Although three of four triage officers in the study were involved in drafting www.selleckchem.com/products/CHIR-258.html the original triage instrument, considerable inter-officer disagreement and lack of confidence in triage decisions were noted. In a situation where triage decisions carry life and death stakes, and family members vent their anguish, these difficulties will be heightened.For example, in one isolated New Orleans hospital after Hurricane Katrina [4], family members objected when clinicians assigned patients with Do Not Resuscitate orders the lowest evacuation priority. Several altered standard protocols, although not that of Ontario, use Do Not Resuscitate status as an exclusion criterion for hospital admission in a pandemic; an expert panel convened by the US Institute of Medicine recently recommended against using Do Not Resuscitate status in this way [5].

To date, rationing protocols for pandemics have been developed like Ontario’s, by expert panels with great effort and intentions but without significant input from the general public. Triage decision-making algorithms, unlike evidence-based guidelines for disease treatment, are shaped by many nonclinical considerations. Medical experts and the lay public may have different views about what ethical principles and values should guide triage priorities (the role of age, chronic illness, disability, and previous access to care are but a few examples); this cannot be known unless those developing guidelines find ways to engage the public [6].

Some authors and an ethics advisory subcommittee to the director of the Centers for Disease Control and Prevention have suggested algorithms that prioritize patients along a scale with a sliding cutoff point rather than categorically excluding certain groups; patients who are assigned a low priority would then be provided treatment if it becomes available [7,8]. Cilengitide In the days after Hurricane Katrina, certain patients triaged to the lowest priority category were not evacuated even after resources became available to do so, suggesting the need to emphasize situational awareness and for frequent reassessment in triage protocols.Ultimately the use of even the best survivorship prediction tool may need to be leavened by individual clinician judgment and be weighed against factors such as fairness, the effect on public trust, and mental distress caused to triage officers, clinicians, patients, and family members. The pilot study by Christian and colleagues lights the way for future work.AbbreviationsICU: intensive care unit.Competing interestsThe author declares that they have no competing interests.NotesSee related research by Christian et al., http://ccforum.com/content/13/5/R170 and related letter by Burkle, http://ccforum.