Making moral decisions when resources are limited – an approach to triage in ICU patients with respiratory failure

In a number of countries around the world there is evidence that the demand for intensive care unit (ICU) resources exceeds supply.1-5 Epidemiological evidence suggests that future demands on intensive care resources will increase, adding to the burden of provision.6 Southern Africa almost certainly faces similar challenges, although there is as yet little published medical literature documenting this.7 When ICU resources are critically constrained, there is an inevitable need to ration the use of ICU beds. This means that while some patients who will potentially benefit from ICU care will be able to receive it, others will not. Assuming an absolute deficiency of ICU resources (available beds and their accompanying manpower requirement, equipment and other resources), the inevitable consequence is that some deserving patients will be denied potentially life-saving ICU care. A critically important decision must therefore be made – which patients will be admitted and which patients will be refused ICU care, and on what basis. A structured process of decision making is vital to maximise consistency and the moral defensibility of these difficult decisions. This paper will describe possible approaches to making these decisions, discuss aspects of triage in patients with respiratory failure, and examine some of the consequences of ICU triage. SAJCC Vol. 21 (1) 2005: pp. 34-44