If Coronavirus Patients Outnumber Ventilators, Who Gets One? Here's How Doctors Decide

What do existing guidelines tell us about how doctors and nurses are likely to allocate scarce resources in the face of a pandemic? For...

What do existing guidelines tell us about how doctors and nurses are likely to allocate scarce resources in the face of a pandemic?

For weeks, ny Governor Andrew Cuomo has pleaded with the federal for more ventilators—most urgently on behalf of latest York City, the present epicenter of the COVID-19 outbreak within the us . and every week that has passed has brought the region closer to a nightmare scenario: having more patients who need ventilators than there are machines for them to use. It’s like watching the ball drop on New Year’s Eve in Times Square , only with none of the thrill , joy, hope—or, God forbid, crowds. It’s the grimmest of countdowns.



The governor hasn’t publicly elaborated on how hospitals will decide who gets the doubtless life-saving equipment within the event of a shortage. When asked at a news conference on March 31, he said, "I don't even want to believe that consequence. i would like to try to to everything I can to possess as many ventilators as we'll need." Technically, ny already has guidelines in situ for rationing ventilators just in case of an influenza pandemic, last updated by the state’s Task Force on Life and therefore the Law in 2015. But some would argue those recommendations need considerable updating to deal with the realities of COVID-19, a highly contagious respiratory virus.




And so behind the scenes, hospitals in ny and round the country are developing and refining guidelines for weeks, enlisting the assistance of bioethicists and other experts to grapple with the impossible question at the core of it all: If patients outstrip ventilators, who lives—or who gets the simplest shot at it, anyway—and who could die?



RELATED: What Does a Ventilator Do, and the way Does It Help People With Coronavirus?




Advance guidelines, which are established by individual states and institutions, are intended to guard clinicians from both the emotional burden of getting to form an irreversible life-or-death call and any legal repercussions that would result from doing so. (As another measure, lawmakers in ny recently moved to grant immunity to hospitals and health care workers who are treating infected patients.)




The guidelines, or “triage protocol,” isn’t formally implemented unless a governor has declared a “crisis standard of care” in his or her state, which, as of press time, no US governor has done. But there are enough well-documented modifications to ordinary standards of care—the sharing of ventilators, for instance—that experts agree there's no time to waste. Hospitals need an idea .




So what happens if, or when, we reach a tipping point in ny , New Jersey, or wherever we see a surge in patients next? What do existing guidelines tell us about how doctors and nurses are likely to allocate scarce resources?




First, it’s important to know that, during a pandemic, a physician’s goal is not any longer to try to to what’s best for every individual patient, but to try to to what’s best for the community—to save the best number of lives possible. Whereas under normal circumstances a doctor might treat a critically injured gunshot victim before moving on to her less seriously wounded patients, under plague rules, the other would be true.




“In very general terms, what [a triage team] looks at is medical survivability,” Nancy Berlinger, a search scholar at The Hastings Center, a bioethics research institute that in March released an ethical framework for health care institutions responding to COVID-19, tells Health. “What is that the potential for this person to truly survive the medical care hospitalization and recover sufficiently to return off of the ventilator?”



RELATED: When Will Coronavirus End—and When Will It Peak within the US?




Arthur Caplan, director of the Division of Medical Ethics at ny University, adds that rationing ventilators isn’t all that different from rationing organs. “I’ve worked for several decades on transplants,” he tells Health. “We don’t take first come, first serve. We’ve always tried to maximise the lives saved with a scarce supply of organs. We yell and scream and ask people to donate more organs, but they don’t, and that we keep having people die a day . But that [has left] us with a system that has rules, very similar to those [we’re discussing here]. It’s not like we've to take a seat down and say, ‘I wonder what we’d all do if we had to ration.’ We’ve been [doing it] for 40 years.”




Of course, that doesn’t make it any less challenging. Consider a hypothetical: a 65-year-old man and 50-year-old woman are in acute respiratory distress and need assistance to breathe, but there’s just one ventilator available. Who gets it? Is it the lady because she’s younger?




Although older patients (especially over age 75) tend to fare worse on a ventilator than younger patients, the broad consensus is that age isn't the determining think about a rationing scenario within the us . Doctors are generally expected to think about physiology first: Does the patient have an underlying health condition that would compromise the result of ventilator use? (New York’s aforementioned guidelines recommend applying the standardized Sequential Organ Failure Assessment or “SOFA” score to group patients into four survivability categories.)




So if our hypothetical woman features a serious heart problem and our hypothetical man is otherwise healthy, her age won't afford her a foothold . But age isn’t off the table, either, which has led some to stress that they or their elderly parents are going to be a target of discrimination should they find themselves hospitalized.




RELATED: Nearly 90% of individuals Hospitalized With COVID-19 Have Underlying Conditions, Says CDC




“It’s not discrimination if you’re trying to work out who’s likely to measure and who’s getting to die albeit they get the scarce resources,” says Caplan. “So nobody said you can’t be considered simply because of your age, but if there are people who need the resources too, then age does become a predictor—very adulthood . Flip-wise, most of the people would say, ‘other things being equal with two candidates, take the younger child.’ You don’t hear anybody protesting the utilization aged there.”




Disability rights advocates have similarly expressed concern that able-bodied patients will receive preferential treatment. together activist and author wrote within the ny Times, “When there isn’t enough lifesaving care to travel around, those that need quite others could also be in trouble.”




Berlinger understands why people are wary: “What is that the background for people with disabilities being really concerned about being discriminated against? Well, it’s the long history of discrimination against people with disabilities, including in health care settings,” she says. But she cautions against escalating tensions. “The titles of op-eds are often very adversarial—this versus this. But if you read journal articles by people in bioethics, they’re saying, ‘Well, yeah, you actually need to guard against bias creeping in.’”




One way to try to to that's to convene a triage team to work out who will receive a scarce resource instead of leave it up to a private doctor. “You don’t say, ‘I guess the doctor who is taking care of those patients will need to decide,’” explains Berlinger. “That’s way an excessive amount of to ask one person to try to to .”




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Again, it leaves an excessive amount of room for bias, “because we all make snap judgments about all types of things,” she says. “Like what if you said, ‘Well, it’s really important to value a parent before an individual who isn’t a parent.’ you would possibly be then overlooking who had more potential to profit from an intervention, otherwise you could be completely overlooking the very fact that the one that wasn’t a parent had other caregiving responsibilities and social relationships.”




And that’s not the sole ethical dilemma which may arise. “Would you give priority to a health care worker?” wonders Berlinger. “Or what about health care workers who don’t work on your hospital? What if it’s a home care aide? It’s really, really hard to work this out, and that’s why you would like a gaggle of individuals .”




But Caplan is skeptical of the decision-by-committee model at now during this particular pandemic. “What’s been happening at the most places is committees are meeting to get out guidelines to advise decision-makers,” he says. “...You have to urge your plans and policies ready. But, look, there’s getting to be tons of judgment left to the doctor at the ER when that ambulance gets you there. They’re getting to , I hope, be guided by medical considerations on who they think goes to try to to well if they get intubated and placed on a ventilator, whether it’s COVID-related or [due to another] condition.”




And that’s if the ambulance even gets you to the ER , he adds. “The first triage isn't the hospital, it’s the emergency responders,” he explains. “They’re getting to field many simultaneous calls as things get crazy, and they’re getting to need to decide where they’re going and who they’re taking.” That impacts not only suspected COVID-19 patients, but anyone who needs an ambulance.




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If you call 911 because your father has a attack , for instance , you would possibly not get the response you’re expecting. they could say, “‘Your dad is 450 pounds during a fifth-floor walkup and that we only have two guys because our crew is down because we’re sick,’” Caplan offers by way of example. “That’s the important world of triage: It isn’t who’s getting into the door of the hospital, it’s whether you create it to the hospital.”




“You need to realize that it’s an epidemic and therefore the rules are different,” he says. “Remember, there are people that don’t even get to ascertain relations if they’re infected—because they won’t let anybody else into those parts of the hospital.”




And if crisis standards of care enter effect, any advance directives you or your loved ones may need for a way you’d wish to be cared for just in case of emergency are ostensibly meaningless. (Hospitals might allow staff to implement “do not resuscitate” policies as how to guard themselves from infection, for instance .)




“You might want to speak to your family that —how you are feeling about that, that it’s okay if it happens,” says Caplan. “Those conversations are not any fun and they’re horrible, but i might be beginning to explore that.”




The information during this story is accurate as of press time. However, because the situation surrounding COVID-19 continues to evolve, it's possible that some data have changed since publication. While Health is trying to stay our stories as up-to-date as possible, we also encourage readers to remain informed on news and proposals for his or her own communities by using the CDC, WHO, and their local public health department as resources.


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