When there are not enough ventilators, who will live and who will die?
As the novel coronavirus, COVID-19, makes its way across the country and the state, hospitals will become inundated with patients who have the virus. Many of these patients will need intensive care beds and ventilators. Experts predict there will be fewer ventilators available than patients who need them.
The question then becomes, how should doctors decide who gets one? Maryland is fortunate in that a framework has already been developed, with public input, to answer that question. In 2013, physicians and bioethicists at Johns Hopkins and the University of Pittsburgh collaborated on a pilot study aimed at developing community-informed criteria for allocating scarce health care resources during disasters. The findings of the study were made publicly available in 2017.
The report recommends a triage procedure that hospitals in the state put in place for allocation of ventilators if the governor declares a catastrophic health emergency and orders the secretary of health to put a rationing system in place. The governor declared a catastrophic health emergency on March 5th, but has not yet ordered the use of the rationing system.
While some details of the 2017 plan may be modified, the allocation approach was designed to save as many lives as possible and is based primarily on two factors:
• Likelihood of short-term survival, i.e. the patient with the ventilator support will live long enough to be discharged from the hospital.
• Likelihood of long-term (at least 12 months) survival.
Patients will be scored, between 1 and 7 points, based on these two components. Short-term survival is based on an adult patient’s sequential organ failure assessment score, which is calculated using certain laboratory values and organ function indicators. Short-term survival for children is based on a similar scoring system called pediatric logistic organ dysfunction. Calculating these formulas is relatively straightforward and involves little discretion. A patient would receive a score of between 1 and 4 for this component.
For long-term survival, patients would receive a score of either 0 or 3. In an effort to avoid discrimination against those with disabilities or chronic illnesses that are not life-threatening in the short term, only patients who have underlying conditions that are so serious that they are likely to die within a year would be assigned a score of 3. Such conditions might include end stage heart or lung disease, advanced cancer or severe trauma.
Those with the lowest total scores would be given priority. If several patients receive the same score, age could be a “tie-breaker” with children and adults up to age 49 given the highest priority and those over 85 the lowest.
“Triage officers” are responsible for calculating the initial score for all patients. These will be individuals from various hospital departments that provide care to critically ill patients. These officers are to work with a “triage team” that the report recommends include an experienced critical care nurse, a clinician familiar with ventilators and a representative from the hospital’s administration.
The allocation approach also calls for assessing individuals who are currently on a ventilator who do not have COVID-19. The same method will be used to calculate a score for these individuals as for those with the virus. Individuals in this category raise the challenging possibility of taking someone off the ventilator without their consent who might otherwise live.
Because of the ethical concerns surrounding such an act, the report calls for the possibility of an appeal of the triage officer’s decision to a Triage Review Committee, which is “independent of the triage team,” to review the accuracy and fairness of the decision. The implementation of the triage process also triggers legal immunity for the health care providers who act in good faith in pursuit of the triage goals of saving the maximum number of lives possible.
We applaud the state of Maryland for having the foresight to plan for this impending health care crisis. We have seen what happened in Italy, where health care providers lacked the advance notice and allocation frameworks to aid in heartwrenching decisions about whom to treat and whomto let die. Wehave an advantage right now of time and a communityinformed allocation framework to guide decision-making.
We need to ensure that hospitals are adequately prepared by having triage systems in place. Applying scores now to patients on ventilators as training for if/when the governor orders the secretary of health to put a rationing system in place could facilitate quick action and save lives. We also urge hospitals, as well as the media and state health officials, to educate the public about the final resource allocation framework adopted by the state, so that patients are not learning about it for the first time upon hospital admission, and to be open and transparent during its implementation.