ICU beds and ventilators shouldn’t be allocated on a first-come, first-served basis. Health-care workers should get priority. Patients with a better chance of recovery should get access to limited life-saving equipment, over those who are more sick.
These and other guidelines were released Monday by a group of global medical experts and bioethicists, aiming to provide a dispassionate framework for decision-making as some hospitals face a surge of patients with severe infections caused by COVID-19.
The report’s departure point is grim: Rationing of life-saving equipment will be necessary in some places, in spite of hospitals’ and authorities’ best efforts to boost intensive-care units and ventilators. In other areas, rationing of life-saving care is already underway.
Published in the New England Journal of Medicine (NEJM), the report could help ease the personal burden on health care workers — who pledge to first do no harm — from making devastating decisions as the number of patients with severe respiratory failure outstrips the capacity to treat them.
It’s not a distant prospect. In the U.S., many medical experts are drawing parallels to Italy, where the global pandemic started to intensify about 10 days ahead of the U.S.
Italy’s health care system has become so overburdened that doctors have reported making heart-wrenching decisions about how to ration care, and in some instances are no longer offering ventilators to patients over 60.
“Undoubtedly, withdrawing ventilators or ICU support from patients who arrived earlier to save those with better prognosis will be extremely psychologically traumatic for clinicians — and some clinicians might refuse to do so,” according to the authors, led by Ezekiel J. Emanuel at the University of Pennsylvania School’s Department of Medical Ethics. “However, many guidelines agree that the decision to withdraw a scarce resource to save others is not an act of killing and does not require the patient’s consent.”
Modeling the effects of the pandemic using data from public health agencies and academic studies, the researchers offer an alarming picture.
While the U.S. has about 85,000 ICU beds and 190,000 ventilators, they write, the number of severe cases is likely to range between 960,000 and 3.8 million.
Even with efforts to create more bed space and manufacture more ventilators, the number of deaths could range between 80,000 and 1.3 million, they conclude. (The moderate scenario was based on the assumption that 5 percent of the population would contract the virus, 6 percent of those infected would need intensive care and 0.5 percent would die. The severe scenario assumed that 20 percent of the population would become infected, with a 3 percent death rate.)
In calling to give priority to heath care workers, the report departs from some previous pandemic preparation plans.
For example, a New York State Health Department task force advised against giving medical workers priority for ventilators in case of a pandemic. Their 2015 report assumed that health care workers were unlikely to recover quickly enough to resume treating patients.
But according to the ethicists writing in the NEJM, the daunting scope and potential length of the COVID-19 pandemic argues for prioritizing treatment of health care workers who could return to treat others.
“Whether health workers who need ventilators will be able to return to work is uncertain, but giving them priority for ventilators recognizes their assumption of the high-risk work of saving others, and it may also discourage absenteeism,” according to the report, “Fair Allocation of Scarce Medical Resources in the Time of COVID-19.”
No single factor should determine who should receive dwindling medical resource, they wrote. Instead, they recommend that people who are sick but could recover if treated should be given priority over those who are unlikely to recover even if treated, and those who are likely to recover without treatment. That “may mean giving priority to younger patients and those with fewer coexisting conditions.”
Emanuel, the founding chair of the bioethics department at the National Institutes of Health and a special adviser to the World Health Organization, co-authored the report with doctors from the University of Pennsylvania, Denver Sturm College of Law, University of Toronto, Western University in London Ontario, Federal University of Sao Paulo Brazil, University of Oxford in England and George Washington University Hospital.
Guidelines for withdrawing ventilators from the sickest patients is so ethically fraught and emotionally charged that medical experts have urged hospitals and health care centers to draw up their own protocols. A team from Harvard Medical School and Boston Children’s Hospital published a separate article Monday in the New England Journal of Medicine calling for the creation of triage committees, not involved with patient care, to formalize procedures for determining who will benefit from scarce equipment.
“Though some people may denounce triage committees as ‘death panels,’ in fact they would be just the opposite — their goal would be to save the most lives possible in a time of unprecedented crisis,” wrote Robert Truog, from the Center for Bioethics and Department of Global Health and Social Medicine.
Doctors on the epidemic’s front lines have already been considering the difficult decisions ahead.
Nicholas Caputo, associate chief of emergency medicine at Lincoln Hospital in the South Bronx, said Monday that even though the hospital had enough ventilators to handle its load of COVID-19 cases so far, doctors were thinking about the difficult decisions ahead.
“You don’t want to let anybody down and we do have limited resources. In the back of your mind, you think, ‘I have X amount of ventilators and Y amount of patients, who can I hold off on and who can I not?’ That’s what we’re trying to figure out now,” Caputo said. “It’s going to matter down the road.”