What do existing guidelines tell us about how doctors and nurses are likely to allocate scarce resources in the face of a pandemic? 

By Patti Greco
April 10, 2020
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For weeks, New York Governor Andrew Cuomo has pleaded with the federal government for more ventilators—most urgently on behalf of New York City, the current epicenter of the COVID-19 outbreak in the United States. And each week that has passed has brought the region closer to a nightmare scenario: having more patients who need ventilators than there are machines for them to use. It’s like watching the ball drop on New Year’s Eve in Times Square, only without any of the excitement, joy, hope—or, God forbid, crowds. It’s the grimmest of countdowns. 

The governor hasn’t publicly elaborated on how hospitals will decide who gets the potentially life-saving equipment in the event of a shortage. When asked at a press conference on March 31, he said, "I don't even want to think about that consequence. I want to do everything I can to have as many ventilators as we'll need." Technically, New York already has guidelines in place for rationing ventilators in case of an influenza pandemic, last updated by the state’s Task Force on Life and the Law in 2015. But some would argue those recommendations need considerable updating to address the realities of COVID-19, a highly contagious respiratory virus.  

And so behind the scenes, hospitals in New York and around the country have been developing and refining guidelines for weeks, enlisting the help of bioethicists and other experts to grapple with the impossible question at the core of it all: If patients outstrip ventilators, who lives—or who gets the best shot at it, anyway—and who could die?

Advance guidelines, which are established by individual states and institutions, are intended to protect clinicians from both the emotional burden of having to make an irreversible life-or-death call and any legal repercussions that could result from doing so. (As an added measure, lawmakers in New York recently moved to grant immunity to hospitals and health care workers who are treating infected patients.)

The guidelines, or “triage protocol,” isn’t formally implemented unless a governor has declared a “crisis standard of care” in his or her state, which, as of press time, no US governor has done. But there are enough well-documented modifications to ordinary standards of care—the sharing of ventilators, for instance—that experts agree there is no time to waste. Hospitals need a plan. 

So what happens if, or when, we reach a tipping point in New York, New Jersey, or wherever we see a surge in patients next? What do existing guidelines tell us about how doctors and nurses are likely to allocate scarce resources? 

First, it’s important to understand that, in a pandemic, a physician’s goal is no longer to do what’s best for each individual patient, but to do what’s best for the community—to save the greatest number of lives possible. Whereas under normal circumstances a doctor might treat a critically injured gunshot victim before moving on to her less seriously wounded patients, under plague rules, the opposite would be true. 

“In very general terms, what [a triage team] looks at is medical survivability,” Nancy Berlinger, a research scholar at The Hastings Center, a bioethics research institute that in March released an ethical framework for health care institutions responding to COVID-19, tells Health. “What is the potential for this person to actually survive the intensive care hospitalization and recover sufficiently to come off of the ventilator?”

Arthur Caplan, director of the Division of Medical Ethics at New York University, adds that rationing ventilators isn’t all that different from rationing organs. “I’ve worked for many decades on transplants,” he tells Health. “We don’t take first come, first serve. We’ve always tried to maximize the lives saved with a scarce supply of organs. We yell and scream and ask people to donate more organs, but they don’t, and we keep having people die every day. But that [has left] us with a system that has rules, much like the ones [we’re discussing here]. It’s not like we have to sit down and say, ‘I wonder what we’d all do if we had to ration.’ We’ve been [doing it] for 40 years.”

Of course, that doesn’t make it any less challenging. Consider a hypothetical: a 65-year-old man and 50-year-old woman are in acute respiratory distress and require assistance to breathe, but there’s only one ventilator available. Who gets it? Is it the woman because she’s younger?

Although older patients (especially over age 75) tend to fare worse on a ventilator than younger patients, the broad consensus is that age is not the determining factor in a rationing scenario in the United States. Doctors are generally expected to consider physiology first: Does the patient have an underlying health condition that could compromise the outcome of ventilator use? (New York’s aforementioned guidelines recommend applying the standardized Sequential Organ Failure Assessment or “SOFA” score to group patients into four survivability categories.) 

So if our hypothetical woman has a serious heart problem and our hypothetical man is otherwise healthy, her age might not afford her an edge. But age isn’t off the table, either, which has led some to worry that they or their elderly parents will be a target of discrimination should they find themselves hospitalized. 

“It’s not discrimination if you’re trying to figure out who’s likely to live and who’s going to die even if they get the scarce resources,” says Caplan. “So no one said you can’t be considered just because of your age, but if there are other people who need the resources too, then age does become a predictor—very old age. Flip-wise, most people would say, ‘other things being equal with two candidates, take the younger child.’ You don’t hear anybody protesting the use of age there.”

Disability rights advocates have similarly expressed concern that able-bodied patients will receive preferential treatment. As one activist and author wrote in The New York Times, “When there isn’t enough lifesaving care to go around, those who need more than others may be in trouble.”

Berlinger understands why people are wary: “What is the background for people with disabilities being really concerned about being discriminated against? Well, it’s the long history of discrimination against people with disabilities, including in health care settings,” she says. But she cautions against escalating tensions. “The titles of op-eds can be very adversarial—this versus this. But if you read journal articles by people in bioethics, they’re saying, ‘Well, yeah, you really have to guard against bias creeping in.’” 

One way to do that is to convene a triage team to determine who will receive a scarce resource rather than leave it up to an individual doctor. “You don’t say, ‘I guess the doctor who is taking care of these patients will have to decide,’” explains Berlinger. “That’s way too much to ask one person to do.” 

Again, it leaves too much room for bias, “because we all make snap judgments about all kinds of things,” she says. “Like what if you said, ‘Well, it’s really important to value a parent ahead of a person who isn’t a parent.’ You might be then overlooking who had more potential to benefit from an intervention, or you might be completely overlooking the fact that the person who wasn’t a parent had other caregiving responsibilities and social relationships.” 

And that’s not the only ethical dilemma that might arise. “Would you give priority to a health care worker?” wonders Berlinger. “Or what about health care workers who don’t work at your hospital? What if it’s a home care aide? It’s really, really hard to figure this out, and that’s why you need a group of people.”

But Caplan is skeptical of the decision-by-committee model at this point in this particular pandemic. “What’s been going on at most places is committees are meeting to lay out guidelines to advise decision-makers,” he says. “...You have to get your plans and policies ready. But, look, there’s going to be a lot of judgment left to the doctor at the ER when that ambulance gets you there. They’re going to, I hope, be guided by medical considerations as to who they think is going to do well if they get intubated and put on a ventilator, whether it’s COVID-related or [due to another] condition.”

And that’s if the ambulance even gets you to the emergency room, he adds. “The first triage is not the hospital, it’s the emergency responders,” he explains. “They’re going to field many simultaneous calls as things get crazy, and they’re going to have to decide where they’re going and who they’re taking.” That impacts not only suspected COVID-19 patients, but anyone who needs an ambulance. 

If you call 911 because your father is having a heart attack, for example, you might not get the response you’re expecting. They might say, “‘Your dad is 450 pounds in a fifth-floor walkup and we only have two guys because our crew is down because we’re sick,’” Caplan offers by way of example. “That’s the real world of triage: It isn’t who’s getting in the door of the hospital, it’s whether you make it to the hospital.”

“You have to realize that it’s a plague and the rules are different,” he says. “Remember, there are people who don’t even get to see family members if they’re infected—because they won’t let anybody else into those parts of the hospital.” 

And if crisis standards of care go into effect, any advance directives you or your loved ones might have for how you’d like to be cared for in case of emergency are ostensibly meaningless. (Hospitals might allow staff to implement “do not resuscitate” policies as a way to protect themselves from infection, for example.)

“You might want to talk to your family about that—how you feel about that, that it’s okay if it happens,” says Caplan. “Those conversations are no fun and they’re horrible, but I would be starting to explore that.”

The information in this story is accurate as of press time. However, as the situation surrounding COVID-19 continues to evolve, it's possible that some data have changed since publication. While Health is trying to keep our stories as up-to-date as possible, we also encourage readers to stay informed on news and recommendations for their own communities by using the CDCWHO, and their local public health department as resources.

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