April 8, 2020 -- If ventilators get scarce in the U.S. during the COVID-19 pandemic, which patients will get one of these life-saving machines? Who will decide and how? Are there any guidelines in place? What’s considered fair and just?
“We’re now beginning to anticipate the issues we’re going to have to face in the next few days about shortages of ventilators and ICU beds,” says Robert Klitzman, MD, a professor of psychiatry at Columbia University Medical Center in New York City and director of the school’s master’s in bioethics program. “It is extremely unfortunate that we do not have enough ventilators.”
The issue has become urgent as doctors, hospitals, and states decide how to ration ventilators should they become overwhelmed with patients.
“As a nation, we’ve not yet had to face this kind of a crisis,” says Klitzman. “But people have luckily thought about this in advance when cooler heads prevailed, where it wasn’t in the middle of a panic, in the middle of a crisis.”
The coronavirus that causes the disease COVID-19 is new, but the question of rationing ventilators is not. Ventilators are life-saving equipment for COVID-19 patients, whose damaged lungs make it hard to breathe. The machines breathe for them, delivering high levels of oxygen so that patients have a chance to recover.
There are no uniform national guidelines on the subject. But some states, hospital systems, and individual hospitals have made their own policies, says bioethicist Paul Wolpe, PhD, director of the Center for Ethics at Emory University in Atlanta.
Wolpe understands the public fears of the shortage, made worse by people’s lack of knowledge on how such difficult decisions are made. “Ethicists involved are extremely sensitive to the worries that the public has,” he says.
He has reviewed many policies and says they often have things in common, including an emphasis on respect for patients and their families, fairness, and transparency.
“Transparency is another value that’s in a lot of these policies, that patients should be told exactly how decisions are going to be made,” Wolpe says. Many policies also allow for an appeals process if patients or families feel that they’ve been unfairly denied, he says. Wolpe is also the president of the Association of Bioethics Program Directors, which includes heads of ethics programs at universities and hospitals.
While many states and medical facilities are trying to get more ventilators, hospitals must go into triage should they fall short of the machines, according to Klitzman.
“There are guidelines for triage, and triage was developed in wartime,” he says. “The fundamental principle that should be used is if there aren’t enough ventilators, which will probably be the case sometime soon, is to give the resource to the people who would be most likely to die if they did not get the ventilator and would be most likely to live if they got one.”
If patients are clearly going to die, even if they’re placed on a ventilator, “they’re not going to get priority,” Klitzman says.
“If people are going to do fine anyway and they don’t really need the ventilator, they’re not going to get priority,” he says.
Decisions shouldn’t be based on a first-come, first-served basis, lottery, or random selection, Klitzman says.
New York state guidelines give patients a SOFA score, which measures the number of organs that have failed, he says. The acronym stands for “sequential organ failure assessment.”
“If you have multiple organs that are not working well to start, the evidence is that you will not do well with a ventilator,” Klitzman says, “and therefore, you would get lower priority.” For example, patients with severe disease of the kidneys or pancreas or other organs, or who are already in a coma, would be unlikely candidates for a ventilator.
“No doctor wants to have to rely on these kinds of criteria,” Klitzman says. “No doctor wants to say, ‘I’m going to not give treatment to a patient.’ We are trained to help patients as much as we possibly can. But again, unfortunately, in the middle of a battlefield … in those kinds of emergency disaster situations, there needs to be a system.”
Rarely would an individual doctor make rationing decisions at the bedside, according to Wolpe.
State and hospital policies almost always call for triage committees or designated triage officers who aren’t involved directly in the care of the patients being discussed, he says. Beyond shielding individual doctors, there’s a larger purpose, he says. “The reasons are so that decisions will be fair and equitable.”
As Klitzman says, “[Doctors] don’t have a conflict of interest where they feel, ‘Gee, this is my patient, Mrs. Jones, and I’m going to do everything I can for Mrs. Jones.’”
Triage committees might include doctors, ethicists, nurses, chaplains, or medical social workers, according Wolpe. Ideally, patients’ identities would be blinded, he says.
“It’s important that the public be aware that there is a logical system that doctors would try to use. It’s designed to avoid discrimination,” Klitzman says. “The system is not based on how much money you have. It’s based on how many organs you have that are failing before you needed a ventilator.”
“Priority absolutely should not be given to who can afford it, what kind of insurance you have, whether you’re rich or poor, your ethnicity, your race, or your gender.”
Who Else Gets Priority?
But with some policies, certain groups, such as health care professionals, may get higher priority. This group includes not only workers who treat patients directly, but also support staff, such as those who decontaminate rooms where a patient has been. “These are people that we are putting at high risk for getting COVID,” Wolpe says.
There are two reasons for such policies. First is reciprocity. “This is what we owe them for putting themselves in harm’s way so profoundly,” Wolpe says.
A second reason, he says: “It makes sense in a tie [between patients] to privilege a health care worker because if we can get them better quickly, we can get them back onto the front lines of helping us beat this.” Doing so would help stem shortages of such workers, he says.
But there’s less agreement within policies on other criteria, Wolpe says; for example, patients’ age.
Some ethicists cite the concept of “just innings.” In other words, when two patients have an equal medical need, “Younger people in general are privileged over older people,” Wolpe explains.
“Age should not be the deciding factor,” Klitzman says, because it’s not nuanced enough. In fact, some critics have argued that a 50-year-old might have more experience and skills to benefit society than a 20-year-old.
But Klitzman views age as a more obvious consideration in extreme cases when it can become a tie-breaker; for example, when two patients have the same SOFA score, but one is 80 and the other is 10.
Unlikely to Get Ventilators
Certain groups are unlikely to receive ventilators during a shortage, such as people with a high chance of dying in a short period. That includes patients with advanced cancer or Alzheimer’s, Klitzman says.
Ventilator rationing is fraught with legal issues, including possible lawsuits. While Klitzman believes there should be a process for families to appeal a decision, he says that liability poses a “major, major issue.”
According to a recent New York Times article, some groups, such as the physically disabled, worry that a looming lack of ventilators and other treatments will leave them shortchanged when it comes to life-saving care during the pandemic. For example, the newspaper cited disabled people’s concerns about Washington state’s recommendations, which state that triage teams should consider transferring patients with “loss of reserves in energy, physical ability, cognition and general health” to outpatient or palliative care.
Disability activists want to ensure that states don’t allow medical systems to discriminate based on things like age, race, and disabilities. Their concerns over rationing plans have prompted the U.S. Department of Health and Human Services Office for Civil Rights to open investigations to make sure that policies comply with civil rights laws.
“There should be no discrimination based on disability,” Klitzman says when asked about the concerns. “It would come down to SOFA scores. If someone has an intellectual disability, that does not affect their SOFA score. If someone’s in a wheelchair, that does not affect their SOFA score. They’re not in coma, they don’t have kidney failure. Being in a wheelchair does not matter at all.”