Ireland's health service would not be able for a bird flu pandemic, writes Muiris Houston
'SIX ONE News, with Brian Dobson and Una O'Hagan.
The headlines: "As the number of people infected with bird flu rises, the pressure on health services is reaching breaking point. It has been decided that hospital patients over the age of 85 and those with certain chronic diseases will no longer be given life-saving care in a bid to reserve scarce intensive care facilities for people admitted with severe influenza."
A somewhat Orwellian news bulletin of the future? Or a realistic prediction of the difficult decisions facing us in the event of a full-blown influenza pandemic?
A report published last week by the American College of Chest Physicians, Definitive care for the critically ill during a disaster, suggests that high-tech care will have to be rationed in the event of an expected bird-flu pandemic.
Drawn up by US and Canadian experts in critical care, the guidelines do not duck difficult decisions and are remarkably prescriptive about who will lose out in the race for intensive care and high dependency facilities.
Dr Asha Devereux, a critical care specialist in San Diego and lead author of the report said: "If a mass casualty critical care event occurred tomorrow, many people with clinical conditions that are survivable under usual healthcare system circumstances may have to forgo life-sustaining interventions due to deficiencies in supply, staffing and space."
The task force recommends that hospitals with ICUs prepare for the initial surge of patients by stockpiling equipment such as ventilators. They should aim to treat triple their usual capacity for up to 10 days without external assistance.
But it is when a disaster extends for a longer period that the really difficult decisions kick in. In the case of an influenza pandemic, expert groups predict that the first phase will last for about 15 weeks, so there is no question of being able to avoid some significant ethical dilemmas.
Last week's report is forthright in listing those patients who will be excluded from critical care facilities. If your risk of death is greater than 80 per cent, you are out of luck.
Those with a severe chronic disease such as advanced heart failure or end-stage respiratory disease will also be excluded. Patients with severe bird flu who are over the age of 60 will lose out, as will those with advanced Alzheimer's disease.
Any notion that the risk of a global pandemic has quietly passed was also dispelled last week.
According to the World Health Organisation's (Who), Keiji Fukuda, "we cannot delude ourselves. The threat of a pandemic influenza has not diminished".
There have been 382 cases of bird flu since 2003. Some 241 people have died, a reminder of the disease's high mortality rate.
And while most human cases have resulted from direct transmission of the H5N1 virus from birds, human to human spread has occurred in at least two cases.
Experts fear the mixing of the bird flu strain with a known human flu strain, causing a mutation, would render the H5N1 virus highly infectious among humans.
The Republic's Pandemic Influenza Expert Group does not appear to have dealt in any depth with the ethical issues highlighted by the North American report. In the clinical management section of its advice, the Irish report says: "In a pandemic situation where high dependency units/intensive care unit beds may not be readily available, prioritisation of patients on an individual basis matched against available resources will be expected."
On the surface, this recommendation is no more than one would expect from any team of doctors practising to good ethical standards. But does it go far enough?
If I have private health insurance, will I be triaged separately from the person next to me with a medical card?
Do we really want doctors playing God?
Is it acceptable to make decisions based on age and adopt a policy of "young and fit to the lifeboats"?
The Department of Health has an ethical obligation to undertake a process that is transparent and publicly debated.
Making decisions behind closed doors in the corridors of power is unacceptable. Given the political, legal and emotional sensitivities, it is not a discussion we can have in the fraught atmosphere of a full-blown pandemic.
This is a debate we need to have now.
• Dr Houston is pleased to hear from readers at mhouston@irish-times.ie but regrets he is unable to reply to individual medical queries