If the current rate of hospitalization and intubation continues in New York, “we have about six days left” of ventilators in the stock, said Governor Andrew Cuomo during Thursday’s coronavirus briefing.
“If a person comes in and needs a fan and you don’t have a fan, the person dies. This is the clearest equation here, “said Cuomo.
Demand for ventilators has soared in intensive care units across the country as coronavirus patients flock. Generally, adult patients will stay in the ICU – and on a ventilator – for only three to four days, as explained by a Connecticut doctor, but Covid-19 patients need it for up to two or three weeks. , which significantly increases demand.
Truog said he has worked all weekend to help hospitals develop policies that determine who receives intensive care during a public health emergency. One of the best frameworks to follow, he said, is that developed by Dr. Douglas White, professor of intensive care medicine at the University of Pittsburgh and the University of Pittsburgh Medical Center (UMPC).
White said he started developing his frame over a decade ago during the avian flu epidemic.
It is essentially a point system calculating the probability of a patient receiving intensive care, based on two considerations: 1) save the most lives and 2) save the most lives.
The lower the patient’s scores, the higher their priority for care. In the system’s eight-point scale, the first four points illustrate the patient’s probability of surviving hospitalization, and the last four points assess whether, assuming they survive hospitalization, they have medical conditions associated with a life expectancy of less than one year or less than five years.
In the event of a tie, White’s framework asks doctors to consider the life cycle, with priority given to younger patients.
“These are inevitably tragic choices with only bad options,” said White. “But the only thing worse than developing a clear allocation framework is not, because decisions made during a crisis will be biased and arbitrary. “
White said his framework is supposed to be inclusive and not discriminate against people with disabilities.
“It is essential to clarify that stereotypical quality of life judgments have no role in these decisions, and no one is excluded from treatment because of disabilities,” said White.
In 2007, White stated that he had reviewed existing recommendations for the allocation of critical care resources and realized that these recommendations were often based on “exclusion criteria”, which simply prohibited large groups from accessing critical care. people during a public health crisis.
“Older people, severe cognitive impairment and chronic heart and lung disease were all used as exclusion criteria. It didn’t seem ethical to me. The exclusion criteria send the wrong message that some lives are not worth saving, “said White.
This could lead to a perception of injustice, he said, during a public health emergency where trust is essential. On the other hand, the framework developed by White and his team guarantees that no one is disqualified from intensive care from the start.
“Everyone who is normally eligible for intensive care remains eligible for a public health emergency,” said White.
Hundreds of hospitals across the country have adopted Mr. White’s framework, he said. The first set of hospitals, including Johns Hopkins and Medstar, came on board after a 2009 article on the system, said White.
But since the beginning of March this year, his email has been inundated with requests for advice from hospitals. UPMC has confirmed that its 40 hospitals have since adopted the framework, and White said the state of Pennsylvania has also implemented interim guidelines for public hospitals based on the framework. The Pennsylvania Department of Health would not give details on the basis of its interim guidelines, but said it intended to release the final guidelines soon.
As hospitals across the country try to figure out how they would ration insufficient supplies in an emergency – their discussions sometimes provoking public outrage, such as when a letter to patients in the Henry Ford healthcare system leaked out last week – guidelines from some states have until recently excluded certain types of people from intensive care in these conditions.
Alabama’s 2010 Emergency Operations Plan, for example, states that “people with severe or profound mental retardation” and “moderate to severe dementia” are “unlikely candidates for support ‘a fan.
These guidelines were updated in February 2020, but the new guidelines make no mention of how to screen patients in the event of a shortage of ventilators. The Alabama Department of Public Health has not confirmed whether the exclusion criteria are still used.
In a 2014 document, Indiana also listed criteria for excluding ventilators during a respiratory disease pandemic, including severe burns or addiction to dialysis. The state told a CNN reporter that “it was not part of our current response plan” and sent a link to a new plan. Like Alabama, it lacks advice on how to screen patients for access to ventilators.
This is hardly a solution, said White after examining the new Alabama guidelines.
“So their advice on standards of care in a crisis now no longer provides advice to doctors on what to do with the shortage of ventilators, which of course introduces its own problem of variability and bias White wrote in an email.
Two other states, Tennessee and Kansas, had guidelines that excluded people from being treated in a pandemic emergency, but took the guides offline Friday after a CNN reporter interviewed them.
A list of exclusion criteria for Tennessee finalized in 2016 included patients with head trauma, severe burns, severe dementia, end-stage ALS and MS; the state says it has no plans to replace the 2016 guidelines. Kansas has deleted a document on public health emergencies, including exclusion criteria, which was last revised in 2013.
“The document to which you are referring is an old one not intended for the COVID-19 response. We are working to update our guidelines, ”wrote a spokesperson for the Ministry of Health.
At Harvard, Truog, who supports White’s executive, recently published articles in the New England Journal of Medicine and the Boston Globe to help prepare hospitals, doctors and the public for the decisions and results he thinks he should make. face soon.
This kind of foresight from specialists is important, White argued, so that doctors facing a pandemic don’t have to grapple with such serious ethical issues on a case-by-case basis. White believes that triage committees should be created with non-primary care physicians to “increase objectivity, avoid conflicting engagements and minimize moral distress.”
Dr. Ira Byock, a palliative care doctor in Los Angeles and founder of the Institute for Human Caring at the Providence TrinityCare Hospice in California, said that doctors’ usual clinical ethics change during a public health crisis.
“For the first time in our experience, we need to balance the well-being of the community with the well-being of each patient, which is usually our only goal,” said Byock.
But even with the ethical advice provided by an executive like White’s, Truog said accountability means the road ahead for American doctors won’t be easy.
“It may very well be that in the next few days, doctors will have to make decisions that they had never even considered before, and the emotional toll for some will be absolutely crippling,” said Truog.