patient from receiving potentially life-saving surgery because of his state-approved medical cannabis use, according to a news wire report by the Associated Press.
According to the report, Timothy Garon may die within days without a liver transplant. Previously, Garon has used medical cannabis under his doctor's supervision and in accordance with state law -- to treat his hepatitis C related nausea, abdominal pain, and lack of appetite. Garon's physician has stated that he was not aware that his patient's medicinal cannabis use would deny him transplant eligibility.

Hospitals might send a lot of people home to get nursing care and basic medicine from their families. The mortality rates for people over 50 are pretty grim. I've prepared for the next pandemic by putting life insurance on my credit card balance.

Lea-Be happy in knowing that morphine is one of the drugs they HAVE been stockpiling in the federal stockpiles. Stab and push syrettes. I think that the people that will be raising the most hell will be the have not at alls. Those that have never worked or depend on the government for everything. Smelly has as pragmatic approach as I do to it.

I also think that they should be bellowing it out loud about preparations at every turn. It would appear that H5N1 is here to stay and it will not go until it cleans some more of humanity from the face of the earth. Indonesia-300,000. Myanmar-100,000. I would say its not done by a stroke... Quakes are next on my list that cause huge tsunami's followed by Bird Flu.

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Re: T. Garon... I think this was the reason here: http://www.sciencedaily.com/releases/2008/01/080128140840.htm.

They probably didnt want to lose a perfectly good liver if the guy had been using weed. My best guess on that.

Hospitalization costs (if handled in a traditional fashion) would be even more outlandishly impossible than MR Kruger suggests above. His nearly $1 trillion rough estimate for hospitalizing 100M people for 2 wks relied on "The average daily cost of a hospital stay was $697 per day in the US.
http://query.nytimes.com/gst/fullpage.html?res=940DE5DA1438F936A15756C0…

But that $697/day figure was from 1987. (And as an average, it's not for specialized care.)

Besides the urgent need to make more ventilators and other "lifeboats" (and stop closing hospitals), hospitals must feel they can afford to treat uninsured people. We need a law establishing ....

Emergency Relief Medicaid that any governor could invoke under defined circumstances when evidence indicates a pandemic or other calamity is starting, without having to wait for days/weeks/months for federal approvals as happened after Katrina. Then a governor should be able to announce everyone is presumptively covered and hosps/docs are entitled to federal reimbursement.

All that, of course, is a separate issue from deciding whether to encourage people, and which people, to go to hospitals vs. stay home.....

Heck yes MRK, they should be "bellowing it out loudly about preparations at every turn." But it ain't happening.
I'm still being laughed at by certain people.

Glad to hear morphine is being stockpiled.

SaddleTramp: Your "we concluded that a hospital is absolutely the LAST place any of us would want to be."
That is our mantra too.
In addition you may want to consider lime, it helps the body decompose faster if burial isn't possible.

MRK: your link didn't work, just got a bunch of annoying pop-ups. Won't link to it again anyway so don't bother, you already know how passionate I am about medical cannabis.

Saddletramp,

Like your plans-I'd much prefer to die at home rather than the present pre-pandemic hospital setting, much less after TSHTF. We plan to pre-dig several graves on our property and if cold weather,store the dirt in a warmer area, like a shed.

Doesn't say much about the current state of the American hospital system, which is on a cliff, leaning over and on a banana peel... Most people don't understand how bad things are now in health care....

They stay at home they dont get sick Debbie. The NPFP specifically states that they will not be providing the coverage you indicate. We will be struggling economically enough post of a panflu that we couldnt even begin to spread the costs as suggested under a UHC. States might cover their people individually but no federal bailouts. This would make the Great Depression look like a slight pothole on the road to life.

BTW the 1988 costs were about the only ones I could find that were from a lefty newspaper. They tend to inflate that a bit so that was the one I used. Specialized care would never happen.... they cant take the heat and there is no kitchen. First couple in are going to get the ventilators. There are about 100,000 as I posted last fall in the US and thats it. Please, post this notice in the hallways of the hospital. "Patients who are lingering along, please kindly bag it within the first week so someone else can get a shot at a ventilator" .;>

Yes, 1 trillion doesnt even begin to cover it. I checked with the State of TN Healthcare Commissioner about the reserves that the insurance companies are required to carry, its appalling. At the 5% number and if all people are covered by CoverTN, or one of the non state insurance gigs and if even 1/3rd of the state gets sick but doesnt die, we will be out of money in under three weeks. We would be at the billion point five number if If it creeps in like it is now, its manageable. If its a fell swoop that hits with the power of a nuke.... All gone.

Brings up another thing. The infrastructure that I spoke of. The fell swoop would finish the NE and LA Basin in about a month. No electricity. Keep it in mind.
________________________________________________________________
Lea....

ScienceDaily (Jan. 29, 2008) Patients with chronic hepatitis C (HCV) infection should not use marijuana (cannabis) daily, according to a study published in Clinical Gastroenterology and Hepatology, the official journal of the American Gastroenterological Association (AGA) Institute. Researchers found that HCV patients who used cannabis daily were at significantly higher risk of moderate to severe liver fibrosis, or tissue scarring. Additionally, patients with moderate to heavy alcohol use combined with regular cannabis use experienced an even greater risk of liver fibrosis. The recommendation to avoid cannabis is especially important in patients who are coinfected with HCV/HIV since the progression of fibrosis is already greater in these patients.

"Hepatitis C is a major public health concern and the number of patients developing complications of chronic disease is on the rise," according to Norah Terrault, MD, MPH, from the University of California, San Francisco and lead investigator of the study. "It is essential that we identify risk factors that can be modified to prevent and/or lessen the progression of HCV to fibrosis, cirrhosis and even liver cancer. These complications of chronic HCV infection will significantly contribute to the overall burden of liver disease in the U.S. and will continue to increase in the next decade."

Researchers found a significant association between daily versus non-daily cannabis use and moderate to severe fibrosis when reviewing this factor alone. Other factors contributing to increased fibrosis included age at enrollment, lifetime duration of alcohol use, lifetime duration of moderate to heavy alcohol use and necroinflammatory score (stage of fibrosis). In reviewing combined factors, there was a strong (nearly 7-fold higher risk) and independent relationship between daily cannabis use and moderate to severe fibrosis. Gender, race, body mass index, HCV viral load and genotype, HIV coinfection, source of HCV infection, and biopsy length were not significantly associated with moderate to severe fibrosis.

Of the 328 patients screened for the study, 204 patients were included in the analysis. The baseline characteristics of those included in the study were similar to those excluded with the exception of daily cannabis use (13.7 percent of those studied used cannabis daily versus 6.45 percent of those not included). Patients who used cannabis daily had a significantly lower body mass index than non-daily users (25.2 versus 26.4), were more likely to be using medically prescribed cannabis (57.1 percent versus 8.79 percent), and more likely to have HIV coinfection (39.3 percent versus 18.2 percent).

The prevalence of cannabis use amongst adults in the U.S. is estimated to be almost 4 percent. Regular use has increased in certain population subgroups, including those aged 18 to 29.

I cant put anything else in because of the fair use gig. I can email the link if you want.
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Grace... Its supply and demand as best I can tell. We are importing nurses from Canada and their work visas are being stamped as fast as they can arrive. We are no kidding 18,000 short in the State of Tennessee today and we are not graduating them like we used to. They are becoming medical malpractice attorneys instead. Add in all of these damned tests and well, you get the expenses that we are familiar with.

Just as you are stubborn in many areas discussed here MRK I am stubborn over the biased "studies" of cannabis. While I respect your choices please no more links.
I'm in the pissed off stage of the grieving process now so give me a break.

Monado, FCD said: "Hospitals might send a lot of people home to get nursing care and basic medicine from their families."
This is where I take the doomer's point of view, or call it what you will.
My take: Hospitals will call relevant authorities and a lot of people will be shipped off to pandemic quarantine camps.

It is interesting that the report of the people that will get treated (from last fall), wasn't included in this article. I can't seem to remember who put it out. Military was first, I believe pregnant women and those with children under 2 were third, I think. Wouldn't that have been a good combination? Maybe a bit too overwhelming for the general public.

Dear All,
You people really frighten me. This smacks of Nazi Germany and its dogma of utilitarianism. I cannot go into my objections right now, but I do want you to consider this guideline from the Catechism of the Catholic Church:

"Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be legitimate; it is the refusal of overzealous treatment. Here one does not will to cause the death; one's inability to impede it is merely accepted. THE DECISIONS SHOULD BE MADE BY THE PATIENT IF HE IS COMPETENT AND ABLE OR, IF NOT, BY THOSE LEGALLY ENTITLED TO ACT FOR THE PATIENT, WHOSE REASONABLE WILL AND LEGITIMATE INTERESTS MUST ALWAYS BE RESPECTED (emphasis mine). (page 549, #2278)

You all should be encouraging citizens to consider writing a "pandemic living will" to get the people ENTITLED TO MAKE THESE DECISIONS (patients and families) to think about your concerns.

Gotta go see Mom, I'll check with you later.
Love,
Library Lady

DebP: We did discuss it here. I questioned why the military should be on the list in any preferred way. The main point, though, is we should be discussing it. My problem with LL is that she considers the discussion closed (by her church). We are already denying help to people on the basis of money so this isn't just a pandemic question. If we don't like this we need to make the pie bigger, not argue over how big a piece of the existing pie people will get. But people would rather argue that than pay any more taxes I guess.

A bigger pie is needed. More supplies and equipment are needed. Honest conversations and public reactions to this policy are needed. During the implementation of this triage approach I expect we will see rules change as people become aware that there is no objective way to ration care. Better to speak up now then wait.

I'm just not comfortable in letting anyone make a Sophie's Choice for me. I'll be joining the at home crowd to ride this thing out.

I don't believe the Church's teachings actually cover what the discussion is all about. There is a difference between choosing who will likely live and who will likely die in the ventilator debate above and what LL quotes about the Church's teachings. You have one ventilator, you have a sick nurse and a sick 17 year old unwed mother, both will likely die without the ventilator and both will likely live if given the ventilator. But you can't have them both on the ventilator. Someone will have to make the decison and convince either the nurse or the unwed mom (or families) that by likely dying its a good thing for humanity. Good frickin'luck with that. Unless you can consider the ventilator treatment as "burdensome, dangerous, extraordinary, or disproportionate to the expected outcome" for one and not the other. Especially if the expected outcome is life for both. Good luck with that too.

Hey revere I guess, in your mind, it would be a good thing for the flu (or whatever) to wipe out the military, sort of like what happened in WWI. The flu just didn't kill enough American/British/French/German/Austrian troops though to stop WWI. I don't think the US Government will allow putting this nation at risk by letting the military weaken because of a pandemic. That is why the miliary is a priority.

No, pauls, I don't think it's a good idea for the flu to wipe out anyone. I object to giving the military preference over others for scarce resources. On what grounds? So they can kill more people in Iraq? Do you think we should give Congress preference so we don't let the country go without a government? Since we need taxes to pay the military and everything else, should we give the IRS preference so we can keep funding the military? Since research is necessary to know how to make new weapons should we give scientists preference to keep our competitive edge? Etc., etc. The question is not whether you want to save the military (the military is not a person, after all; it is made up of people whose lives have value) but what kind of choices you want to make and I don't see the military as a priority over other priorities, for example, police, fire, manufacturing of critical goods and workers in critical infrastructure, health care workers, etc., etc. In that hierarchy they seem fairly low on the list.

I agree with Revere. They are establishing this now to provide them cover if it comes.

Truth be known...It wont matter if either are on a ventilator statistically speaking if they are below the age of about 48 which seems to be a cutoff line for "surviving" BF. Even then 1 out 3 in the 49-65 age group dies.... Ventilators just make sure that the patients breathing actually happens. If there is funk in the lungs it doesnt matter if its in there at all. They still die.

The Doctor and the Nurse would get the vents if it were up to me. The 90 year old would just be a loss and the mom and child would be next on the list to save if possible. The miltary guys if they were on the example would be on the same level as the HCW's. We will still have a population that will need policing, we will still need doctors and nurses afterwards. Full military control might be needed to keep things under reasonable control but I would be very cautious of that...Maybe as support forces submitted to the local control as the new laws post of Katrina would allow.

For me and if I knew they were heading out the door I would hit them with 3-5 syrettes of morphine and ease their suffering. I wouldnt hesitate for more than one second.

LL-You are a pretty even hand here most of the time but Church dogma in the face of reality sometimes doesnt fly. I am Episcopal and very conservative but in this case the true nature of the beast will be that the system will collapse, reconstitute and collapse several times before its over. Just when you think you have heard the last horrific story or edict, another one will roll out. That will mean hard choices will have to be made. Do you boot a dying 90 year old with metatastic cancer from a Catholic hospital to accomodate a survivable 18 year old. IMO yes. I have posted on this before. We have to have little taxpayers growing up and the choices above are tough. Do you put extraordinary measures on a patient that has nothing left to contribute to society except that they are 90 and living on S. Security?

A doctor turns and says this kid is savable where can we put him? Well the 90 year old is breathing assisted just to wait out the end of her cancer. The kid can make it if he gets the ventilator....Not a hard decision for me, but I wouldnt do it without legal authority to do so. I would require two doctors to sign off on it at the least but not run it by some damned committee.

Even if we spent 1 trillion dollars it wouldnt change the outcome right now. As I said a billion dollars to make a vax would be better.

How would someone in a Catholic hospital be treated if the above criteria was in place? Just as they would any other day until there is a declaration of emergency or martial law. After that the docs will either refuse to do it, or they'll do it. Or if there is total refusal they will get corpsmen to administer morphine to a level that will take them.

Its not frightening... But it does tell me fully that they believe its coming and they want to have their shelters built before it arrives. Full immunity from prosecution and lawsuits for this one is whats needed. Else, the docs wont show up. I wouldnt blame them as people who havent done a medical round since graduating med school will be put into terrible positions. I want them to have the law and/or an edict that allows them to do what is necessary with no ambiguities in the process. No person may be deprived of life, liberty or pursuit of happiness or property without due process of law. If they enact it now, its not a question.

yeah revere so the military can kill more bad guys in Iraq or wherever the bad guys happen to be.. Well it would appear the military is high on the list. Get over it.
My parents lived through WWII and they told me what it was like. The miliary got priority on scarce resources, including my father who in my mom's opinion was a scarce resource (duration +1). Anyway, if it ever comes down to it, you can best believe Congress, the WH, the Supreme Court, staffers of all, and the rest of the Feds will get whatever before the rest of us will. Then the state governments including police, followed up by all you doctors and nurses.
We are going to need the miliary and the police to kill the rest of us unclean, rioting average folk. My goodness, pestilence, famine, and 4 dollars for a gallon of gas! Get your guns ready revere!!!

pauls: Don't own a gun -- not for moral reasons but for public health reasons. So you will be able to kill me easily if you want to. The issue is not whether to save you dad. Red herring. The question is how to decide how to apportion scarce resources. If your idea is that it should be done with guns (or political power), fine. That may be a cynically realistic proposition but it isn't one that we fight to defend in this country. At least I didn't think so. Maybe you do and that's why you want to preserve the military. Because that's what your argument boils down to. We need the military to preserve what we have and what we have is a system where the rich and powerful get to live and others come later, if at all.

Realistically, it will come down to saving only those in the first stage of the flu.

No hospital system has the resources to save everyone.

victoria: Except that those in the first stage of flu won't need to be and won't be in the hospital. The health care facilities will only be seeing the ones who are really sick.

Which Revere is right about. Pandemics generally wave into populations if the bio book from the military is to be respected. That is unless its a superbug that mutates as it goes to ensure it cleans a populations clock. But the herald wave cases will be mild to moderate, the ones after that are going to get hammered by it. Saving everyone isnt an option if its a rapid onset pandemic sweeping across the globe in a few weeks as models suggest. Ah, but if it comes slowly we will lose people more slowly and the system can adapt. We still lose say 5-30% but we can apply our resources as they go. Vaccines could be produced rapidly enough to give them to people albeit likely with no testing but it would indeed keep them alive mostly.

But take the official 5% number and then take your city or county or region population being served by your hospital system. Then count the number of beds, then count the number that have to be in them at 5% even if its to die... The numbers dont work now do they? They could never ever amass enough support for a rapidly spreading bug to change the outcomes very much. Mostly its going to be you and your immune system.

Two posts up Revere postures that the rich get to live and etc. I disagree with that. The smartest and the strongest/healthiest via whatever means rise to the top... Survival of the fittest. To me the assertion is that if you get rich at the expense of others is immoral or a crime is wrong. The military is there to protect the people from the public enemy both foreign and domestic. We wont be in Iraq if the shit hits the fan with BF. They would have at least two brigades back here in a month as suddenly even with a 5% event, there will be no need for oil from the middle east. Domestic production for the better part. Besides, the dollar and euro would be worth nothing anyway, how to pay for it?

Pauls

The price of petrol is already way above $4 a gallon. Nobody pulled a gun out over it.

Revere,

Good point. We're screwed.

Ah Nat old buddy, not here yet anyway, besides you need to add the pestilence and famine parts of the unholy triangle. Although, MRK has a point, if most of us die from the flu and/or famine, gas prices will probably drop as demand drops. Basic economics.

Dear Revere,
I did anticipate you objecting to my interjecting the Catechism onto the thread, but it had to be done. That statement in the Catechism give believers the comfort that they do not have to submit to procedures that are "disproportionate to the expected outcome". You can refuse treatment. The choice is the patient's not the doctor's.

In your reply to msb above you say, "Yes, many "rules" will go out the door but structures and WAYS OF THINKING put in place after deliberation before the emergency will also affect things." (emphasis mine)

I object to the graph, the way it is presented, the idea that some people are expendable and some are precious.

The WAYS OF THINKING that I see here are disturbing. So many of you just slid right by the morality of what you are THINKING into the mechanics of what you will DO.

Why is the 17 year old mother "unmarried" in your chart? Is that not a prejudicial adjective meant to sway the reader? Why are there two medical people on the chart? Save yourselves first? Just how many 90 year old hopelessly doomed and useless people are on respirators right now, wasting your precious resources and time? I intensely dislike your categories. I intensely dislike your premise.

Your WAYS OF THINKING and the planning that results from the THINKING has happened before. The Nazi Party had WAYS OF THINKING and acting long before Hitler invaded Poland.
The build up to the invasions corresponded to the emptying of hospitals, mental institutions, orphanages. They anticipated not wanting to feed those mouths, change those beds, wash that dirty laundry for those useless people.
So they starved a few at first and when that was too slow they directly euthanized the rest.

Your chart smacks of utilitarianism--the doctrine that the worth or value of anything is solely determined by its utility.

Revere, MRK, no DOGMA there?

MRK, the Catholic hospital would say NO to booting a 90- year-old to save an 18-year-old. They would try to save both. If the military confiscates the facility, so be it, that is out of the Church's control, but their consciences will be clean.

Sophie's Choice was the most devastating movie I have ever seen, even worse than Schindler's List. The cruelty to Sophie was that the camp soldiers gave her a FALSE choice, suckered her into thinking she could save one, so she chose the boy over the girl, but he died too. The Nazi's not only murdered Jewish persons. They murdered the will, destroyed the peace of mind, and obliterated the sense that the world was good in the survivors that lasts down to this day. Sophie commited suicide.

Do not let yourselves be suckered into considering FALSE choices. You don't have to go there.

Consider promoting THOUGHT about a "pandemic living will" that states a person would forego treatment in times of disastrous shortages. Write a draft, see what it would look like. I know that if I needed a respirator and a 5-year-old next to me needed one I would give mine to that child in a heart beat. I would put that in a living will. You have forgotten the self-sacrificial goodness in humans once they understand what's at stake. Build on that goodness. All you have to do is ask people, and they will come through for you.

Love,
Library Lady

LL: The graph was based on what has been talked about, not what I think is right. I deliberately chose an unwed 17 y. o. to make the choice more difficult. She is young, has a dependent but also suffers the scorn of society (not my opinion but the premise that much of our work to welfare policies are based on and a reality). If you refuse to discuss these issues ahead of time only the powerful will have their way. You are hiding behind the catechism because it is based on a false premise -- that everyone is in fact equal in our society. Would that it were so. But it isn't. So we need to think what kind of safeguards can be put in place so that the deciding qualities will not be only the ones favored by the powerful. The choices you deplore -- and I agree with you -- are being made today by default by refusing to recognize social inequalities in our world and the catechism refuses to recognize those inequalities. The catechsm is thus the unwitting handmaiden of Nazi thinking (IMHO). It allows it to progress behind a veil of piety.

Dear Library Lady:

I wish that you can post often here. You have provided distinctive perspectives as fresh air to this thread; full of humanness and clear conscience.

Get rid of utilitarianism is a very hard task; nevertheless, you are talking to the right person- I feel that Revere never feel tired and never happy staying in the second rated quality. He just needs constant reminding and occasional soft punch. You have done a great job!

Paiwan
from Phuket

Again, I agree with Revere. The decisions are not going to be made by patients or their doctors. It will be made by people who have orders. Conscience isnt going to come into play and yes, in my Episcopal mind I would try to save both if I could as long as there is a reasonable chance at a favorable outcome. As I know you are religious but likely never having been in the military you probably never had to send anyone into combat. Or that in doing so you knew that there was a better than 50% chance that you wouldnt see them in the afternoon. It is an application of course of a military situation to a medical one that will go from medical to military in very short order anyway. But it will sound good on the news as they report it.

LL-Think of it this way. This is a test. For the next 4 months after the day of inception of high path pandemic flu, mankind will be put to the test. Which comes first a Nazi way of thinking or, thinking beyond the pandemic? What you assert is the "final solution." Thats not what this is. I for one would NOT send my medical staffs into harms way unless there was a clear reason to do so, that by doing so it would change the outcomes, and only on a volunteer status. Look up "Devil in the Freezer" and the accounts of the 1960-1970's accounts of doctors refusing to enter smallpox wards. They could not change the outcomes and one out of every ten people who got it survived. The doctors? All but three died. Again, can it change the outcome to try to treat both? Does it make anything but belief system sense to send them in. No. Might it change the outcome to treat one by taking from another? Maybe.

The real heroes will volunteer but this does turn it into a military situation. Would those docs and nurses come out of it alive? Maybe the 65 year old, likely not the 40 year old nurse, the 17 year old mom with a dependent very unlikely, the 90 year old God help me would just get the OD of morphine. I would then remove it and give it to one of the other three. Death sentence to the 90 year old? Look beyond what happens if they make it. Starve to death post of the pandemic.

I would though ask if a family member would volunteer to stay with them and not do the morphine and care for them. Once in, that family member would not come out statistically. By doing so it ensures once again that all criteria are met for all and they are treated. But are we talking about just ventilators?

You also have to consider that food production in the US at least if it happens going out of winter into spring it will drop to nearly zero. So a full season before the next harvest. You miss in August, you miss until the next August. That means that even if you prepped up, you likely are not sitting on a years worth of food. So in fact, we are looking at nearly 2 years of no food. As we are the breadbasket for many parts of the world, this has farther reaching impacts on more than just us. This is of course the worst case scenario with a high path virus running thru us like herpes at a frat party. We might get a slow onset. We should be so lucky.

You LL represent what will be considered to be an old school of thought and the Catechism is important. It is what will be put back into place post of this. We will be involved a huge war post of this as many areas will be ripe for the taking. Old scores will be settled and likely at the head of a religious leader. In the same breath, that war might also be of our choosing to take those resource laden areas. But all of this is intermingled and goes back to the one thing that starts us all spinning out of our orbits...pandemic with no vaccine. Prepare, prepare, prepare. Revere wont prepare with the idea being that he is too old. Our government might screw up his plans too by putting him into the fray and forcing him to perform as a doctor as volunteer or as forced labor. Yes, forced labor and thats where this gets into Nazi ways of thinking. Euthanizations, totalitarianism and "selection" for survival. I can just about bet you that if it goes beyond 10% that we will see "you work, you eat."

Best way to ensure that it never happens is to grab your neighbors and make them read as I do by emails all of the daily news on bird bug. Thats what really got them moving here and of course telling the neighborhood busybody. It will create pockets of humanity that will survive. They will be the "smartest and the fittest" to take over control of the earth.

LL-Events will change for a time how and what we do, but even after the Black Death it returned to a belief based system. It will again. The US and other countries might not survive as named entities but society will simply begin again. If I am there I would move quickly to reestablish it as the US. It might not be possible, but the thoughts that you and I hold dear will come first in that new society eventually.

My Dear Revere,
I am not hiding behind my Catechism. I am right out front with it, pages open, trying to show you a different way of thinking about the problem you posted today. You would not know what the Catechism has said over and over, that everyone is equal in the sight of God (not society). Society is a human invention and is imperfect. We are called to help each other. You do this and I do this as best we can.

MRK, the patients HAVE to make these decisions. There is no other way for us to trust Revere, or you, or the other health care workers and military who might work under you. If citizens find out that you are thinking this way there will be anarchy. We HAVE to have a say in what happens to us. Each human has dignity and worth beyond their income, marital status, number of children to care for, age, occupation, and on and on.

Please, no more charts and discussions about humans being expendable. Revere, I have re-read all of the above and I cannot see anywhere that you disagree with the exercise as written. In other words, you did not say, "This is crap!" like you do on so many other posts.

It hurts me to see you and MRK thinking this way, because I really like you both.
Be Good.
Love,
Library Lady

P.S. Dear Paiwan, Thank you. I needed a hug.

revere I believe the Church teaches we are all equal before God, not that we are all equal in society.

MRK - after the Black Death the Church was very much weakened as an institution both spiritually and politically. The Church never regained its political power and in fact lost it with the Reformation. So after the Black Death humanity might have returned to a belief system but not quite the same belief system.

I should say Western Europe might have retured to a belief system but not quite the same belief system.

A bit pretentious of me. Sorry.

pauls, LL:

revere I believe the Church teaches we are all equal before God, not that we are all equal in society.

That was exactly my point. Since we aren't all equal in society, to say we are all equal in the eyes of God is irrelevant unless you do something about what is going on in the world. Unless all you care about is what happens after you are dead. Since many of us are non-believers you might understand that isn't of any interest to us. To invoke that is to hide behind the catechism as a way to evade the reality of the here and now.

As a person who believes in God my respect for revere/Revere has grown, regardless of the fact that they are atheist.

I've never heard you talk this way Library Lady so there must be something else going on in your personal life that is carrying over into this post.

This post is important and needs to be talked about, and the people in charge of this movement should be commended for taking the actions they have ahead of time.
When the pandemic hits it will be too late to make these kinds of decisions.

I disagree Lea.. She is expressing her beliefs system in regard to something that will decimate that. Revere is 100% correct. Belief in God isnt going to be increased from this event. Pauls Lane is also correct though in saying that the religious system de-evolved for a while under the Black Death but it was re-constituted under Calvinism and others. The power of the CATHOLIC Church though was permanently damaged. It truly gave rise to the Protestant Church as a new found belief system. Revere though would have been happy in believing nothing, but under the old system he would have been heretic and burned.

LL is obviously a Catholic and like me she would find solace in the writings of the past. But this too would sweep away the Protestant, Muslim and Catholic faiths if it happens at even a 15% number. Belief in God would just fall by the wayside. The people would be more involved in food gathering and staying alive overall than their belief system. LL as you do Lea believe what you want to believe as I do. I believe in God and that Jesus is both messenger and saviour. Dont ever get me to making decisions between eating and God, else you would see a very skinny MRK if thats what he wanted me to do. Most though are PC'd believers. I doubt seriously that LL is one of them and she would die before going against God in her interpretation of them/him.

She likely would stick to her guns all the way down while the Revere's would say what a waste if she did.

Colonel Crosnine my old commander before he was killed used to say a couple of things over and over... "Always make contingencies for when you are possibly wrong. Exercise them when you know you are wrong to salvage the situation. Finally if an when the situation grows beyond your ability to deal with it and death is imminent, make your peace with God because it son is simply just your time to go." Colonel Raymond Crosnine 1950-August 1987.

Dear All,
Lea is right, in a way, but my reaction was not because of a sudden event, but because of a long-time labor of love. My fatherin-law has had several surgeries and serious health events over the last 3 years. I believe I have mantioned some of that in other posts. He is 82 years old and I have watched his health decline and his bravery increase one-hundred fold. I so admire the man--he just keeps going. He still finds value in life.

He would never say this, but he shows me how an old, sick person lives with dignity. The thought that the Reveres put him at the bottom of the chart, and then in the list of expendables, was too much for me. The family has done a wonderful job of helping him, letting him make his own decisions.

If there were a pandemic, and medical equipment was to be rationed, Grandpa would be the FIRST to say, "Give this to the child, I have had my life, I want this child to live." Anyone younger than he is a "child". You would just have to ask him.

This has been my point all along. All you have to do is ask and people will sacrifice themselves for another.

This should be part of the THINKING/planning process, but Revere would have to be mighty brave to suggest it to his colleagues. Revere is indifferent, perhaps antagonistic, to the concept that people will sacrifice for each other. He cannot be sure of it, cannot count on it, it does not fit neatly onto the chart, it is neither mathematical nor scientific.

Well, OK.
I'm going to affix an addendum to my living will. I hope others who have read this discussion will do the same.

I love you all,
Library Lady

Dear Library Lady:

I have remained the affirmation on what I posted.

The Health involvements are supposed to heal the physical, mental and soulful. No dichotomy is allowed. Revere has the concept and performs the healing of physical and perhaps extending partly to mental which I have appreciated. Unfortunately most of doctors neglect the part that they need to be healed as much as patients in many areas.

Your post reminds me of the message of Isaiah chapter 53; you are a living example and bringing the light to us.

Please keeping writing more, if I could have the honor to be your first flock of readers, please share. (Revere has my email address.)

Love and peace.

Dear Paiwan,
Thank you so much for those kind words. My habit has been to visit EffectMeasure as I can to read and educate myself. I post only when I feel the blog has acquired the character of an echo chamber of narrow thought and the subject is serious. I know how Revere feels, it is his blog, I try to be respectful.
You can be assured I will write when it is important to write. This was a very serious subject and I do appreciate the opportunity to express a different view.
Revere has provided a great service here and the fact that he opens himself up to this, invites it, shows he is a thinking person who wants to do the right thing.
Love to all,
Library Lady

LL-And trust me, if birdie bug comes he will roll up his sleeves like the rest of us to get us thru it. He would and will do what is necessary in his mind and if able with the consent of the families. No one is going to just up and start euthanizing people. If an order is given to not treat the elderly and to treat the Senators wife, then there will be an open revolt in my way of thinking. Hell, I might be at the head of it. Its all about what level of order will be maintained. If some hardassed Colonel is standing behind a brigade then yep, going to go his way. Else, its left to guys who think about what they are doing.

Current guidelines by declaration have already stated though that those family members are to get preferential treatment anyway. I like a nice level playing field myself as does Revere.... I would go out of my way as a supply person during this stuff to ensure that those same robust rich people didnt get it...Kind of reverse euthanization. Call it a paperwork problem.

As the pandemic has yet to start, no one knows what will happen. However, those that have educated themselves about the past and have a good inkling as to what could happen in the future, know that when the pandemic arrives it will be life changing to say the least. In my mind, The pandemic, when it hits, has the capacity to completely change the complexion of the world; entire economic systems could fail, the stock exchange could become redundant, trade could fail, etc. There are so many variables that to get on ones hobby horse about equality of treatment is a bit like two fleas arguing about ownership of the camels back. It is a nonsense.

Ah Victoria! That is unless there is only one camel to go around!!!!! This is already territory marking as far as I am concerned. If we are lucky, mostly politicians will get it.... Efficiency in government will improve geometrically if that happens.

LL, Randy, Victoria:

In fact, we need to suggest to Revere, this thread needs to add a new category- Medical Ethics.

I remember that not long ago, a president of Harvard University stepped down because he mentioned the issue of aptitude between male and female. His tone was not bad in that time; nevertheless the female faculty rejected him seriously. Lately, Dr. Watson- the DNA discoverer and the Nobel Prize winner also stepped down because of his speaking of African's intelligence's inferiority.

They all boil down to Ethical arena- the value of attitude which belongs to "being"; Library Lady has pinpointed this part very precisely.

Randy has mentioned the "doing" and Revere's work on "knowing" are very important. But they have to be consistent with the "being"- under the right context.

It is a hard question though. I am glad that Revere has brought this topic for more thinking and exploring.

Ah yes Paiwan, the incident where one lady suffered a case of the vapors and nearly fainted at the Harvard University president's statement. A truer example of the equality of the sexes as has ever been presented.

palwan: the categories are imperfect to be sure. I will consider adding another one for Bioethics. I'm not sure I understood your points, however. I brought up the topic of priorities and triage because they are a fact for pandemic preparedness. In my view, not to discuss them is irresponsible. We already practice them in the US but use money and power as our criteria. That will only be worse in a pandemic. Virtually all bioethicists in the US believe discussing this ahead of time is the thing to do. I know of none that take the position that there is nothing to discuss because the Church has decided it, as LL does.

I never advocated euthanizing anyone. The "graph" is actually an illustration of the underlying problem, not a recommendation, but it does use as examples the kind of choices that are routinely talked about by bioethicists. If one reads the post carefully you will see it is used to illustrate the underlying problem, not to suggest those categories are the proper (or improper) ones. But let's engage the example. Do you or LL belive that if there is only one vent and the choice is between a 17 year old unmarried mom and a 90 year old on life support that the choice here of the mom is at the very least defensible? If not, then what is to be done if and when such a decision comes up? I'm interested to here. Since I am not a philosopher or a theologian but a doctor, tell me what to do and why, don't tell me to read Buber.

pauls: you know quite well that is not what happened. Is that your idea of an argument? When I state an opinion, like 253 days and counting, it is usually directly tied to what I have been discussing and the line of argument clear. The fall of Larry Summers at Harvard did not hinge on his statement about the abilities of women but was part of a much larger context that had been going on for some time. Since he was a Clintonite I would think you would be delighted, as all of your opinions seem 100% in line with Bush/Republican Talking Points. You will love Senator McSame.

Revere whether or not that specific occasion caused the downfall of Summers is debatable; although it was certainly the straw that broke the camel's back. I wasn't really arguing, just making an observation. I give you the Boston Globe from Jan. 17, 2005, "Nancy Hopkins, a biologist at Massachusetts Institute of Technology, walked out on Summers' talk, saying later that if she hadn't left, ''I would've either blacked out or thrown up." Just the sort of reaction expected from a learned scientist, huh Revere? Summers was getting flack because he wasn't hiring enough women in the science departments, which led to his comments, which led to poor Nancy almost blacking out or throwing up. Larry might have been a Clinonite but he wasn't a very good one. Clinton knew/knows how to handle his troublesome women, a skill that didn't rub off on Larry apparently. Your 253 days and counting throw aways just pander to your audience. Well most of your audience, anyway.

pauls: Saying my comments pander to my audience presupposes two things. One, that I know who my audience is. In fact I have no idea what the political leanings of most of my audience might be. The ones that comment hear seem to run the gamut. Second, that I say them to curry favor with my audience. I assure you I make those comments purely out of conviction. I frequently say things here I know annoy many readers, e.g., my views on Israel and Palestine; my general sympathy for immigrants to the US; my view that Afghanistan was a terrible mistake; my opposition to capital punishment and particularly the execution of Saddam; etc. I might be accused of many things here but I don't think pandering is one of them.

Please revere, when you make those comments about the Bush Administration, they pop up preening and displaying all their hatreds and delusions about Bush. Just read the first couple of comments in your now_making_us_safe_is_illegal as an example. I didn't say all of your comments pander, just the countdown. They pander.

Well if it is McCain we dont have to worry too much about the pages and the interns...too friggin old. But Revere Bush has done some good, but more in the first than the second. I agree that he has let it become management by committee rather than kicking ass and taking names. He has gone out of his way in the racial equality department and really made some companies uncomfortable, but he has also failed miserably in closing the borders. Then in a complete flip making statements or allowing statements to be made that "they take jobs that no one else wants." Well not at that price they dont. So by not enforcing wage and hour standards, and the immigration laws we are bunched up at the gate and many are getting crushed. Thats a flub up for sure of major proportions.

When I grab a kid at Xmas last year who hasnt eaten in three days, cant turn him over to INS because they wont take him, thats a flub up. If the police wont take him, thats a flub up because he was just going to go out and steal to survive. Big time case of frostbite on that kid and it cost me 600 bucks to send him back and to make sure INS got him back across the border. Thats a flub up. But it was cheap compared to having arrest and house him, allow him to make babies that would be citizens and of course the crime itself. Thats a flub up. I too am counting the days but not in such a nasty way as you are.

I want someone that would just wipe Al-Sadr's army in Iraq, say piss on the Pakistanis and go in and get Osama, knock drug planes out of the sky, walk into Bethesda or Ft. Bragg and tell the base commanders they are fired and get a diversion of money down there to take care of our wounded. But I am flat bow legged fucked if I think any of that is going to change under anyone who is running. This group of weako's are flat disturbing. Its like a bad case of a government test...Pick the best worst answer.

253 days and counting to WHAT old son? You are a good guy and I admire you for the ideals that you have but shit, I cant see any of it changing except maybe incrementally. Even your posture on UHC and helping the poor is great and one of the reasons that I swear you might make it into heaven ahead of me, but I simply cant see how we can pay for all of these frills when we are pumping our money off shore as fast as we can pull into a gas station.

We have never used food as a weapon and we just might have to now. Much to your dismay. You think that Afghanistan was a disaster as was Iraq. I do too but only from the standpoint that we just didnt kill enough or the right people. I want every nation to not necessarily to fear us but they goddamn well better respect us. If that means knocking the snot out of one of them from time to time great.... Just forget that nation building shit.

We blow it now and they are going to be on the EU just as fast as they can raise the price of oil and Abdul Nasser's UAR might just come into play 40 years post. GWB isnt the most fucked up President in the history of the US, he comes from a long line of fuck ups and PC people. I honestly think we started down the wrong road in the late 40's and early 50's. Racial tolerance? Please, I treat everyone the same...like dog shit. I have fought alongside people I couldnt even decide what color they were except red, white and blue. So how does this racial shit get started anyway except by people like J. Jackson and Al Sharpton, or that women just are going to start puking and leaving meetings because they feel benighted? Everyone is running around with a chip on their shoulders.

I dont think its a crime that someone is making a 100 million and sacking a company's profits. Thats a board of directors decision. Its actually okay to be a legal thief and fire a bunch of people to boost the company numbers. But now as far as responsibility or whether they should get a pass, now theres a group you could stick it up their butts with. But, did I hear any of this out of my current Prez? Nope. Did I hear it out of the last? Nope. Will I hear it out of lets make armoring up a Humvee a political issue Hillary saying these things? Nope. Will it ever come out that it makes the Humvees useless in the sand cause they sink and are sitting ducks then? Nope.

Will we see UHC? Yep, if you want to bankrupt the country but thats just Obama, we will just raise taxes even though outlay will exceed intake by all accounts? But will we hear of how they actually will pay for it? Nope.

Will I see a gas tax cut, maybe but it wont amount to shit or 210 worth of shit a year.

So Revere we all love you but we think you might be out of touch with what happens post GWB. I say it again.....253 days until WHaaaaaaaaat!????

Ok and one other thing folks, lets watch this personal attack stuff. It aint right and you can make your point without name calling or denigrations okay? I do a pretty good job of it and call it too when I see it. I dont do it unless someone jumps me for not agreeing with their position. Snide is okay, just dont go too far. Revere runs a pretty lenient ship and as a right winger I do give everyone respect so respect where respect is given.

R

It's not 253 days until something, it's 253 days from something. I'm not a fan of Obama's policies -- I think they are too tame, too centrist, not at all radical -- but I'll welcome the change in rhetoric and the return to normal government incompetence, not superincompetence.

I guess we all have our limits eh Revere?

Dear Revere,
I have been doing some homework and I will get to that in a minute. First I must respond to some statements above.

You stated, "I know of none that take the position that there is nothing to discuss because the church has decided it, as LL does." I have never said there was nothing to discuss. The Church says a patient can refuse treatment. What is illogical about that? You put those words in my mouth and I don't appreciate it. We are discussing it. You just don't like my source material.

You said you never advocated euthanizing anyone, but MRK did and you did not call him on it. He said, "For me and if I knew they were heading out the door I would hit them with 3-5 syrettes of morphine and ease their suffering. I wouldn't hesitate for more than one second." In case that's too subtle for you he said later, "...the 90 year old God help me would just get the OD of morphine."
It's your responsibility to catch things like that and haul them up short.

Now my homework:
In the list of task force members from "The Summary of Suggestions" in "Chest" 2008;133;1-7 I could only identify one ethicist out of the 37 members--Ken Berkowitz from the VHA National Center for Ethics in Health Care, NY.

He also wrote "Draft for Public Comment", March 15, 2007, "Allocation of Ventilators in an Influenza Pandemic NYS DOH/NYS Task force on Life & the Law". The document is 52 pp long. You may want to check these:
pp.1-3, the "Executive summary" states there must be an ethical framework.
pp.13-18, "Ethical framework for allocating ventilators" discusses pitfalls that an allocation system must avoid.
pp. 28-30,"Implications of triage for facilities" points out some ethically unsound judgements based on third-party assessments of quality of life.
pp. 32-37,Emergency services, time trials, exclusion criteria, palliative care, appeals process and communication about triage.
An exerpt:
Communication About Triage
"...Patients and families must be informed immediately that ventilator support represents a trial of therapy that may not improve the patient's condition sufficiently, and that the ventilator will be removed if this approach does not enable the patient to meet specific criteria...Communication should be clear upon hospital admission and ICU admission, as well as upon initiation of ventilator treatment". Three instances of informed consent.

A second contributor to both documents is Nancy Dubler, Montefiore Medical Center, Bronx.

A third contributor to "Summary" is Tina Powell, New York State Task Force on Life and the Law, NY. She is also a contributor to "The Five People You Meet in a Pandemic--and What They Need from You Today", "Bioethic Backgrounder", The Hastings Center. (www.thehastingscenter.org)

The Hastings Center is a Catholic organization. Some people ARE interested in what we have to say.

CIDRAP has an article "Pandemic triage plan addresses tough ventilator decisions", 12-1-2006, by Lisa Schnirring.
"A tool for prioritizing patients for admission to the ICU ...incorporates the Sequential Organ Failure assessment (SOFA). Later, "...two bioethicists from Dalhousie University in Halifax say it isn't clear how bioethics principles shaped the development of the pandemic triage protocol, WHICH THEY SAY GIVES THE DOCUMENT A UTILITARIAN FOCUS. (emphasis mine) 'We must be clear why certain values are priveleged and others are not.' Using the SOFA criteria was cautiously supported, but the cutoffs were questioned.

To answer your question, Revere, "What is to be done when such a decision comes up? Tell me what to do and why."

The answer:
Informed Consent--because the PATIENT has the right to accept or refuse treatment.

An Appeals Process--in case two doctors disagree on how the triage criteria applies to a certain patient.

Something else for you to think about:
In "What's Wrong with Ethics Consultatiom?: A National Survey", by DuVal and Davis, presented at The Cleveland Clinic's 1st International Assessment Summit, April 4-6, 2003, their study showed:
"On a 10-point scale (with 10 being the highest), all respondents...rated the usefulness of ethics consultation with a mean score of 6.0. AMONG THOSE INTERNISTS WHO DID NOT RATE ETHICS CONSULTATIONS HIGHLY, the following drawbacks were identified:
--consults are inefficient,
--the ethics consultants qualifications are inadequate,
--consults only make things worse,
--consults are unhelpful,
--AND RESPONDENTS FEEL QUALIFIED TO RESOLVE ETHICAL ISSUES ON THEIR OWN. (emphasis mine)

Revere, do you feel qualified to resolve ethical issues on your own? I don't. Following a chart or consulting a list of expendables isn't going to make a doctor feel better when he lets a patient die. His conscience will come into play at some point.

You have to inform patients and their families, and ask THEM what they want to do, even in a pandemic. First, do no harm.

Love,
Library Lady

Pauls, Revere and MRK:

Let us skip the debate of political stances in this thread for a while, it is not the main point which I drew Larry Summers metaphorically here to debate the value of attitude in our modern ethical reasoning. To clear the argument, I just add Paul Wolfowitz from World Bank's step-down; so both parties all had incidences. Their political affinities could not save their smooth vocational journeys, perhaps only leadership counts. Ha, issue of ethical controversy nowadays, people will not tolerate the discrepancy!

In fact, Summers' lesson was mainly his lack of coherent viewpoint, it was not relating to scientific conclusion of male and female's intelligence over the aptitude of science. (Males have two polarities in comparison with females; smarter and dumber. Nevertheless, the average is almost the same.) Watson's issue was similar; poor coherent expression which had lost the context therefore retarded the leadership in motivating the talented team.

Library Lady's criticism indeed has been very relevant in echo chambering the misleading debate in preventing the miseries of ethical controversy. That was the reason that I complemented her great job. Human beings can not be measured by utilitarianism - that is very important context and coherent expression.
------------------------------------------------------------

Revere said: "Do you or LL believe that if there is only one vent and the choice is between a 17 year old unmarried mom and a 90 year old on life support that the choice here of the mom is at the very least defensible? If not, then what is to be done if and when such a decision comes up? I'm interested to here."

If based on Library Lady's comment per se, the answer is parsimonious; no such question at all!

If the 90 years old come first, he/she will be served first. The same guideline applied to 17 years old- pregnant girl. The reporting time will decide; even one minute difference is justified. Once, you are accepted then you are entitled to the right and the obligatory payment. You would like to waive it and give it for next pitiful patient that is your decision, not the clinic's decision. That was the point that Library lady has pinpointed. Human beings are not measured by utilitarianism, how useful is the patient is not answered by doctors.

But myself as a business executive and post-ecumenical person; I would like to add a little more. Plus: I came from a community which had been assaulted by SARS in 2002 Taiwan; for instance -a doctor died of treating the SARS, a nurse refused to report /work because of concerning the unequipped facility. I have been reasoning this by experiencing the true encounter; an issue of mortality in moment.

I assume that this preparedness to be done:
Prior to that it would happen, I assume that the preparations at least have the followings:
-Designated area and space which are separated from the regular clinic treatments for existing patients, preventing the contamination and contagion.
-Signed pandemic treatment personnel who have committed in this dangerous task.
-Trained network of voluntary team for community extension service.
-Assured donation program for possibly increased expenditure.

Strategic planning and pre-operation of pandemic special workforce to finish:
-Clear mission statement; maximal accessibility by equal chance for incoming patients within affordable facility
-Operating guidelines such as acceptance of the period under various conditions, out treatment, etc.

So, does my answer sound reasonable? Revere.

LL: Just to be clear. I don't police or correct comments here. I may respond to them, that's all. If I don't respond to the gizillion statements made by MRK here it doesn't mean I agree with them. 90% of them I strenuously disagree with.

Now to the "nothing to discuss." I apologize if I misconstrued you, but I took you to say that there is no decision to be made about who lives or who dies because of what the Church says. In my book, that means "nothing to discuss." Perhaps you can clarify this for me.

But in my world there are indeed decisions to make. Two people, one vent. That's a decision to make. I have no idea how "informed consent" comes into the picture here. Maybe you can clarify. We aren't talking about taking people off life support because someone decides there is no hope even though no one needs the vent. That's another subject, although as you will see below I have some experience with it.

But the subject of this post is different. Again, let me ask you. You have a 90 year old on life support with a vent, no one has any good hope they will survive; and a 17 year old single mom who needs the vent. What do you do? I understand this is a wrenching decision. But I can't say, "The catechism tells me I can't remove the vent from the 90 year old" and have that be it. There has to be a reason why I am going to let a 17 year old girl die that is better than that. For me. If you say, because the Church says that's the way it is, then that's what I mean by "no discussion." I don't know what my conscience would say if faced with that choice. But I would surely be letting someone die. I have seen many people die, by the way. I am tomorrow on my way to my brother in law's funeral. He refused treatment and died in a hospice. I know the pain of this all the way around. I knew this man for almost 60 years and had a deep affection for him. He stopped eating and when he lapsed into a coma his family (my sister and her children) allowed him to die. I think they did the right thing.

I am confused by your bioethicist account. I don't know what you are saying here. You name at least 3 bioethicists, but I don't know what for. I know at least one of these people and she is a fine bioethicist.

The Hastings Center is not a Catholic organization, at least to my knowledge. I have not only been there many times but I have written for their journal a number of times. The discussions of bioethics there are nuanced and deep. I never heard anyone cite the Baltimore Catechism as a reason for a position at The Hastings Center.

palwan: I'm not sure what your answer is except that there is no question (and hence nothing to discuss). First come, first serve. Of course there may be some difficulty telling who came first and where you measure it from, but I get you point. It is not an ethical issue. It is just a factual issue of luck or circumstance. That means that people who live near the hospital or who have friends there or know there way around it or know where it is are more likely to get the resources. If you live in the city, good for you. If you live in a rural area, too bad. You got there too late. All the vents are gone.

I don't want to get involved in a discussion of utilitarianism (or consequentialism, if you prefer) unless it gives me a good guide how to act in a way that I won't have a problem with my conscience later. I think that using the log-in sheet to decide who lives and who dies is just putting the decision into another form and that bothers me, especially if I suspected that this is not a random allocation. Maximum accessibility for equal chance is meaningless unless you can tell me how you could achieve it and I doubt very much you can. Otherwise you are just waving your hands and invoking "equal chance" to make yourself feel better.

These are extremely difficult problems that can't be answered facilely with the instruction to read the Baltimore Catechism or the Bible or ask The Pope. Nor, alas, are they theoretical or academic questions. They are the reality of life and death in modern medicine, although we usually refuse to acknowledge it and instead choose to let "the market" or the health insurance company tell us what to do and take it off our consciences. For some of us those devices don't work. It's still on our conscience.

That's why we need to talk about it ahead of time and not say the subject is closed and can't be discussed under penalty of it being considered Nazism.

Paiwan...I also draw your attention to the US Constitution and until its suspended, those doctors had better be doing the first come, first served or they will be in to trouble up to their necks. Once on and no declaration by the state or federal government and someone could end up in jail. I do though insist that they get this ironed out before this becomes an issue. If everyone knows what the game is and how its played then no one has anything to expect when it does happen.

Just like the NPFP, everyone has been warned and given ample time to gather their supplies. Anyone failing to prepare likely will not be here after the expected four months. Its as simple as that.

LL asserts that a Catholic hospital would try to save all. Good. But if the law comes into play they had better follow it or there would be a takeover. Bureaucrats and doctors... now theres a mix I really want making decisions about treatments. Inevitably, doctors mostly lose on this kind of deal. The 90 year old under all plans so far LL has been expected to just die. I can assure you that this was the reason for the morphine. Not to kill them but to put them out of their misery if they had BF induced pneumonia and were suffocating. You might also be happy in knowing that at my cost I purchased hand rescuscitators (40 of them) and oxygen masks for both adults and children. Once that goes if it happens, then I go into a mercy mode. I doubt I could watch someone go through the pain of bilateral pneumonia. That death rattle when they cough is terrible to hear and even worse to watch. I would do that morphine just as soon as a doctor said there was nothing else they could do. It also wouldnt be murder under the new and old guidelines.

Dear Revere,
I don't know which of the Reveres I will be speaking to next, but I will take a deep breath and respond to the latest Revere, as you all seem to be in agreement.

There is plenty to discuss. You did put words in my mouth and I accept your apology.

Are any of the Revere's M.D.s? If so, you should understand "informed consent". This is such a basic patient right. I don't understand how informed consent does NOT apply to pandemic situations, and I don't think most of the public will, either. Perhaps you would like to explain, since doctors have had informed consent requirements for years, why all of a sudden it's not necessary in a pandemic.

My bioethicist account is a reading list. Google the titles of the documents and you can find them easily. I apologize for not being clear on that.

I am very sorry about your brother-in-law. The same thing has happened in my family--twice in the last two months. Hospice is a wonderful organization, I don't know what we would do without them.

Revere, I did give wrong information. The Hastings Center is not religiously affiliated, is not a Catholic organization. I made an assumption based on a citation that the publication "The Five People You Meet..." was produced "in collaboration with The Providence Center for Health Care Ethics at Providence Health and Services and made possible through a grant from the Providence St. Vincent Medical Foundation". Providence is Sisters of Providence and it is a Catholic hospital group.
The author, Nancy Berlinger, has a Masters of Divinity, and is the Deputy Director Associate for Religious Studies.
Hastings could be called inter-religious, or perhaps open to religious thought? Hastings accepted a grant from a Catholic hospital group.

The Baltimore Catechism was in print when I was 5 years old. The Church doesn't use it anymore. The current Catechism was comissioned in 1986, took 6 years to write, and was published in English in 1994. It is text-heavy and nearly 2 inches thick. If you thought I was using the Baltimore Catechism no wonder you have been so upset with me. If you knew better, then I might be upset with you for letting others think I was using an elementary school text.
I wouldn't hurt for you to take a look at it.

I would like you to read "a Matrix for Ethical Decision Making in a Pandemic", by Fr. John F. Tuohey, PhD. He is the director of the Providence Center for Health Care Ethics. I think he speaks your language better than I do.

Perhaps we can start to understand each other if you will read these texts.

Love,
Library Lady

So much for your:
Announcing a summer schedule
Posted on: April 27, 2008 4:44 PM, by revere

Your last paragraph reads: At the moment we aren't planning to shut the blog, only turn down the intensity. Who knows? Maybe this will improve it. Plenty of room for that.

*************
Maybe next time don't announce a summer, autumn, winter, spring or Pandemic is here schedule.
It appears, to me, the intensity has gone up dear revere/Revere after this announcement.

Lea-Maybe its the subject matter?

LL's Para about "Informed Consent" doesnt apply if a state of emergency or martial law is declared. In the former, it means that the laws where they can be used will, in the latter, it means there is only the general law. There are not for instance any rights under the Constitution... it is therefore suspended. The Congress could override that but that would take a while and even if injuncted against, it would only be appealed and therefore would stay in effect. Without a reach down from the Supremes you would see a lot of unfortunate misguided people who think they have rights in the latter getting shoved at the least into jails. At the extreme they could be shot down and shoved into pits. In addition, the doctors could be ordered as to which patient gets the vent, but not until that Dec of Emerg or Martial law. Its pretty much a moot point LL, There is only a month point five of supplies available under normal consumption, just like food. It will be gone within a week. Pezzulli's fairly large town suffered in a simulation in under a week, and was at shutdown status I think at that time from a hospital standpoint.

We have been discussing ventilators and the care of the ill. What if there isnt a thing that can be done, vents or otherwise? To go to a hospital to take of a loved one would result in your death because you had no supplies and the system "wrote the whole place off." A dead zone if you will. The word goes out that no one is to go to the hospital. Thats another concern. We are operating on the minimalist idea of what this would be and thats 5%. I think we should assume the worst and then make as many contingencies as we can personally against it as we can and not depend on government. Its not about ventilators, its about the complete and total takedown of the system as we know it. Food, water, jobs, healthcare might fit in somewhere, economic collapse, electric and gas transmission, bank failures, housing market collapses etc. It wont be ventilators if it happens, it is a micro problem about the lack of ventilators and their use. immediately even with the protection protocols.

Revere always posts up some yummy ones and this is one of them.

There is no "calling me on it" LL. The Catechism of the Catholic churches is varied. We have one in the Episcopal church as well but its an agreed upon one and a single one. My own Bishop isnt happy with it but he gets one vote like the rest of the Bishops. There will be those that will roll up their sleeves and head into the zone knowing full well they wont come out of it. There will be those that are forced into it. The decision for euthanizaton is totally against both churches teachings, but let me say this and it is my personal feelings about it and I am very, very devout in my beliefs. I would rather have a Revere making a decision to cut me loose rather than my own family doctor or because of the teachings of the Church. I dont want my doctor to do it because she is Catholic. I wouldnt though in normal times go to anyone else. She is a very good MD and urologist. But when I questioned her she simply said she would prescribe a non lethal dose of morphine to me or my family, even if the outcome would be the same.

Ease the pain of suffocation is the idea rather than ending it. "First Doctor, do no harm". That oath is in my opinion relative to the situation. But I am glad they are taking the steps to give the doctors the best ability to ensure the survival of the most people and this nation. Anything less than that and we have McDonalds and then we have chaos.

Lea-Maybe its the subject matter?

Yes but mostly No.

Maybe it's commenter's here that need and want attention. Something revere/Revere is no doubt growing weary of.
(and I'm not exempt from desiring that attention however, I've noticed that negative attribute in myself, which is more than I can say for most (in as kind a way as is possible)).

Lea and Randy:

We have un-finished task here, let us try to complete it. I had military service experience and quite familiar with special operation and so does Randy.

I've thought a while that Randy is the best person to commission this operation of relieving Mr. Kurtz's trouble. Randy estimated the spending of Mr. Kurtz perhaps was more than USD100, 000. Right? Because Randy has very good network in legal advices and is also very knowledgeable in the current practice of law; his expertise is not less than an attorney I guess.

Mr. Kurtz perhaps is in far left based on Randy's spectrum, is Randy willing to show his compassion that I am not sure. You see that I am away twenty thousand kilometers and have the empathy for Mr. Kurtz-an artist of passion and vitality for creativity and a very gentle and loving person. How can we leave him suffering as an underdog so long and costing his savings for retirement?

If we tell Randy the probable fact- Mr. Kurtz is the first cousin of Revere; is this fact motivating Randy a bit? (Revere, please do not need to read this part)

So, Lea: can you help Randy to cast off his hilarious nihilist style? and do an excellent example for us.

Revere: "These are extremely difficult problems that can't be answered facilely with the instruction to read the Baltimore Catechism or the Bible or ask The Pope. Nor, alas, are they theoretical or academic questions. They are the reality of life and death in modern medicine, although we usually refuse to acknowledge it and instead choose to let "the market" or the health insurance company tell us what to do and take it off our consciences. For some of us those devices don't work. It's still on our conscience."
---------------------------
LL: " The current Catechism was comissioned in 1986, took 6 years to write, and was published in English in 1994. It is text-heavy and nearly 2 inches thick. If you thought I was using the Baltimore Catechism no wonder you have been so upset with me. If you knew better, then I might be upset with you for letting others think I was using an elementary school text."
---------------------------

The religious authority has to be updated (Evolutionary epistemology again); pretending that there is no authority at all is a wrong attitude.

So far, this thread has achieved the consensus of recognizing the bioethical domain and the dimension of conscience in medical treatment; the area that requests both from scientific and religious convergences to deal with.

LL's inputs seem more coherent and easier to achieve the convergences, IMHO. We need to look deeper in this area, though. Scientific knowledge now is viewed tentative which is very similar to latest religious epistemology- not literally, but more symbolically and metaphorically.

Eventually, Revere has to recognize the new ration( I would like to discuss in the future more) of including God the ultimate giver of life and the source of nature. It does make the ration different; as said by a theologian, "It entails an acknowledgement of our own creatureliness and responsibility towards what is not ultimately ours."This point is responding to LL's question; "Revere, do you feel qualified to resolve ethical issues on your own?" It is a very good question for everyone here.

(Revere: this time I didn't bring Martin Buber who you had known him well before my previous post I believed :-)

"New ration" should be read- "new rationality". Sorry.

Revere wrote the following in his final paragraph;

Maybe instead of arguing who will go in the lifeboats if the ship sails into an iceberg we should be building safer boats with more lifeboats. Of course it's not a question of one or the other. We can do both. Unfortunately we are only doing one.

In the event of a high death rate pandemic, all bets will be off. Our governmental and health systems will be overwhelmed. All the arguments about whose god is better, and universal health for all will disappear in a puff of wind.

Revere, do you think that we will be able to build more lifeboats in time?

Dear Revere,
There is only one Catechism of the Catholic Church. MRK is mistaken. There may be different editions, but it is all the same text.

This has been a very important discussion. Lea is right, it is wearying.

What has been very instructive for me has been the steadfastness of the Reveres and MRK in their viewpoints. MRK, especially, has no qualms about euthanizing during Martial Law, but, ironically, shows a great deal of respect for his physician who has a different viewpoint.
He confuses me.

MRK, just how does the military train it's soldiers to form a firing squad, shoot, and shove peaceful American citizens into a pit? I don't believe a word of that, and your going to have to prove to me that your soldiers will follow orders. Your own physician could wind up at the edge of the pit.

This thread is a microcosm of what will happen. There will be millions of "me"s and only thousands of "you"s. Citizens will not understand. If you think this is wearying now, just wait until the media choses to focus it's pea brain on this.

The Reveres seem to think that desperate situations requires the desperate measures posted at the top of this page, without the active and continuous input of ethicists. The chart and list of exclusions is by no means a done deal. I maintain there is a different way of thinking about this.

If H5N1 comes I do not want to be caught in the grip of these desperate measures as they stand now.

So, people, please read what the ethicists have to say.

Love,
Library Lady

When I am able and feeling quite tolerant then yes paiwan there will be efforts at helping anyone who posts comments here. Although ... I'm to the point where I'm not willing to let anyone 'drain my energy' any longer.

Just to set the record straight, I may believe in God but I do not follow any man-made religious dictates. What the churches have done to the majority of people is a crime in my eye, period. And please, don't go off on me about religion. No one, absolutely no one, has to be religious to be ethical or conduct themselves in that way.

Victoria said it well: "All the arguments about whose god is better, and universal health for all will disappear in a puff of wind".

revere/Revere is atheist and quite frankly I'm more fond of atheists than I am of religious minded people.

LL-There is no formal training. But they dont all have "live ammo" so as to relieve the people selected of the burden of having to take a comrade down. There are many reasons for doing this, but mostly for cowardice under fire, or failure to follow a direct order. You can be shot on the spot in a combat zone with a witness if an officer or NCO orders you to do something and you dont follow that order. You will be warned once and then failing that with the witness present, the officer or NCO can cap you.

http://en.wikipedia.org/wiki/Firing_squad

This has a fairly good explanation of the selection process. You dont have an option though not to participate.

As for your info request its covered in basic training and it is that "peaceful American citizen" that will be violating the Constitution under a declaration of martial law. They can do it in a police emergency in a declaration of emergency (N. Guard) but its only been employed like four times in the last century. Douglas McArthur had to on his former soldiers when the 29 crash happened. (dont know if there was a declaration, but its the District of Columbia ) another was Kent State, the Watts riots of the 60's and the last, it escapes me. IF a declaration of either is in effect and you are told to do something, your chances at getting arrested go up about 500%. If there is just too much for them to handle under a DoE or DoML, they can upon the chief executive of the state or federal government take you out. If indeed they are being peaceful in say a protest, then yup I wouldnt follow that order and neither would anyone under my command. If they are throwing rocks, maybe. If they are in the middle of a food riot and the cease and desist order is given and they fail to obey, its pine box time. Understand that in the case of a riot it is just that a riot. Everyone would be hungry, everyone would be of a ant mound mind... Food. Not anything the government is going to be able to do about it having given four years of ample warning or more. Sorry folks, go home or go to the cemetary. You have to have order to have a society.

My own physician said she would NOT give an OD of morphine or other. I had terminal BF or SARS and it was obvious that I was going to bag it, I would tell my doc even if I had to write it on a brown paper sack to take me out. SHE wouldnt do it because of her beliefs. I on the other hand would gladly give that ventilator up to a kid that might make it. Morphine into the arm, better living or less of it by chemistry IMO. Thats the reason I want Revere attending to me. Not because I would want to go, but because I would know that I am going to go and he for one is one that could be trusted. Not a panflu DNR, its take it right the hell now so the kid might make it. Sacrifice by choice or sacrifice by selection... it will happen. God help the survivors who have to make these kinds of decisions. They will haunt them for the rest of their lives and that includes me if it got down to it. I dont want it to ever "get down to it" but that is the mind set of our over dependent on government population. They have now accountability themselves ever when something happens, Katrina, Rita, Andrew, North Ridge Quake, Oakland fire etc. But they always feel that government will be there with the net... Not this time out.

Wouldnt want to think that the soldiers would be put into the position but hospitals in particular to function MUST keep the people out of the hallways and away from the staff and isolate. 20 man tents on football fields and samples and stuff running back and forth.

As for shooting them down, this will be the briefing. Threat assessments, response, Rules of Engagement, deployment, engagement and trust me they WILL follow orders or they will be shot on the spot themselves. Crowd control is taught at every combat school now as part of base defense, perimeter control. You dont necessarily have to shoot someone to get them to do what you want. Me, I like concussion grenades. Two of those in quick succession generally will make you a slobbering bubble-headed idiot for a day or two. Next riot out though would be live fire.

Also LL....Medical Ethicists exist within a pre and post framework of a pandemic. That framework will have two sets of guidelines. One for 10 seconds before it happens, and then the second after they collect all of the data for what really happened during. There will be no ethics at all if there is no system for it. At a current 85% CFR for the year, and 25% of the post pan flu people dying of bacterial pneumonia within 6 weeks of the the viral flu....Its a moot point really anyway. If you make it, then you likely were selected by God to make it.

You are very much right though I really like my Doctor and she welled up a bit when I put her to the question about what she would do. One side of her says ease the suffering, the other is the Catholic side that is telling her that dogma and Catechisms are important enough to risk ones life on. I personally dont think she is going to see it because after a month there likely wont be too much of a military or police presence due to attrition.

Lea:

I am confused about your mood. I was talking to you about Mr. Kurtz and possible help from Randy. Because I read your interactive posts with Randy and realized your care for Mr. Kurtz, so do I; it has prompted me to ask you this favor.

Your comment was totally off this topic. You might mistake Randy for Revere as per my post.

As for religious viewpoints in relating to ethical issue, it is another topic, not my point to you. Since you mentioned it, let me respond to you as well: I understand that this blog's mainstream at this moment is atheism; nevertheless the dialogues are not inhibited. They are debatable.

Ya, maybe my input is sort of countdown-annoying to some people. But you want me totally surrender or immigrate to "France" immediately?

Dear Revere and MRK,

MRK, thank you for the clarification on the military's responsibility to keep order. I am glad that you noted there are non-lethal methods, because I wasn't hearing that in your earlier responses.

I do not believe ethics relies on a system, that is, a system of charts, lists of expendables, military orders, CDC rules, Homeland Security mandates, systems that can change based on what is "happening on the ground"--a situational ethics.

Ethics is in the heart of the human. It is the conscience whispering in your ear that "This is not right". Ethics principles can be agreed upon by a group of people that "Together, we will do this, and we will not do this, ever." The Catechism, along with the Bible, is a source I can use to help clarify events around me that cause me to worry about the less fortunate, the sick, the aged.

Revere, going back to the original post, my concern was with the exclusion criteria. It was a tough concept for me to absorb, and I do not yet accept it.

How will the exclusion criteria be applied?

Can Revere answer directly or give me a citation that can answer the following State of Emergency or Martial Law hypotheticals? Not specifically, but something that says, "Together, we will do this, we will not do this, ever"?

Christopher Reeve is still alive on his respirator. He has a fixed unit at home and a portable for trips. He does not have bird flu nor does any member of his household. He falls under the exclusion criteria. Do you ask for his equipment? Can he say no?

Every resident at Happy Haven Nursing Home has equipment, supples, and staff needed to care for heart problems, diabetes, kidney failure, dementia, etc. All residents fall under the exclusion criteria, but there is no bird flu at Happy Haven. Are these facilities to be let alone?

Is the exclusion criteria ONLY applicable to triage at the hospital emergency room door, military hospital tent, or parking-lot triage (as in Katrina), for patients who present as bird flu victims? For example: A patient has dementia AND bird flu, diabetes AND bird flu, heart attack AND bird flu, dialysis patient AND bird flu? What happens to this same category of patient who does NOT have bird flu?

Can you anticipate a scenario where the exclusion criteria "thinking" will bleed into the community and be acted-upon by non-hospital, non-military, non-authorized personnel--perhaps the Happy Haven staff, or Visiting Nurse, or Hospice?

Do you hold firm that "informed consent" is not applicable, necessary, or desirable during a State of Emergency?

I would appreciate a response.

Love,
Library Lady

Dear Revere,
I have answered, partially, one of my own questions. The CIDRAP article "Pandemic triage plan addresses tough ventilator decisions", by Lisa Schnirring, 12-1-06, states, "The protocol is designed to guide clinicians' triage decisions for patients WITH AND WITHOUT influenza during the first days and weeks of a pandemic....The report was published in the November issue of "Canadian Medical Association Journal (CMAJ)". (emphasis mine)

Do you agree with this protocol?

Love,
Library Lady

LL: I'm glad you went back to the original post as that is the proper point of reference. It was specifically about triage during a pandemic or other emergency where the resources are limited and difficult decisions must be made. Most of the post was about what the underlying logic of this was: the need to sequence (number, rank, whatever word you want) people when the underlying order was a partial order and not a total order. You and palwan solve that problem in a specific way. You turn the partial order into a total order (where everyone has a prescribed rank) on the basis of who got a ventilator first. That's pretty much the way we do it now. Maybe it's the right way but it deserved discussion. That's what I was doing. Do I agree with the proposals made in Chest? Not necessarily. I expressed the opinion in fact they wouldn't be much guidance. But I do agree we have to figure out how to do this and not just accept the way it is done now. The idea that "first come first served" is fair and just ignores the fact that who gets something first may not be fair and just.

But I also want to address another misconception you have. You seem to assume that if I don't object to something, either something I report in a post or something someone else says in a comment, that I agree with it. In particular you seem to conflate MRK's views on martial law, which I object to strenuously, and my views. Let me be clear about how we operate here. I usually hope that the comments police themselves, that is, that when someone says something really outrageous others will take care of it. I respond here to the best of both my ability and my time and whatever else is tugging at my sleeve and the same goes for all the Reveres. I have spent the last few days at my brother in laws funeral, hoping to comfort my sister even slightly by my presence and my emotional support for her. I was connected only some of that time and any comments I made were just snapshots of when I stuck my had in the door of the comments threads. So if I do or don't respond is often a matter of chance and circumstance, not a reflection of my opinion or lack of opinion (although it may be that, too). The general principle we hold is that we have control of the front page and the comment threads are for the readers. We rarely (but sometimes) step in and stop something and in the case of the flame war going on at the Bush Legacy thread we were too preoccupied with our family to bother with it. It wasn't worth it to us to spend time on it at that point.

I rarely respond to MRK because that would be a full time job in itself, just checking his links, firehose volume of assertions and everything else. We are fond of MRK (aka Randy) but that doesn't mean we agree with him. We rarely (although sometimes) do. Despite the outrageousness of his expressed views (in our opinion) he behaves himself here as a good member of this community and we feel he is entitled to express his views in the comments. And despite the outrageousness of his views in the abstract, he has shown himself to be personally sympathetic and generous to others. That's a lot more than I can say for some people on my side of the political spectrum who have views I agree with but can be beastly to others (I am not referring to any commenters here on the blog, BTW).

So I was glad to answer your specific question to me, LL, since it is clearly very important to you that you know my views, but I remind you that your question is misplaced. My objective was to open Pandora's Box, not to endorse anything or everything that flies out of it.

Dear Revere,
Thank you so much for your thoughtful response. I really understand, now, how you want to run the blog. And, you are correct about MRK, he is sympathertic and generous. So is Paiwan, Lea and many others.

You are kind of like my husband. Sometimes when we talk and I ask a specific question (let's say the Christopher Reeve-type question) he will be vague, as you are when you say you don't nessesarily agree with the content of the "Chest" article. That's all I get.

It's like trying to nail Jello to a wall. From now on, I will remember that you can slip into the Jello mode (pun intended) any time, and I can just stop coming here any time.

So what do I do with the information in your original post? Go about my business as this has not come up? This is important, and I'm not getting anything from you.

I wanted to know, what you (as an insider), your colleagues, the CDC, Homeland Security, and the American scholars involved in the Canadian product are going to do. Are the "ways of thought" finalized, set in concrete, non-negotiable? Or is there a shiny, new manual in your office that says "This is what we will do, this is what we will not do, ever"?

I am truly sorry about your brother-in-law, his family's loss, and for your loss. I will pray for you all.

Love,
Library Lady

LL: Thank you for your kind thoughts. What will I do? Good question. I am hoping never to face it in a pandemic. I don't have any answers, which is one of the reasons we bring things up here. For us, writing is thinking and we often are thinking things through via the blog. The main point about this particular issue is that we don't consider it to be an abstract or theoretical question but a real question we sometimes are forced to answer to the best of our abilities. We are never satisfied we have answered it correctly as for every answer there is another "yes, but ..." attached to it. When dealing with matters of life and death, as we do routinely, it is easy to slip into conventional answers or matters of habit or answers we claim are forced on us by regulations or laws. We don't consider any of those an adequate basis so we keep asking about them and revisiting the questions. This is the main reason for our posting this here and also for my reaction to your catechism answer. We think it is proper to question everything when it comes to these matters as we have yet to find an answer we feel confident is based on thinking we feel is irrefutable or even wouldn't be questionable under some circumstances (but perhaps not in others).

I am not even sure how well and honorably I will behave in a a pandemic. I hope I will behave with honor and integrity and truly don't fear much for my own life at my age. But would I do things to protect my children and grandchildren that aren't strictly fair and just? I don't know. We have tried to think ahead about this, for example by not taking advantage of the fact that we can write a prescription for a private supply of Tamiflu for the family, something others can't do and the supply is still short. That may be a principled decision I will regret later but at least I am able to make it now without the pressure of immediate fearing for the lives of my children and their children. But despite my hope that the community will pull together and help each other I can never be sure I won't take the family and run and hide when the time comes. I don't know. I hope they can get somewhere safe and I can do my thing but it's easy to say when things aren't coming apart around you.

In any event, think of this blog as a workshop for my thinking and you'll have it close to right.

Dear Revere,
God bless you and keep you.
Love,
Libray Lady

And you too LL. Here is my best read on the exclusions. Lets not get there. If you are a librarian start putting the really ugly stuff out on the table for suggested reading. Do as I do and spout pandemic to all who will hear. If everyone jsut grabs the food and preps you'll save thousands here. My conscious thoughts are based on the USA and the effects. You may be appalled to hear that there are only some 8 countries that have made real progress on prevention, preparedness and post pandemic planning. The rest of the world....excluded by stupidity or lack of resources. Nigeria has a huge population, but they stopped culling birds because of the cost to the state. Indonesia? I cant begin to think of what will happen if 100 million people just up and died in under a month or two. Same here. There simply isnt enough of anything to go around if pandemic happens.

Africa? Exclusion in Africa will be in the old ways. They will evacuate the villages and leave the sick in huts. If they survive they will be allowed to occupy their old homes, nothing new. Food and water will be left for them. But caring for them? Zip. If the hut becomes a death house, they will poke their heads in and make sure they are all gone and then fire the hut. This is the way of old and we sit around thinking about ventilators and saving people. There they have less than 1 chance in hell of making it.

And we think we will have it bad....?

LL, Randy and Revere:

We finally agree that first come, first served basis.

Dear LL, I have seen your spiritual love for Revere; risk of loss to care for a person's spiritual growth. Amazing!

Second one is Randy.:-) If he will let me first, no problem. Anyway, I am the third. :-)

Sunday Sermonett has quoted your name from my post. Sorry to use it as convinience.

palwan: I do not agree on first come, first serve. I think it is often (but not always) a policy fraught with the danger of injustice.

Nor do I Paiwan. But as stated, until the declaration of either is made it is and will be first come, first served.

Dear Revere and All,
I have just finished reading an abstract for "Impact of a Pandemic Triage Tool on Intensive Care Admission", by Bailey, Leditschke, Ranse and Grove, in "Critical Care". March 13, 2008, at ccforum.com/content/12/S2/P349. I will quote the abstract:

Introduction
The issues of pandemic preparedness and the use of critical care resources in a pandemic have been of increased interest recently. We assessed the effect of a proposed pandemic critical care triage tool on admissions to the ICU. The tool aims to identify patients who will most benefit from admission to the ICU and excludes patients considered "too well", "too sick", or with comorbidities likely to limit survival in the shorter term.

Methods
To assess the impact of the pandemic tool on our current practice, we performed a retrospective observational study of the application of the pandemic triage tool described by Christian and colleagues to all admissions to our 14-bed general medical surgical ICU over a 1-month period.

Results
One hundred and nineteen patients were admitted to the ICU. Using the pandemic triage tool, 91 of these patients did not meet the triage inclusion criteria on admission. As required by the triage tool, patients were reassessed at 48 and 120 hours, with only one of the 91 patients becoming eligible for admission on reassessment. Further assessment of the 29 patients (24%) who met the triage inclusion criteria revealed that 17 of these met the exclusion criteria, leaving 12 patients (10%) from the original 119 as qualifying for ICU. One of these 12 was deemed "too sick" by the triage tool and therefore was also excluded, leaving 11 patients (9%).

Conclusion
Application of this triage tool to our current ICU patient population would radically change pracitce, and would generate substantial capacity that could be used in the situation of a pandemic. In addition, as the triage tool aims to exclude patients who are less likely to benefit from admission to the ICU, these results have implications for ICU resource management in the nonpandemic situation."

I cannot believe what I am reading. By using the Canadian triage tool for their study, they (on paper) "emptied" their ICU and only "served" 11 patients the entire month. The triage tool rejected 91% of their patients. Not a one had bird flu. I am assuming the "rejected" patients would have died. An empty ICU. Unbelievable!

Is this really what hospitals ought to be doing during a pandemic? Remember, the Canadian triage applies to all patients WITH or WITHOUT avian influenza.

I am hoping someone else has access to the full article so I can link to it. I would like to read it.

Thank You,
Library Lady

LL: As I read this, it is asking the question about what the triage tool, as it is constituted, would do to ICU census. The answer is that it would free up many ICU beds. The triage tool has nothing to do with avian flu in the sense that it doesn't give any preference to people with flu over those without flu but keys in on medical salvageability and (I guess) age. To go back to my original post, it recognizes that the beds have to be doled out on some system and rejects the idea that first come first served is automatically the right system. As I noted, first come first served (or, "It's my bed because I'm in it") has serious fairness questions because we know that being in the bed is not random. The better off and those with pull and those who by accident live closer, etc., are more likely to be in the bed. Does that mean that the poor from rural areas should be abandoned on those grounds alone? Maybe, but if that's what we are deciding to do we should do so with our eyes open and do it knowingly, not by pretending as if this is all a matter of chance.

When resources are scarce it affects everyone. Those with heart attacks and auto accident victims and children with life threatening asthma and women in childbirth. The shortage might be caused by bird flu but the victims won't just be people with bird flu.

LL-

US
http://id-center.apic.org/cidrap/content/influenza/panflu/news/dec0106t…
CANADA
http://www.cmaj.ca/cgi/content/full/175/11/1393
UK
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1819377

Trust me dear, you are not the only one grappling with this. The UK even has a scoring system to determine whether you actually make it even into the hospital much less onto a ventilator.

Indeed, CIDRAP's post above states equal opportunity under normal conditions. When the hospital apparently declares a medical state of emergency, the government will follow suit and do theirs. Once there, neither can be held liable for ability or inability to provide healthcare.

Read that cool one from the UK. They cover it like a paint brush.

Dear Revere and MRK,

You know, it has taken me, a non-medical person of considerable research skills, quite a long time to find the information I need to understand the practical applications for a Canadian-model pandemic triage. I have learned a lot.

All the pandemic triage literature states that public input is necessary. Several authors state that they doubt there will be much public discussion, for a variety of reasons, apathy being the first reason. We are discussing now, here, and I do appreciate the time you both have taken for this. Does it surprise you that the other thread participants have dropped off, it seems, permanently?

I cannot agree with the Canadian triage recommendations. I hate them. The New York document is more palatable, as it does rely heavily on ethics consultation.

I am comforted that Tia Powell (New York State Workgroup...) has said there will be different "triage for different facilities: chronic care facilities will maintain different ventilator allocation standarsd from acute care facilities." I dearly hope this means that patients in nursing homes that are on a ventilator will keep theirs.

Other literature regarding nursing homes and other residential care facilities are more disturbing.
Ahrq.gov has included nursing homes in their "Alternative Care Site Selection Matrix". I am worried that to designate nursing homes as Alternative Care Sites, which, as part of an overall Pandemic Plan would be required to implement the Canadian triage exclusion criteria we have been discussing, would empty the nursing homes.

ahrq.gov also states in "Atered Standards of Care in Mass Casualty Events":
"Needs of current patients, such as those recovering from surgery or in critical or intensive care units; the resources they use will become part of overall resource allocation. Elective procedures.... In addition, certain lifesaving efforts may have to be discontinued." They also state in the same document that "Providers may not have time to obtain informed consent..." which confirms what Revere has been telling me and which brings me back to square one. Informed consent, I have to have it, or no deal.

The State of Utah, in its pandemic plan, suggests that triage, using the Canadian exclusion criteria, be implemented by in-house medical staff at residential institutions, such as nursing homes, assisted-living homes, mental hospitals, prisons, and homes for the mentally retarded and disabled. Hospital ER physicians will not be involved at all. This give me a sick feeling in the pit of my stomach. We simply cannot let states say, "This Canadian plan looks good, we'll just copy it," which is what Utah seems to have done.

I hope we will still share information here as it comes in, or Revere will enter a related story higher up on the blog.
I am still very concerned about the "ways of thinking" I am seeing in my research.

Got to go see Mom. I love that lady, we have so much fun!
Love,
Library Lady

LL: Yes, we want people to talk about this, which is why I posted it. The main post is off the front page which is probably why discussion has dropped off (and I am having a lot of trouble with comment spam clogging up the recent comments list) so we'll do it again at some point. Returning to the last para. of the original post, along with arguing/discussing what to do with too few lifeboats we should also be urging construction of more boats, i.e., strengthening public health, health care and the availability and accessibility of staffed beds, vents, etc. Every extra bed and vent is one more person whos life can be saved. If we choose not to do this because we don't want to pay for it, that's a conscious choice with consequences. We know what is coming and we can act on it or not.

LL, Randy and Revere:

I have kept thinking of the possible code of conduct in pandemic situation, the parts both for clinic inside and community extension services(directed by clinic).

The part for clinic perhaps has to include the protection for medical people ( un-necessary sacrifice of medical people). More works have to be done in connection with community extension services.

I am like LL are non-medical persons. But my job is involving with marine viruses, and I have known how fearful they are!