How would overwhelmed hospitals decide who to treat first?
NEW YORK — A nurse with asthma, a grandfather with cancer and a homeless man with no known family are wracked with coronavirus-induced fevers. They are struggling to breathe, and a ventilator could save their lives. But who gets one when there aren't enough to go around?
Health care workers are dreading the prospect of such dire scenarios as U.S. hospitals brace for a looming surge in patients who need breathing machines and other resources that could soon be in critically short supply.
That has meant dusting off playbooks they’ve never before had to implement on how to fairly ration limited resources during an emergency.
“I pray for their good judgment and their capacity as they make very difficult choices,” said Erik Curren, whose 77-year-old father died this month from respiratory complications related to the virus after becoming infected at an assisted living home in Florida.
Harrowing scenarios already are unfolding in country after country hard-hit by the COVID-19 pandemic, including Spain, where one nursing home official said sick residents are dying after being unable to get into overflowing hospitals.
Like much of the rest of the world, ventilators that help people breathe are in particular demand across the U.S., given the respiratory problems common among people severely ill with COVID-19.
As many as 900,000 coronavirus patients in the U.S. could need the machines during the outbreak, according to the Society for Critical Care Medicine. Yet the group estimates the country has only 200,000, many of which already are being used by other patients.
In New York, the U.S. epicenter of the outbreak, one city hospital has already logged 13 coronavirus deaths in a single day and officials are setting up hundreds of hospital beds in a sprawling convention center as cases climbed past 30,000 in the city.
In preparation, health officials across the country are reviewing guidelines from sources including state governments and medical groups on how to ration limited resources in emergencies.
The general principle spanning those plans: Bring the most benefit to the greatest number of people and prioritize those with the best chance of recovery. But exactly how that’s determined is fraught.
Automatically excluding certain groups from receiving ventilators, such as those with severe lung disease, invokes ethical issues, said Dr. Douglas White at the University of Pittsburgh. Many hospitals seeking guidance on COVID-19 in recent weeks have adopted a policy he devised without such exclusions, he said.
Guidelines previously developed by New York state’s health department exclude some seriously ill people from receiving limited ventilators in major emergencies, but note that making old age an automatic disqualifier would be discriminatory. The plans go on to add, however, that given the “strong societal preference for saving children,” age could be considered in a tie-breaker when a child’s life is at stake.
Recommendations published this week by German medical associations in response to COVID-19 also say age alone shouldn’t be a deciding factor. Among the situations where they said intensive care should not be provided if availability is in short supply: if the patient would need permanent intensive care to survive.
The crushing emotional burden of carrying out potentially life-and-death decisions is why the guidelines typically designate separate triage teams to make the call, rather than leaving it to the doctors and nurses providing bedside care.
“This is a really terrifying decision -- you don’t want any doctor or nurse to be alone with this decision,” said Nancy Berlinger of the Hastings Center, a bioethics research institute.
Having separate teams make decisions also is intended to ensure patients get a fair shot at care regardless of their race, social status or other personal factors.