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As coronavirus pandemic surges, hospitals prepare for grim possibility of ‘ventilator triage’

ugurhan/iStock
ugurhan/iStock

(NEW YORK) — Faced with more critically ill COVID-19 patients than equipment to treat them, hundreds of hospitals are mapping out how they can ration care and equipment in order to save the greatest number of patients possible.

In the last two days, guidelines were provided to scores of hospitals around the country, including every hospital in Pennsylvania, that include a point system that could — in extreme cases — end up determining what patients live or die.

“Priority is assigned to those most likely to be saved, and most likely to live longer,” said Dr. Scott Halpern, professor of medical ethics and health policy at the University of Pennsylvania.

On Monday, Halpern and Dr. Douglas White, chairman of ethics in critical care medicine at the University of Pittsburgh, released guidance to hospitals that is now being adopted throughout the nation.

White said “the existing approach to allocate ventilators was unfair because it excluded large groups of patients.”

In recent days, internal memos from a chairman of surgery at New York Presbyterian, one of the city’s largest hospital systems, raised alarms that the estimated crush of coronavirus patients within the next month would require 700 to 934 intensive-care beds, well beyond the current capacity.

The Queens branch of New York Presbyterian is actively putting together an ethics committee to help make such critical-care determinations in an emergency, hospital staffers told ABC News, so individual doctors would know what to do at the moment it matters most.

According to emails reviewed by ABC News, that hospital has already convened an ethics committee to address the “triage of ventilators,” a process that dictates how medical staff would decide which patients are assigned ventilators in the event the number of patients needing those breathing machines surpasses the number available in the hospital.

According to Halpern and White, one important factor in making such excruciating decisions about patient care is to take the doctor at the patient’s bedside out of the equation.

“What is clearly needed is an independent arbiter apart from the bedside clinician to assign priority to different patients,” Halpern said. “Otherwise, you have different physicians advocating for their own patients, which is appropriate for clinical care but doesn’t lead to just allocations.”

In the point system envisioned by Halpern and White, critically ill patients would be given a score from 1 to 8, the lower the score translating to a higher priority for critical care resources. Patients with things like advanced cancer, dementia or chronic lung disease would score more points and, therefore, be lower on a list for resources in short supply.

“These are all tragic choices, but the work we’ve done is to try to make them more fair especially compared to other guidance that is out there,” White said.

The guidance puts people into four age categories: 12 to 40; 41 to 60; 61 to 75; and older than 75. Ties could be settled by age, with first responders or healthcare workers who are vital to providing continued acute care to others also prioritized in the event of a tie.

According to the guidance, patients who aren’t able to receive ICU services would still get medical care including symptom management and, if needed, palliative care.

Ethics committees are not new, though few hospitals have fully functioning panels. But for those committees that are in place, the types of decisions now being contemplated are rare in developed countries like the United States, more common in a faraway combat zone than in a big-city medical center in urban America.

Ventilators, also known as artificial breathing machines, are considered to be the most effective way to treat patients in respiratory failure from a critical case of COVID-19.

New York Gov. Andrew Cuomo has repeatedly said the 6,000 ventilators currently operating in his state is woefully inadequate to handle the surge of patients caused by the pandemic that is now sweeping through his state.

On Tuesday, the governor made an impassioned plea to the federal government to send to New York as many ventilators as can be found, calling the need “critical and desperate.”

“FEMA says they’re sending 400 ventilators,” Cuomo said of the Federal Emergency Management Agency. “You pick the 26,000 people who are going to die because you only sent 400 ventilators.”

Because of the anticipated shortage, the New York state Health Department is in the process of drafting rationing rules for hospitals in the state.

“The conversations are happening,” said Brian Conway, spokesman for the Greater New York Hospitals Association. “We are awaiting some kind of state guidance.”

Cassie Sauer, executive vice president of the Washington State Hospitals Association, told ABC News that hospitals in her state are also grappling with the issue of triaging ventilators.

“I understand it’s scaring the public,” Sauer told ABC News. “The public should be scared. The public should be demanding action to keep this from happening.”

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