In Victoria, whether you get an ICU bed could depend on the hospital



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Lisa Mitchell, Deakin University; Emma Tumilty, Deakin University, and Giuliana Fuscaldo, Monash University

Although most hospitals are coping right now, COVID-19 has brought up many questions about how health-care resources should be rationed during a pandemic.

Ideally, every unwell person should get anything they need to get better. But important resources like medications and hospital beds, including intensive care unit (ICU) beds, can become limited if demand outstrips supply.

We’ve had access to confidential documents outlining how various health services are to make decisions on who gets ICU resources in the event they become overwhelmed.

We found there’s significant variation between hospitals’ procedures on this front. And worryingly, the public doesn’t have access to this information.

Resource allocation in hospitals

Resource allocation procedures or triage plans help to work out who gets that bed, ventilator, or vaccine if and when the system comes under significant strain.

Ideally, these procedures should be created well ahead of when they might be needed, and be underpinned by three factors:

  • local context — what’s available/possible

  • medical evidence — what works, and for whom

  • ethical values — what we consider fair and the right thing to do.




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The Victorian Pandemic Plan suggests health services should “adopt a systematic and transparent prioritisation of services as demand for treatment grows”.

It also says:

Triage will be enacted at the same level across the state, to promote equity of access of patients to intensive care.

Safer Care Victoria, the peak state body for quality and safety improvement in health care, had been preparing a document to guide hospitals on ethical resource allocation. But it only released this to the health services a few days ago, and the contents are considered sensitive and not for wider distribution within or outside the health services.

In contrast, Queensland Health released an ethical framework to guide clinical decision-making during COVID-19 in April, that’s available to the public.

Red sign says 'Emergency' with arrow.
If resources are stretched, the hospital you go to could determine whether or not you get an ICU bed.
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Different hospitals, different procedures

In the absence of a statewide approach in Victoria, most health services have developed their own resource allocation documents and triage plans.

To our knowledge, none of these documents are publicly available. But we’ve been able to informally review COVID-19 resource allocation procedures from a number of Victorian hospitals.

We’ve found these procedures vary in how ICU resources would be allocated to sick people (with or without COVID-19) in the event resources were scarce.

Some health services would use a standardised scoring system that predicts short-term survival (that is, the person deemed most likely to live would get the bed). But when they use the scoring system, and what additional criteria they take into account, varies between hospitals.

Some hospitals would use exclusion criteria based on certain health conditions. The types of conditions vary between hospitals. For example, one hospital would use a body mass index (BMI) above 40 to exclude people who are obese, while another would exclude people with alcohol dependency.




Read more:
Coronavirus and triage: a medical ethicist on how hospitals make difficult decisions


In “tie-breaker” situations, when it’s not possible to make a decision based on the scoring system, health conditions, or the severity of illness alone, hospitals may use tie-breaker criteria.

Tie-breaker criteria were also different across different hospitals. Some hospitals would prioritise pregnant people, sole parents, health-care workers, and so on. Others would not.

Several of the hospitals plan to use a team of experienced clinicians not involved in the patient’s care as a triage team. Some hospitals have indicated a lottery is the fairest thing to do in tie-breaker situations.

Hospital x, y or z?

Most hospital patients won’t need ICU-level support. Some people, even if they’re very unwell, may choose not to receive treatment in the ICU. And some people will not benefit from ICU care. But for anyone who might benefit, the different plans could mean different access depending on which hospital they go to.

For example, if you’re pregnant, it would be better to go to hospital x. If you’re a widowed parent with young children, you should go to hospital y. If you’re obese, you should try your luck somewhere other than hospital z.

Again, these resource allocation procedures are not publicly available, so we can’t provide information here to guide you.

Health-care worker wearing yellow PPE attends to unconscious patient.
Medical staff would need to make resource allocation decisions using their hospital’s procedures.
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Variation in procedures across different hospitals is understandable in the face of uncertain medical evidence, or when available resources differ in local contexts, or because local communities have specific health needs. For example, you could reasonably expect variation between a smaller regional hospital and a bigger city hospital.

But where resources are similar — for example in two Melbourne hospitals only a few kilometres from each other, with overlapping catchment areas — plans should essentially be the same. If they’re not the same they should at least be publicly available.

It appears they vary, and the current lack of transparency around these resource allocation procedures means patients have no way of knowing whether they would be better to present at one emergency department over another.




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Transparency and equity

The pandemic has highlighted various health inequities. In Victoria, the highest case numbers have occurred in areas with the greatest socioeconomic disadvantage.

Resource allocation is considered fair when processes are accountable, transparent, justifiable, and revisable. Where they’re not, they can further disadvantage people and communities.

If Safer Care Victoria and the individual health services were to make their ethical framework document and resource allocation procedures available to the public, this would allow for discussion and engagement, and where possible, enable people to choose which health service will serve them best.The Conversation

Lisa Mitchell, Conjoint Clinical Senior Lecturer in the School of Medicine, Faculty of Health, Deakin University; Emma Tumilty, Lecturer, Deakin University, and Giuliana Fuscaldo, Associate professor, Monash University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Government wants church to stop contruction in Malaysia


Christians in a small village in Malaysia have been told they can’t build a church. Reports coming out of Malaysia say Christians in the Temiar village of Pos Pasik, about 70 km northeast of Gua Musang Kelantan, have been told by the Department of Orang Asli Affairs (JHEOA) that they have no permission to build a church on their land, reports MNN.

On 20 May 2010, the village head wrote to the Director-General of the JHEOA to inform him of their plan to build the church in their village, half of whom have converted to Christianity in recent years.

In response, the Deputy Director-General writing on behalf of the D-G replied that their "application" to build the church had been rejected and the community was asked to stop work on the building immediately.

This is contrary to what Malaysian Prime Minister Najib Razak said this week. He praised the work and mission of the Inter-faith Relations Working Committee. It’s a group of Malaysia’s religious leaders representing Christians, Hindus, Buddhists, Sikhs, and Muslims. In a 45-minute session he praised Malaysia’s pluralism, saying, "It’s the foundation of national unity, rather than a front of division."

Todd Nettleton with Voice of the Martyrs says, "While the prime minister is saying we celebrate religious diversity and we celebrate the freedom to worship, the reality on the ground for some of the Christians in Malaysia is a little different."

Nettleton says it appears that religious tolerance depends on your ethnicity. "It is not uncommon for an ethnic Chinese person to be a Christian. So that is thought to be acceptable. It is much less common for an ethnic Malay person to be a Christian. They are thought culturally to be Muslims. Typically you see a harsh response from that."

Nettleton says, "There is some type of revival movement that is going on there. The ethnic villagers are becoming Christians. They want to have a church building. What I’m not clear about–and I think it deserves a little bit more study–is why this government agency said you can’t build this church building."

If the church is demolished or stopped, it will be the second Orang Asli church in the state of Kelantan (and no less than 5 in the peninsular altogether) that has been demolished by the authorities on the basis of various excuses, including that the Orang Asli do not have rights to the land concerned. But it is evident that the issue is religion-related as other structures, including suraus, have been built on such lands without any issue.

Report from the Christian Telegraph

Kyrgyzstan: Religious freedom survey, December 2009


In its survey analysis of freedom of religion or belief in Kyrgyzstan, Forum 18 News Service finds that the state continues to violate its commitments to implement freedom of religion or belief for all. Limitations on this fundamental freedom and other human rights have increased – in both law and practice – under President Kurmanbek Bakiev.

A harsh new Religion Law was adopted in 2009, despite international protests, and a similarly harsh new Law on Religious Education and Educational Institutions is being drafted. There are also plans for a new Law on Traditional Religions.

State actions, including banning unregistered religious activity and raids on meetings for worship, show little sign of either a willingness to implement human rights commitments, or an understanding that genuine security depends on genuine respect for human rights.

As a Baha’i put it to Forum 18: "Our country has so many urgent problems – poverty, the lack of medicine, AIDS, crime, corruption. Why don’t officials work on these instead of making life harder for religious believers?" Kyrgyzstan faces the UN Universal Periodic Review process in May 2010.

Report from the Christian Telegraph 

TURKEY: MUSLIM SENTENCED FOR STABBING PRIEST IN IZMIR


Assailant influenced by TV series defaming Christian missionaries.

ISTANBUL, January 12 (Compass Direct News) – A judge in Turkey sentenced a 19-year-old Muslim to four-and-a-half years in prison on Jan. 5 for stabbing a Catholic priest in the coastal city of Izmir in December 2007.

Ramazan Bay, then 17, had met with Father Adriano Franchini, a 65-year-old Italian and long-term resident of Turkey, after expressing an interest in Christianity following mass at St. Anthony church. During their conversation, Bay became irritated and pulled out a knife, stabbing the priest in the stomach.

Fr. Franchini was hospitalized but released the next day as his wounds were not critical.

Bay, originally from Balikesir 90 miles north of Izmir, reportedly said he was influenced by an episode of the TV serial drama “Kurtlar Vadisi” (“Valley of the Wolves”). The series caricatures Christian missionaries as political “infiltrators” who pay poor families to convert to Christianity.

“Valley of the Wolves” also played a role in a foiled attack on another Christian leader in December 2007. Murat Tabuk reportedly admitted under police interrogation that the popular ultra-nationalist show had inspired him to plan the murder of Antalya pastor Ramazan Arkan. The plan was thwarted, with the pastor receiving armed police protection and Antalya’s anti-terrorism police bureau ordering plainclothes guards to accompany him.

Together with 20 other Protestant church leaders, Arkan on Dec. 3, 2007 filed a formal complaint with the Istanbul State Prosecutor’s office protesting “Valley of the Wolves” for “presenting them as a terrorist group and broadcasting scenes making them an open target.”

The series has portrayed Christians as selling body parts, being involved in mafia activities and prostitution and working as enemies of society in order to spread the Christian faith.

“The result has been innumerable, direct threats, attacks against places of worship and eventually, the live slaughter of three innocent Christians in Malatya,” the complaint stated.

The Protestant leaders demanded that Show TV and the producers of “Valley of the Wolves” be prosecuted under sections 115, 214, 215, 216 and 288 of the Turkish penal code for spreading false information and inciting violence against Christians.

The past three years saw six separate attacks on priests working across the country, the most serious of which resulted in the death of Father Andreas Santoro in Trabzon. As with Fr. Franchini, many of the attacks were coupled with accusations of subversion and “proselytizing.”

Although a secular republic, Turkey has a strong nationalistic identity of which Islam is an integral part.

Television shows such as “Valley of the Wolves” may not be the norm, but the recent publication of a state high school textbook in which “missionary activity” is also characterized as destructive and dangerous has raised questions about Turkey’s commitment to addressing prejudice and discrimination.

“While there is a general attitude [of antipathy], I think that the state feeds into it and propagates it,” said a spokesperson for the Alliance of Protestant Churches of Turkey (TEK). “If the State took a more accepting and more tolerant attitude I think the general attitude would change too.”

At the end of 2007 TEK issued a summery of the human rights violations that their members had suffered that year. As part of a concluding appeal they urged the state to stop an “indoctrination campaign” aimed at vilifying the Christian community.

TEK will soon release its rights violations summery for 2008, and it is likely that a similar plea will be made.

“There is police protection, and they have caught some people,” the TEK spokesperson said. “There is an active part of the state trying to prevent things, but the way it is done very much depends on the situation and how at that moment the government is feeling as far as putting across a diplomatic and political statement. There is hypocrisy in it.”

A survey carried out in 2005 by the Pew Global Attitudes Project also suggested a distinctly negative attitude towards Christians among Turks, with 63 percent describing their view of Christians as “unfavorable,” the highest rate among countries surveyed.

Niyazi Oktem, professor of law at Bilgi University and president of a prominent inter-faith organization in Turkey called the Intercultural Dialogue Platform, said that while the government could do more to secure religious freedom, he would not characterize Turkish sentiment towards Christians as negative.

“I can say that general Turkish feeling towards the Christian religion is not hostile,” said Oktem. “There could be, of course, some exceptions, but this is also the case in Christian countries towards Islam.”

Report from Compass Direct News