Ethics and COVID-19
Who gets to live?
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:
Arizona End-of-Life Options

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