by Craig Klugman, Ph.D.
Doctors in Italy have run out of beds. They have run out of ventilators. They are now having to decide who may live and who will likely die. For many, utilitarianism has helped making decisions—maximizing likeliness to survive and remaining years of life. The U.S. may not be far behind in having to make these tough choices.
Some hospitals in harder hit regions like New York City and Seattle are already finding themselves stretched thin. They have had to expand their surge capacity (the ability to meet the expanded needs of a growing patient population beyond normal operations) by increasing beds in each room, putting gurneys in hallways, and setting tents. Based on the statistics of likely number of deaths, number of infections, and number of people needing intensive care, the U.S. does not have enough ICU beds and ventilators. This reason is why we are all trying to #flattenthecurve, to limit the extent of the spread and increase the period of time over which people are infected with the goal of not inundating the health care system as we have seen in China and Italy.
When there are more patients than one can treat, we enter a situation called triage, a term from the French meaning “to sort”. Some triage options are simple and help to reduce morbidity. Others choices are more complicated and are decisions of who lives and who dies. The question is the same for all these scenarios, how do we decide who to treat and who not to?
Beginning in 2012, the Institute of Medicine came out with a report on crisis standards of care. They encouraged jurisdictions to develop their own plan for responding to disasters, including pandemics. The original call to arms cited three operating stages for planning: Conventional, Contingent, and Crisis.
Conventional is our operations in normal times. In the U.S. we already ration medical care, we do it through money: You get the care that you (or your insurance) can afford. Since 2012, U.S. health care facilities have been “streamlined” by administrators who have tried to maximize dollars from sick people. This has meant getting rid of services and programs such as storage for disaster supplies, “excess” staff capacity, and also means operating close to full at most times.
Contingency is when we know that a disaster is coming and start changing some operations in preparation. For example, the U.S. Surgeon General has advised hospitals to cut back or cancel elective surgeries, an action that some hospitals have done and others have resisted. Some hospitals are converting non-ICU rooms into more intensive care rooms. Hospital beds are emptied, elective surgeries postponed, and vacations and conference leaves are canceled (we saw this last week) to be sure there is staff available.
At this level we start practicing forward triage, which means assessing patients before they even enter the hospital. If patients are assessed before they enter as to whether they symptoms, we can separate COVID patients, and people with symptoms that look like COVID from everyone else. COVID patients can be sent to one waiting area; those with symptoms are sent to a second waiting area, and everyone else goes to a third waiting room. This way, we avoid the situation recently seen at international U.S. airports where everyone was thrown into a cattle pen and could easily cross-infect. Forward triage method was used successfully in Australia to combat multidrug resistant bacteria and serves to protect patients.
In crisis times, the health care system has been overwhelmed and there are not enough resources to help all of the people in need. Resources including staff, beds, medications, IV fluids, and blood become limited. The FDA is concerned about a shortage of blood brought about by social distancing and the cancellation of blood drives. Already health care providers are expressing exhaustion and burnout, and we have barely begun the U.S. portion of the pandemic. We know that ventilators are a limited resource, but there is also a small number of trained staff who can use them. Health care providers face a shortage of personal protective equipment (PPE). Washington State made a request to the federally controlled National Strategic Stockpile for masks and they are being sent less than half of the ask. Some hospitals are thinking about how to clean N95 masks, or putting surgical masks over N95 masks to make them last longer (neither approach is recommended). Who gets the gloves, gown, face shield, and mask when we have few and resupply from shuttered factories will be slow in coming? After all, intubation can aerosolize lung secretions and that is how COVID spreads. This exposure also means that an increasing number of health care workers are themselves under quarantine, reducing an already limited care force.
In these situations, how do we staff adequately without exhausting people. Some medical schools have sent their students home, while in other plans medical and nursing students are recruited to assist with non-infectious cases and provide caring services. Some locations have asked all retired health care professionals (sometimes only still licensed; sometimes all) to return to service. After all, the need has outgrown capacity in a crisis.
What patients get medications and who delivers them? If we are short of IV fluids, which patient gets them? Blood and blood products? What about ECMO treatment? And perhaps most dramatic, who gets the precious few ventilators? In one sense, there are more ventilators than currently in hospitals. Some states have stockpiles with portable vents (about the size of suitcases) than can be used (but again, there are a limited number of trained staff to use them). The federal government also has a supply in the National Stockpile, though they will not say how many vents there are. President Trump told governors that they should look elsewhere for more vents.
When sorting out which patients get life-saving treatment and which are given comfort care only, we have to adopt a more communitarian approach. Rather than advocating for getting each patient everything they need; health care providers have to decide how to divide the few resources they have among all the patients. Does everyone need their own ventilator or can you put in a splitter to put breathe for more than one (not likely to work with COVID)? Does everyone get a full dose of meds or give more people partial doses (we are not here yet)? Do we institute unilateral DNR orders for COVID patients (because of the risk of spread to health care providers, we will not attempt to resuscitate these patients)? In Italy, the decision is being made to maximize aggregate years of life—likelihood of survival + remaining likely years of a patient’s life. This formula means that younger patients are more likely to get the vents than older ones. This raises additional issues: For example, if a younger patient comes in needing a vent, and none were available, would we remove someone who is older from their vent to help the newer patient? The formula says we should, but many doctors are resistant—they feel it is abandoning the patient or even murder. Unfortunately, many state laws lack exceptions for crisis times, and a physician might face a homicide charge once the crisis is past.
Triage choices are hard. The sickest among us, the people who need the most resources and the most care and still have a high likelihood of dying, will likely not receive the medical care they need. Instead, they will be placed in a quieter location and provided with comfort and palliative care. Patients who have a greater likelihood of survival using fewer resources (drugs, ORs, ICU beds, staff time) but need immediate care, will be given priority. Those who can wait a bit (the “walking wounded”) will wait until the priority patients are treated. There are some formulas to quantify these decisions like SOFA, though they are not without criticism. Should we use all of the supplies we have and when we run out, we run out (and hope for resupply)? Perhaps should we be conserving supplies now to be able to treat future patients (i.e. not anticipate future resupply)? A resource from the Minnesota Department of Health offers some good suggestions.
There are some basic lessons for triage decision-making: (1) Never make decisions alone. No one person should make these life-and-death choices. This helps spread the responsibility for the choice, increases the chances of creative thinking and making sure different perspectives are represented. (2) All lives are equal. It should not matter if someone is rich or poor; documented or undocumented; cis or trans; every patient is treated the same. (3) Once a prioritization formula is instituted, it should be followed. This helps eliminate choosing favorites or making emotional choices. What if the patient needing a vent is your 90-year-old grandparent? Or the CEO of the hospital? Or the mayor? A system might be like the Italian model (remaining years of life), or it could be more egalitarian (first come, first served; a lottery), or medical need (a large factor in who gets an organ for transplant)? There is no one right system, but it is important that there be an agreed upon system. In Illinois, we tested our proposed system in 18 cities each year, for several years, to see if it aligned with community values. (4) We owe reciprocity. If health care providers, EMTs, truck drivers, electrical workers are working to protect us and keep the world functioning, they may deserve to jump the line ahead of others. In some plans, they get to jump the queue only if they can be fairly quickly returned to their task of helping others; in other plans, they get to be in the priority line based on what they have done. These essential workers also may deserve to know that their family is safe and taken care of whether that be someone bringing food to the home and ensuring child care. (5) Be clear and transparent in communicating. This is hard but in the long run is the better choice. (6) Ideally, rationing systems are regional, not hospital-by-hospital. For example, when New York shut down public spaces, they did it in conjunction with New Jersey and Connecticut to make sure that people did not simply go to a different state to get to a bar, and then bring the virus back home. If each medical institution has their own system, then people may “hospital shop” to find a place that will treat their loved one. Of course, this has to be done before the crisis. For now, institutional systems may have to do.
As of March 17, most of the U.S. in in the contingency phase. Some places, like parts of Washington State and New York City, are already in crisis mode. We can and must learn from the experiences of Asia and Europe as to what worked, who is vulnerable, and how they made decisions on distributing care. These facts are important, because good ethical decisions depend on them.