Coronavirus: As cases increase, US experts call for ‘rationing’ of hospital resources and ventilators
Of all the medical care that will have to be rationed, the most problematic will be mechanical ventilation, say experts
The COVID-19 pandemic has led to severe shortages of many essential goods and services, from hand sanitizers and N-95 masks to ICU beds and ventilators. And experts from the US are now calling for rationing of medical goods and services.
“Although rationing is not unprecedented, never before has the American public been faced with the prospect of having to ration medical goods and services on this scale. Of all the medical care that will have to be rationed, the most problematic will be mechanical ventilation,” write experts from Boston, US.
They are from the Center for Bioethics, the Department of Global Health and Social Medicine, the Office of the Dean of the Faculty of Medicine -- all at the Harvard Medical School as well as the Department of Anesthesiology, Critical Care and Pain Medicine at the Boston Children’s Hospital.
Dr Eric Topol, Director and Founder, Scripps Research Translational Institute, says it is a “bad prognostic sign” for the US when studies talk of rationing hospital/ICU resources and ventilators. “And the overrun is already happening at some centers in NYC,” he tweeted.
The experts of the current study say that the CDC estimates that 2.4 million to 21 million Americans will require hospitalization during the pandemic. The experience in Italy has been that about 10 to 25% of hospitalized patients will require ventilation, in some cases for several weeks. Based on these estimates, the number of patients needing ventilation could range between 1.4 and 31 patients per ventilator, says the study published in The New England Journal of Medicine (NEJM).
“Whether it will be necessary to ration ventilators will depend on the pace of the pandemic and how many patients need ventilation at the same time, but many analysts warn that the risk is high,” say experts.
So far, over 54,890 cases have been reported in the US and over 660 have died.
The researchers explain that while shortages of other goods and services may lead to deaths, in most cases it will be the combined effects of multiple shortages that will result in worse outcomes.
According to the authors, many states have developed strategies for rationing during pandemics. They say the New York Guidelines target saving the most lives, as defined by the patient’s short-term likelihood of surviving an acute medical episode.
“Rationing is performed by a triage officer or a triage committee composed of people who have no clinical responsibilities for the care of the patient. Triage proceeds in three steps: application of exclusion criteria, such as irreversible shock; assessment of mortality risk using the Sequential Organ Failure Assessment (SOFA) score, to determine priority for initiating ventilation; and repeat assessments over time,” says the team. They further say that patients whose condition does not improve are removed from the ventilator to make it available for another patient.
The experts warn that the ‘angst’ that clinicians may experience when asked to withdraw ventilators for reasons not related to the welfare of their patients should not be underestimated — it may lead to “debilitating and disabling distress” for some clinicians. They say one strategy for avoiding this tragic outcome is to use a triage committee to buffer clinicians from this potential harm. Besides removing the responsibility for triage decisions from the bedside clinicians, committee members should also take on the task of communicating the decision to the family, they recommend.
“We believe that such a committee should be composed of volunteers who are respected clinicians and leaders among their peers and the medical community,” says the study. The team also cautions that in the weeks ahead, US physicians may be asked to make decisions that they have never before had to face and for which many of them will not be prepared.
“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. Creation and use of triage committees, informed by experience in the current pandemic and prior written recommendations, can help mitigate,” they recommend.
Fair allocation of scarce medical resources?
According to experts of another study, the choice to set limits on access to treatment is not a “discretionary decision,” but a “necessary response” to the overwhelming effects of a pandemic. “The question is not whether to set priorities, but how to do so ethically and consistently, rather than basing decisions on individual institutions’ approaches or a clinician’s intuition in the heat of the moment,” says the team.
It includes experts from the University of Pennsylvania, Philadelphia, University of Toronto, Toronto, Western University, London, Federal University of São Paulo, University of Oxford, UK and George Washington University Hospital, Washington.
They say even a conservative estimate shows that the health needs created by the coronavirus pandemic go well beyond the capacity of US hospitals
“Even in a moderate pandemic, hospital beds and ventilators are likely to be scarce in geographic areas with large outbreaks, such as Seattle, or in rural and smaller hospitals that have much less space, staff, and supplies than large academic medical centers,” says the study, also published in NEJM.
The research team emphasizes that rationing is already here. In the US, perhaps the earliest example was the near-immediate recognition that there were not enough high-filtration N-95 masks for healthcare workers, prompting contingency guidance on how to reuse masks designed for single use.
The experts say that previous proposals for allocation of resources in pandemics and other settings of absolute scarcity, including their own prior research and analysis, converge on certain fundamental values: maximizing the benefits produced by scarce resources, treating people equally, promoting and rewarding instrumental value, and giving priority to the worst off.
“No single value is sufficient alone to determine which patients should receive scarce resources. Consensus exists that a person’s wealth should not determine who lives or dies. Although medical treatment in the US outside pandemic contexts is often restricted to those able to pay, no proposal endorses ability-to-pay allocation in a pandemic,” they argue.
The experts say these ethical values give rise to six specific recommendations for allocating medical resources in the COVID-19 pandemic. They include maximizing benefits; prioritizing health workers; not allocating on a first-come, first-served basis; being responsive to evidence; recognizing research participation, and applying the same principles to all COVID-19 and non-COVID-19 patients.
To help doctors navigate the challenges, in this study too, the experts recommend triage officers -- physicians in roles outside direct patient care, or committees of experienced physicians and ethicists. They will help apply guidelines, to assist with rationing decisions, or to make and implement choices outright — relieving the individual front-line clinicians of that burden, says the study.