Public perspectives on COVID-19 triage protocols for access to critical care in extreme pandemic context

Marie-Eve Bouthillier; Yanick Farmer; Claudia Calderon Ramirez; James Downar; Andrea Frolic; Joseph Dahine; Lucie Opatrny; Diane Poirier; Gina Bravo; Audrey L’Espérance; Antoine Payot; Peter Tanuseputro; Louis-Martin Rousseau; Vincent Dumez; Annie Descôteaux; Clara Dallaire; Karell Laporte; Nathalie Orr Gaucher

doi:10.1371/journal.pone.0314460

Peer Review History

Original SubmissionJune 27, 2024
18 Sep 2024 Decision Letter - Rodrigo Toniol, Editor PONE-D-24-25281Public perspectives on COVID-19 triage protocols for access to critical care in extreme pandemic contextPLOS ONE Dear Dr. Bouthillier, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Nov 02 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 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The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf. 2. We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match. When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section. 3. Thank you for stating the following financial disclosure: [Corresponding author Marie-Eve Bouthillier received funding from a grant awarded by the Canadian Institutes of Health Research (CIHR). Funding Reference Number/ EG4-79448. ]. Please state what role the funders took in the study. If the funders had no role, please state: ""The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."" 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If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: N/A Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The manuscript presents a fundamental discussion on contemporary bioethical issues and contributes to the deepening of issues related to decision-making in critical contexts in health emergencies. Considering the multiple factors and controversies surrounding the access and distribution of healthcare in a scenario of limited resources. Below are some suggestions for improving the quality of your article, in line with the journal's criteria: The demographic analysis of the data presented in the "Results" section could be improved. For example, I suggest that when mentioning demographic categories specific to Canada, such as "visible and non-visible minority", a footnote be inserted explaining what this means in the Canadian census (e.g. who is included in this category). Considering that this is an article for an international audience. In additon, although table 3 mentions the gender of the participants, it is not described in the body of the text. I suggest including this and mentioning that there were no gender diverse participants. Finally, even though the results presented are consistent and show the complexity and relevance of the subject through the survey participants' responses, the discussion section could be developed further. It would be interesting for the authors of the article to include a paragraph on the bioethical controversies involved in the application of triage protocols, expressed by the opinion of the participants categorized as "neutral or Don't know". The ethical issues seem to be associated with the variety of values and principles of equality mentioned by the DD participants. Reviewer #2: First of all I want to thank the team for submitting the article and presenting the results in such an adequate manner. I am happy to say that the article is rich and should be published. As a researcher that has witnessed the difficulties faced by healthcare workers during the covid 19 pandemic, specially in the process of decision making and resource allocation, I’m glad to see this discussion being made outside of hospitals. Besides the conclusions presented I think one of the great merits of this article is to have made a platform for discussing the ethical and moral quarrels of these decisions. The quotes presented show the innate struggles of reaching consensus on extreme situations like the ones experienced during the covid 19 pandemic. At the same time I would provoke the writers to take a step further with its analysis. The discussion of the DD shows the tensions and dissents that were brought up when lay people tried to discuss - roughly put here - “the fairer approach” to the triage protocols during covid-19 pandemic. The results show that, again, putting in a rough manner, “the fairer approach” would be an “egalitarian, utilitarian, transparent and accountable approach”. At this point I would point out that some of the concepts highlighted by the DD are not necessarily self explanatory, they carry within them moral and ethical values. Let’s take the idea of transparency, for instance. Transparency as a democratic value is a rather recent idea, dating back to the 1990’s. The study made by Hetherington, “Guerrilla auditors: the politics of transparency in neoliberal Paraguay.” (2011, Duke Press) showcases how the idea of transparency was executed in Paraguay by a multiplication of papertrail that eventually would become an overbearing shadow for those that were willing to better understand the processes that should be made more transparent in the first place, and worse, this would be the only socially legitimate way to achieve clarity over the guerilla processes that Herington was investigating in the first place. Anyway. As I said, this isn’t a necessity and the article works fine without these debates, but I think maybe the article would gain a lot by showcasing some of the nuances of these ideas and the different values that were inhabiting the notions of transparency, accountability, etc. I would suggest that these values are not inherent, but can only be built and legitimized in an effective manner through the exchange of views made possible by the DD. More than an exercise to produce data, I would argue the DD was an exercise on making the triage protocols fairer and this is a major accomplishment by your team of authors. Finally, I would suggest adding a small point on how the authors have perceived the points made by the participants and if, as health workers themselves, they felt that the discussion was able to showcase some of their own worries and difficulties as decision makers. ****** 6. 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Revision 1
24 Oct 2024 Author Response Point by point responses 1. When submitting your revision, we need you to address these additional requirements. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf. Answer: We consulted the PLOS ONE style templates and adapted our manuscript to meet PLOS ONE's style requirements. 2. We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match. When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section. 3. Thank you for stating the following financial disclosure: [Corresponding author Marie-Eve Bouthillier received funding from a grant awarded by the Canadian Institutes of Health Research (CIHR). Funding Reference Number/ EG4-179448. ]. Please state what role the funders took in the study. If the funders had no role, please state: ""The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."" If this statement is not correct you must amend it as needed. Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf. Answer: We reviewed the financial disclosure and added the role of the funders as recommended : “Corresponding author Marie-Eve Bouthillier received funding from a grant awarded by the Canadian Institutes of Health Research (CIHR). Funding Reference Number/ EG4-179448. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.” We included this information in our revised cover letter. 4. We note that you have indicated that there are restrictions to data sharing for this study. For studies involving human research participant data or other sensitive data, we encourage authors to share de-identified or anonymized data. However, when data cannot be publicly shared for ethical reasons, we allow authors to make their data sets available upon request. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Before we proceed with your manuscript, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., a Research Ethics Committee or Institutional Review Board, etc.). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of recommended repositories, please see https://journals.plos.org/plosone/s/recommended-repositories. You also have the option of uploading the data as Supporting Information files, but we would recommend depositing data directly to a data repository if possible. Please update your Data Availability statement in the submission form accordingly. 5. In the online submission form, you indicated that [Data supporting the findings and materials are available upon reasonable request to the corresponding author. Some data are confidential.]. All PLOS journals now require all data underlying the findings described in their manuscript to be freely available to other researchers, either 1. In a public repository, 2. Within the manuscript itself, or 3. Uploaded as supplementary information. This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If your data cannot be made publicly available for ethical or legal reasons (e.g., public availability would compromise patient privacy), please explain your reasons on resubmission and your exemption request will be escalated for approval. Answer: I contacted my research ethics committee at the Université de Montréal and they informed me that my ethical certification does not allow the sharing of data (even anonymized) on a public repository since the participants did not consent for large sharing of their data. Here's their reply: Hello Ms. Bouthillier, Thank you for your e-mail. More and more journals are requiring this type of access, but it doesn't always correspond to the provisions set out in the protocols, or to the commitments made to participants. Looking at your project on Nagano, it appears that a secondary use of data has been foreseen, but within a very specific framework: “Your data could be shared with the other co-researchers and students of the research team of this project, who will also commit to keeping your data and everything discussed in the deliberation confidential”. Thus, making your project data publicly accessible could run counter to the commitments made to the participants at the time. Indeed, they did not consent to the wide distribution of their data. If you are uncomfortable with this public release, and know that it was not planned and was not consented to by the participants, it is ethically possible to refuse this request. However, if you wished to allow this distribution, a request could be submitted to the committee to do so, but this would potentially require several adjustments, or even a re-contact of the participants if you still have their contact details. I hope you find these clarifications useful, If you'd like to discuss this in person via Teams, I'd be delighted to do so. Of course, I'm always available if you need me. Have a nice weekend, Yours sincerely Marie-Alexia MASELLA, M.A. Research Ethics Advisor Office of Responsible Conduct in Research Université de Montréal Website: crr.umontreal.ca Conclusion : For these reasons, we will provide access on request to certain parts of the data as long as this complies with the guidelines determined by our ethical certification. Thereofre this statement would remain valid : “Data supporting the findings and materials are available upon reasonable request to the corresponding author. Some data are confidential.” 6. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. Answer: We included captions for our Supporting Information files at the end of the manuscript and made sure that the in-text citation match accordingly. 7. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. Answer: We reviewed our reference list to ensure it is complete and correct. We did not include nor retracted any references. 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The manuscript presents a fundamental discussion on contemporary bioethical issues and contributes to the deepening of issues related to decision-making in critical contexts in health emergencies. Considering the multiple factors and controversies surrounding the access and distribution of healthcare in a scenario of limited resources. Below are some suggestions for improving the quality of your article, in line with the journal's criteria: The demographic analysis of the data presented in the "Results" section could be improved. For example, I suggest that when mentioning demographic categories specific to Canada, such as "visible and non-visible minority", a footnote be inserted explaining what this means in the Canadian census (e.g. who is included in this category). Considering that this is an article for an international audience. Answer : Thanks for pointing this. We added a footnote stipulating : “In Canada, the Employment Equity Act defines visible minorities as "persons, other than Aboriginal peoples, who are non-Caucasian in race or non-white in colour". The visible minority population consists mainly of the following groups: South Asian, Chinese, Black, Filipino, Arab, Latin American, Southeast Asian, West Asian, Korean and Japanese. The 'Multiple visible minorities' category includes persons who provided two or more groups designated as visible minorities.” For the sake of clarity, we also added two sentences (line 161-163) : “Participants were able to self-identify as belonging to any one of the visible minority groups, a category composed of multiple visible minority groups, or not belonging to a visible minority. These groups are mutually exclusive.” And we made changes in the Table 3, we think this presentation is clearer. Nothing substantial has been changed, just the name of one categories : we change «Ethnocultural groups» for «Self-reported visible minority groups», we think it is more precise. In addition, although table 3 mentions the gender of the participants, it is not described in the body of the text. I suggest including this and mentioning that there were no gender diverse participants. Finally, even though the results presented are consistent and show the complexity and relevance of the subject through the survey participants' responses, the discussion section could be developed further. It would be interesting for the authors of the article to include a paragraph on the bioethical controversies involved in the application of triage protocols, expressed by the opinion of the participants categorized as "neutral or Don't know". The ethical issues seem to be associated with the variety of values and principles of equality mentioned by the DD participants. Answer: Thank you for this comment. We reviewed all the transcripts in NVivo related to «neutral» or «I don’t know», and we added our interpretation of the bioethical controversies in the discussion line 376-387 : “While the majority of participants who took part in the process were in favor of a triage protocol based on best chance of survival, a few said they were neutral or didn't know. This emphasizes an important point. In extreme situations of resource scarcity, in the opinion of the experts and participants consulted, a clear, easy-to-use and transparent emergency plan is needed to avoid catastrophe and improvisation. Being indecisive or neutral could lead decision-makers to make no choice. There are many reasons for not making a choice: fear of making a mistake in the face of uncertainty and lack of evidence, fear of the political stakes or repercussions of a decision, inability to choose in the face of a plurality of equally important values, such as respect for life, the right to equal opportunities, etc. All these reasons “paralyze” decision- making. However, not making a decision is still a choice: to face the consequences of potential chaos leading to death and moral distress for all parties involved. Taking a stance on the question of triage upstream and even during a crisis enables better planning, more consultation and the avoidance of many pitfalls.” Reviewer #2: First of all I want to thank the team for submitting the article and presenting the results in such an adequate manner. I am happy to say that the article is rich and should be published. As a researcher that has witnessed the difficulties faced by healthcare workers during the covid 19 pandemic, specially in the process of decision making and resource allocation, I’m glad to see this discussion being made outside of hospitals. Besides the conclusions presented I think one of the great merits of this article is to have made a platform for discussing the ethical and moral quarrels of these decisions. The quotes presented show the innate struggles of reaching consensus on extreme situations like the ones experienced during the covid 19 pandemic. At the same time I would provoke the writers to take a step further with its analysis. The discussion of the DD shows the tensions and dissents that were brought up when lay people tried to discuss - roughly put here - “the fairer approach” to the triage protocols during covid-19 pandemic. The results show that, again, putting in a rough manner, “the fairer approach” would be an “egalitarian, utilitarian, transparent and accountable approach”. At this point I would point out that some of the concepts highlighted by the DD are not necessarily self explanatory, they carry within them moral and ethical values. Let’s take the idea of transparency, for instance. Transparency as a democratic value is a rather recent idea, dating back to the 1990’s. The study made by Hetherington, “Guerrilla auditors: the politics of transparency in neoliberal Paraguay.” (2011, Duke Press) showcases how the idea of transparency was executed in Paraguay by a multiplication of papertrail that eventually would become an overbearing shadow for those that were willing to better understand the processes that should be made more transparent in the first place, and worse, this would be the only socially legitimate way to achieve clarity over the guerilla processes that Herington was investigating in the first place. Anyway. As I said, this isn’t a necessity and the article works fine without these debates, but I think maybe the article would gain a lot by showcasing some of the nuances of these ideas and the different values that were inhabiting the notions of transparency, accountability, etc. I would suggest that these values are not inherent, but can only be built and legitimized in an effective manner through the exchange of views made possible by the DD. More than an exercise to produce data, I would argue the DD was an exercise on making the triage protocols fairer and this is a major accomplishment by your team of authors. Answer: We're delighted to hear your thoughts on the subject and to receive your positive feedback on our project. We believe, as you do, that the DD process helps to get the word out, thereby improving protocols and making them fairer. We agree that these values are not inherent, but can only be built and legitimized in an effective manner through the exchange of views made possible by the DD. Thank you. Finally, I would suggest adding a small point on how the authors have perceived the points made by the participants and if, as health workers themselves, they felt that the discussion was able to showcase some of their own worries and difficulties as decision makers. Answer : Thank you for inviting us to commit ourselves more to the study. At the end of the discussion, just before the limits of the study, we add the following few sentences, lines 415-421.: “Many authors of this study were involved in triage protocols in one way or another, as managers, designers, clinicians or patients. During the development of the protocols, w Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0314460.r002
12 Nov 2024 Decision Letter - Rodrigo Toniol, Editor Public perspectives on COVID-19 triage protocols for access to critical care in extreme pandemic context PONE-D-24-25281R1 Dear Dr. Bouthillier, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Rodrigo Toniol Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0314460.r003
Formally Accepted
19 Nov 2024 Acceptance Letter - Rodrigo Toniol, Editor PONE-D-24-25281R1 PLOS ONE Dear Dr. Bouthillier, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Rodrigo Toniol Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0314460.r004

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