‘Triage officers’ could decide who gets care as L.A. buckles under COVID-19

LOS ANGELES — Stretched to the breaking point by a deluge of COVID19 patients, Los Angeles County’s four public hospitals are preparing to take the extraordinary step of rationing care, with a team of “triage officers” set to decide which patients can benefit from continued treatment and which are beyond saving and should be allowed to die.

The county’s top health officials have not yet declared a shift to a crisis level of care, which would trigger the rationing system, but the leader of the public hospitals acknowledged in a letter reviewed by The Times this week that “there will likely come a point when we simply don’t have sufficient staffing or critical supplies to care for all our patients in the way we normally would.”

The crisis designation would empower the newly named triage officers — usually critical care and emergency room doctors — to decide which patients at county hospitals would get access to resources such as ventilators, respiratory therapists and critical care nurses when they become too scarce to be provided to every patient.

Hospitals outside the county system will have to decide on their own whether to invoke similar urgency measures, though state officials told them last week that they should have triage plans ready.

Inside many overflowing Southern California hospitals, a form of undeclared rationing appears already to be taking place. Ambulances carrying COVID patients have been diverted from overtaxed medical centers. Critically ill patients sometimes wait days to get intensive care beds.

At one private hospital in Lynwood this week, doctors stood in a hallway, loudly arguing over whether to give one of the few remaining ventilators to an elderly woman. The doctor describing the scene said the hospital had no formal plan to resolve such disputes.

To confront the life-anddeath triage choices, the California Department of Public Health and some hospital systems recommend reliance on clinical scoring systems that evaluate patients’ organ functions, generating numerical scores meant to indicate an individual’s survival chances.

County health leaders called the most common scoring system too rigid and imprecise to be used as the lone criterion for making triage decisions.

They have directed triage officers to use a broader “principle-based approach” that seeks to shift care away from patients judged to be terminal to patients judged to have the best chance of survival.

“Our goal as a health system will be to save as many lives as possible,” Dr. Christina Ghaly, who oversees the county’s public hospitals, said in a letter to staff this week. “That means shifting from providing the best care for each individual patient to providing the best care for our whole patient population. It also means possibly reallocating resources from a patient who is not benefiting to a patient who would benefit.”

Physicians, clerics and ethicists have debated for generations how to equitably allocate scarce resources in a time of crisis.

“Now we are on the verge of entering uncharted territory, as we may have to actually make those decisions,” said Dr. Arun Patel, the physician and lawyer overseeing the triage program for L.A. County. “No one in the United States has had to implement guidelines like this, at this scale, or for the duration that we may have to.”