Utah implements harsh triage guidelines for bioterror, epidemic emergencies

did so when it comes to dementia, based in part on surveys asking whether people would want life-sustaining treatment if they had it, said ethicist Jacobson. “There is a judgment [that] even if they did survive, the duration of survival and quality of that survival is poor in terms of the value to society,” said Rolfs, the epidemiologist.

Physician Norman Foster agrees it is reasonable to allocate scarce care based on a person’s underlying cognitive abilities. He worries, though, about the guidelines’ vague language. He is unaware of anyone with expertise in geriatrics or neurological diseases being consulted on the guidelines.

Foster, director for the Center for Alzheimer’s Care, Imaging and Research at the University of Utah, said most Utah dementia patients are not properly evaluated. That means medical staff in a triage situation would not know if the condition was severe, he said. He fears staff could deny care to more people than intended, including people with mild forms of dementia, those with reversible delirium, those with speech problems or the elderly in general.

“Dementia care is not a priority in our health system or among health professionals,” he wrote in an e-mail. “There is a significantly greater risk of abuse of these patients in a triage system of any kind.”

Other language excludes those with end-stage multiple sclerosis “requiring assistance with activities of daily living.”

That language should be eliminated, since “there are many healthy, high-functioning people who require such assistance,” the National MS Society said in a statement.

May writes that Utah has also been criticized for using DNR status as a reason to deny care. “Do not resuscitate” refers to not wanting life-sustaining measures if a person’s heart or breathing stops. People who sign them likely would not anticipate they would be denied a ventilator for the flu.

The orders “reflect individual preferences” more than “an accurate estimate of survival,” said a report by the Institutes of Medicine, which evaluated crisis guidelines from Utah and other states.

Helen Rollins, a retired nurse who helped develop end-of-life care programs in Utah hospitals, said patients typically sign DNRs when they are critically ill. If they get better, it would be “unfair” to use that status to refuse treatment during a separate emergency, she said.

Excluding patients based on DNR status “is one that continues to worry me a little bit,” said Rolfs, the epidemiologist. “Judgment [by a physician] is needed.”

Besides excluding certain patients, the recommendations prioritize patients for admission and use of a ventilator based on the Modified Sequential Organ Failure Assessment — a tool that predicts mortality.

One point could make the difference between being sent home or getting a bed — or being removed from a ventilator. The scale “was not designed as a prospective predictor of survival,” the IOM report said, noting it is unknown whether the difference of a single point means a patient is more likely to recover.

Wynkoop said Utah doctors evaluated the scale by examining the records of past intensive care patients. Those who would be denied care under the guidelines died even after the most aggressive treatment, she said. “We’ve got to start from somewhere,” she said. “Just saying we’re not going to have any [evaluation tool] doesn’t appear to be humane.”

Patients denied care would be sent home or to another facility and provided with sedatives and painkillers to keep them comfortable until they die. “Many of us have a family member or a friend who is on that exclusion list,” Rolfs said. “You look at it and you think about it. ‘These are not going to be easy times.’”