We have now topped 10,000 COVID-19 deaths in
the U.S., and even as exhausted healthcare workers struggle with lack
of essential supplies, they tell us the worst is yet to come.
Example: A
hospital in Washington State projects that within 10 days it may not
have enough ventilators. New York State may be thousands of ventilators
short of what it needs. In Michigan, a hospital system has prepared
warnings for patients about what will happen if it gets more patients
than it can handle. The questions are countless and the answers are
stark.
If a healthcare facility is forced to resort to a triage system, some patients would get full intensive care treatment, some would not. But which ones?
Across the
country, hospitals and public health officials are working on plans for
what happens if the number of coronavirus patients exceeds the available
space in intensive care units.
Many states have developed triage plans for what happens in a natural
disaster or a severe pandemic, if hospitals are overwhelmed. As the
coronavirus pandemic expands, they have been re-examining those plans,
hoping they will be useful if hospitals have more critically ill
patients than ventilators.
The New York Times
reviewed triage strategy documents from Alabama, Arizona, Kansas,
Louisiana, Maryland, Michigan, New York, Pennsylvania, Tennessee, Utah
and Washington State to see what factors they propose to use to decide
which patients get potentially life-saving treatments. Some of the plans
may be revised as more information on COVID-19 becomes available. Most
of the plans give priority to otherwise healthy people who are most
likely to fully recover. But it is not that simple.
The plans
struggle to address a range of ethical issues, in addition to matters of
social and racial equality. People with underlying medical problems may
get ranked lower, yet low-income people and people of color often have
more health problems because they cannot afford top-notch care. So, do
they go to the back of the line? Advocates for people with disabilities
are expected to scrutinize triage plans around the country to see if
they provide equal access to lifesaving care.
How much legal
force these plans carry varies from state to state. Some states have
laws that may protect providers from at least some types of liability
for following the guidelines in an official emergency; in most states
the legal protections they offer are less clear.
Washington
State’s triage document includes a range of factors for hospitals to
consider in deciding who gets complete care. Much of the effort focuses
on prioritizing people who have a better chance of survival. Among the
factors it calls for, hospitals are to consider a patient’s “baseline
functional status” and indications of declines in energy, physical
ability and cognition.
“When the system
is at risk of becoming overwhelmed, the goal then becomes to conserve,
substitute, adapt and reuse,” according to a report released Sunday by
the National Academies of Sciences, Engineering and Medicine. Making
these life and death choices, it said, should be done “only in the most
extreme of circumstances.”
Fifty years ago,
doctors in the U.S. could be charged with crimes for rationing health
care,” according to Thomas Raffin, former associate director of
the intensive care unit at Stanford University hospital and a
bioethicist. “It was considered murder or manslaughter. Treating
everyone equally was a matter of law and ethics. Even when survival
chances were uncertain, the ethical and legal mandate was to continue
treatment.”
The use of the
term triage (a French word) in medical contexts comes from the military
in the 19th and early 20th centuries. During wartime, injured solders
brought into a hospital were quickly categorized into three groups: the
ones who obviously could be saved, the ones who had 50/50 odds, and
those who probably couldn’t be saved. The first group got immediate
treatment, said Raffin. The third category was left to die.
One way to ease
the ethical problem today is for physicians is to use committees to help
make the decisions, taking the burden off individual doctors.
In Italy, a set
of rules newly formulated by the Italian College of Anesthesia,
Analgesia, Resuscitation, and Intensive Care (SIAARTI) gives external
support for the decision. Physicians can then follow the guidelines. The
allocation decisions need to guarantee that those patients with the
highest chance of therapeutic success will retain access to intensive
care, the guidelines say. They then set an age limit, though it’s not a
hard and fast rule -- the physical condition of the patient would factor
into it -- and came up with the age of 70. Patients over 70 could be
unlikely to pass selection when the demand for ICU beds is too high.
Hospitals would center their treatment on those patients who would live
longest. This may sound cruel, but the alternative, the document argues,
is no better.
In American hospitals that become stressed, similar rules or guidelines
will likely apply. If there is a 25-year-old cancer patient and a
60-year-old in good health, the hospital might choose the 60-year-old,
said Arthur Caplan, professor of bioethics at the Grossman School of
Medicine at New York University.
“So it’s not just
age, but age usually correlates with the likelihood of benefit.” said
Caplan. Researchers at Harvard and Boston Children’s Hospital, wrote in
the New England Journal of Medicine, that “the angst that clinicians
experience when asked to withdraw ventilators for reasons not related to
the welfare of their patients, should not be underestimated -- it can
lead to debilitating and disabling distress for some clinicians.” They
suggest a committee make the decision.
Then there are
questions such as who is going to tell the family? The Italian
guidelines suggest that be done by volunteers or members of a triage
committee and not the attending physician.
These kinds of
rationing approaches have rarely been seen in the U.S. since 1918 when a
flu pandemic killed about 50 million people around the world.
Yet as COVID-19
cases continue to soar, American hospitals are staring in the face of
impending shortages of equipment and personnel. And American doctors
will likely face the same agonizing choices that have been necessary in
other countries facing the pandemic.
FYI: a copy of Arizona's crisis plan is available here:
https://www.azdhs.gov/documents/preparedness/emergency-preparedness/response-plans/azcsc-plan.pdf
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