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The Hardest Questions Doctors May Face: Who Will Be Saved? Who Won’t? The Hardest Questions Doctors May Face: Who Will Be Saved? Who Won’t?
(about 13 hours later)
The medical director of the intensive care unit had to choose which patients’ lives would be supported by ventilators and other equipment. Hurricane Sandy was bearing down on Bellevue Hospital in New York City in 2012, and the main generators were about to fail. Dr. Laura Evans would be left with only six power outlets for the unit’s 50 patients.The medical director of the intensive care unit had to choose which patients’ lives would be supported by ventilators and other equipment. Hurricane Sandy was bearing down on Bellevue Hospital in New York City in 2012, and the main generators were about to fail. Dr. Laura Evans would be left with only six power outlets for the unit’s 50 patients.
Hospital officials asked her to decide which ones would get the lifesaving resources. “Laura,” one official said. “We need a list.” After gathering other professionals, Dr. Evans checked off the names of the lucky few.Hospital officials asked her to decide which ones would get the lifesaving resources. “Laura,” one official said. “We need a list.” After gathering other professionals, Dr. Evans checked off the names of the lucky few.
Now, she and doctors at hospitals across the country may have to make similarly wrenching decisions about rationing on a far bigger scale. Epidemic experts predict an explosive growth in the number of critically ill patients, combined with severe shortages of equipment, supplies, staffing and hospital beds in areas of the U.S. where coronavirus infections are surging, hot spots that include New York, California and Washington State.Now, she and doctors at hospitals across the country may have to make similarly wrenching decisions about rationing on a far bigger scale. Epidemic experts predict an explosive growth in the number of critically ill patients, combined with severe shortages of equipment, supplies, staffing and hospital beds in areas of the U.S. where coronavirus infections are surging, hot spots that include New York, California and Washington State.
Health workers are urging efforts to suppress the outbreak and expand medical capacity so that rationing will be unnecessary. But if forced, they ask, how do they make the least terrible decision? How do they minimize deaths? Who even gets to decide, and how are their choices justified to the public?Health workers are urging efforts to suppress the outbreak and expand medical capacity so that rationing will be unnecessary. But if forced, they ask, how do they make the least terrible decision? How do they minimize deaths? Who even gets to decide, and how are their choices justified to the public?
Medical providers are considering these questions based on what first occurred in China, where many sick patients were initially turned away from hospitals, and now is unfolding in Italy, where overwhelmed doctors are withholding ventilators from older, sicker adults so they can go to younger, healthier patients.Medical providers are considering these questions based on what first occurred in China, where many sick patients were initially turned away from hospitals, and now is unfolding in Italy, where overwhelmed doctors are withholding ventilators from older, sicker adults so they can go to younger, healthier patients.
Choosing between patients “goes against the way we used to think about our profession, against the way we think about our behavior with patients,” said Dr. Marco Metra, chief of cardiology at a hospital in one of Italy’s hardest-hit regions.Choosing between patients “goes against the way we used to think about our profession, against the way we think about our behavior with patients,” said Dr. Marco Metra, chief of cardiology at a hospital in one of Italy’s hardest-hit regions.
In the United States, some guidelines already exist for this grim task. In an effort little known even among doctors, federal grant programs helped hospitals, states and the Veterans Health Administration develop what are essentially rationing plans for a severe pandemic. Now those plans, some of which may be outdated, are being revisited for the coronavirus outbreak.In the United States, some guidelines already exist for this grim task. In an effort little known even among doctors, federal grant programs helped hospitals, states and the Veterans Health Administration develop what are essentially rationing plans for a severe pandemic. Now those plans, some of which may be outdated, are being revisited for the coronavirus outbreak.
But little research has been done to see whether the strategies would save more lives or years of life compared with a random lottery to assign ventilators or critical care beds — an option some support to avoid bias against people with disabilities and others.But little research has been done to see whether the strategies would save more lives or years of life compared with a random lottery to assign ventilators or critical care beds — an option some support to avoid bias against people with disabilities and others.
Some commonly recommended rationing strategies, researchers found, could paradoxically increase the number of deaths. And protocols involve value judgments as much as medical ones, and have to take into account the public’s trust.Some commonly recommended rationing strategies, researchers found, could paradoxically increase the number of deaths. And protocols involve value judgments as much as medical ones, and have to take into account the public’s trust.
If hospitals withhold treatment by age, where do they draw the line? If they give lower priority to those with certain underlying health conditions, they may in effect be offering black Americans less treatment than white Americans. If physicians try to redirect resources — putting a patient on a ventilator for a few days, then giving it to someone else who appears to have better prospects — more people may die because few would get adequate treatment. And if many patients have a similar chance of survival, what fair way is there to make a choice?If hospitals withhold treatment by age, where do they draw the line? If they give lower priority to those with certain underlying health conditions, they may in effect be offering black Americans less treatment than white Americans. If physicians try to redirect resources — putting a patient on a ventilator for a few days, then giving it to someone else who appears to have better prospects — more people may die because few would get adequate treatment. And if many patients have a similar chance of survival, what fair way is there to make a choice?
The federal government, so far at least, is not providing national rationing guidelines for the coronavirus outbreak. Officials from various states, medical associations and hospitals are discussing their own plans, potentially resulting in very different decisions on life-and-death matters about which there are deep disagreements, even among medical professionals.The federal government, so far at least, is not providing national rationing guidelines for the coronavirus outbreak. Officials from various states, medical associations and hospitals are discussing their own plans, potentially resulting in very different decisions on life-and-death matters about which there are deep disagreements, even among medical professionals.
“You have to be really clear about what you are trying to achieve,” said Christina Pagel, a British researcher who studied the problem during the 2009 H1N1 flu pandemic. “Maybe you end up saving more people but at the end you have got a society at war with itself. Some people are going to be told they don’t matter enough.”“You have to be really clear about what you are trying to achieve,” said Christina Pagel, a British researcher who studied the problem during the 2009 H1N1 flu pandemic. “Maybe you end up saving more people but at the end you have got a society at war with itself. Some people are going to be told they don’t matter enough.”
Just before the coronavirus outbreak, Dr. Evans, the physician at Bellevue, moved across the country to direct the intensive care unit at the University of Washington Medical Center in Seattle. The city became one of the first areas in the United States to see community spread of the virus.Just before the coronavirus outbreak, Dr. Evans, the physician at Bellevue, moved across the country to direct the intensive care unit at the University of Washington Medical Center in Seattle. The city became one of the first areas in the United States to see community spread of the virus.
The hospital is doing whatever it can to prevent the need to ration — what Dr. Evans referred to as “an ethical obligation.” Like other institutions, it is trying to increase supplies, training staff to act in roles that may be outside their usual jobs and postponing elective surgeries to free up space for coronavirus patients. Some cities are racing to construct new hospitals.The hospital is doing whatever it can to prevent the need to ration — what Dr. Evans referred to as “an ethical obligation.” Like other institutions, it is trying to increase supplies, training staff to act in roles that may be outside their usual jobs and postponing elective surgeries to free up space for coronavirus patients. Some cities are racing to construct new hospitals.
Strategies to avoid rationing during the pandemic were published by the National Academy of Medicine. But hospitals across the country vary in their adherence to such steps. At the University of Miami’s flagship hospital, surgeons were told last Monday to cancel elective surgeries, but across the street at Jackson Memorial Hospital, they were “given wide discretion over whether to cancel or proceed,” according to an update sent to physicians.Strategies to avoid rationing during the pandemic were published by the National Academy of Medicine. But hospitals across the country vary in their adherence to such steps. At the University of Miami’s flagship hospital, surgeons were told last Monday to cancel elective surgeries, but across the street at Jackson Memorial Hospital, they were “given wide discretion over whether to cancel or proceed,” according to an update sent to physicians.
Dr. Evans is working with health leaders in Washington State to figure out how to implement triage plans. Their goal, she said, would be “doing the most good for the most people and being fair and equitable and transparent in the process.”Dr. Evans is working with health leaders in Washington State to figure out how to implement triage plans. Their goal, she said, would be “doing the most good for the most people and being fair and equitable and transparent in the process.”
But guidance endorsed and distributed by the Washington State Health Department last week suggested that triage teams under crisis conditions should consider transferring patients out of the hospital or to palliative care if their baseline functioning was marked by “loss of reserves in energy, physical ability, cognition and general health.”But guidance endorsed and distributed by the Washington State Health Department last week suggested that triage teams under crisis conditions should consider transferring patients out of the hospital or to palliative care if their baseline functioning was marked by “loss of reserves in energy, physical ability, cognition and general health.”
The concept of triage stems from Napoleon’s battlefields. The French military leader’s chief surgeon, Baron Dominique Jean Larrey, concluded that medics should attend to the most dangerously wounded first, without regard to rank or distinction. Later, doctors added other criteria to mass casualty triage, including how likely someone was to survive treatment or how long it would take to care for them.The concept of triage stems from Napoleon’s battlefields. The French military leader’s chief surgeon, Baron Dominique Jean Larrey, concluded that medics should attend to the most dangerously wounded first, without regard to rank or distinction. Later, doctors added other criteria to mass casualty triage, including how likely someone was to survive treatment or how long it would take to care for them.
Protocols for rationing critical care and ventilators in a pandemic had their beginning during the anthrax mailings after the Sept. 11 attacks, but have not previously been implemented.Protocols for rationing critical care and ventilators in a pandemic had their beginning during the anthrax mailings after the Sept. 11 attacks, but have not previously been implemented.
Dr. Frederick M. Burkle Jr., a former Vietnam War physician, laid out ideas for how to handle the victims of a large-scale bioterrorist event. After the SARS outbreak stressed Toronto hospitals in 2003, some of his ideas were proposed by Canadian doctors, and they made their way into many American plans after the H1N1 pandemic in 2009. “I have said to my wife, ‘I think I developed a monster here,’” Dr. Burkle said in an interview.Dr. Frederick M. Burkle Jr., a former Vietnam War physician, laid out ideas for how to handle the victims of a large-scale bioterrorist event. After the SARS outbreak stressed Toronto hospitals in 2003, some of his ideas were proposed by Canadian doctors, and they made their way into many American plans after the H1N1 pandemic in 2009. “I have said to my wife, ‘I think I developed a monster here,’” Dr. Burkle said in an interview.
What worried him was that the protocols often had rigid exclusion criteria for ventilators or even hospital admission. Some used age as a cutoff or pre-existing conditions like advanced cancer, kidney failure or severe neurological impairment. Dr. Burkle, though, had emphasized the importance of reassessing the level of resources sometimes on a daily or hourly basis in an effort to minimize the need to deny care.What worried him was that the protocols often had rigid exclusion criteria for ventilators or even hospital admission. Some used age as a cutoff or pre-existing conditions like advanced cancer, kidney failure or severe neurological impairment. Dr. Burkle, though, had emphasized the importance of reassessing the level of resources sometimes on a daily or hourly basis in an effort to minimize the need to deny care.
Also, the plans might not achieve their goals of maximizing survival. For example, most called for reassigning a ventilator after several days if a patient was not improving, allowing it to be allocated to a different patient.Also, the plans might not achieve their goals of maximizing survival. For example, most called for reassigning a ventilator after several days if a patient was not improving, allowing it to be allocated to a different patient.
But rapidly cycling ventilators might not give anyone enough chance to improve. When the coronavirus causes severe pneumonia, doctors are finding that patients require treatment for weeks.But rapidly cycling ventilators might not give anyone enough chance to improve. When the coronavirus causes severe pneumonia, doctors are finding that patients require treatment for weeks.
In Canada, a study of H1N1 patients found that 70 percent of those who would have been withdrawn from ventilators after a five-day time trial if a rationing plan had been implemented actually survived with continued care.In Canada, a study of H1N1 patients found that 70 percent of those who would have been withdrawn from ventilators after a five-day time trial if a rationing plan had been implemented actually survived with continued care.
Researchers at a British hospital had similar findings, concluding that “a new model of triage needs to be developed.”Researchers at a British hospital had similar findings, concluding that “a new model of triage needs to be developed.”
Many of the original plans in the U.S. were developed exclusively by medical personnel. But in Seattle, public health officials gathered community input on a possible plan more than a decade ago.Many of the original plans in the U.S. were developed exclusively by medical personnel. But in Seattle, public health officials gathered community input on a possible plan more than a decade ago.
Some citizens feared that using predicted survival to determine access to resources — a common strategy — might be inherently discriminatory, according to a report on the exercise. Citing “institutional racism in the health care system,” they were concerned that the metrics for some groups, like African-Americans and immigrants, would be skewed because they had not received the same quality of care.Some citizens feared that using predicted survival to determine access to resources — a common strategy — might be inherently discriminatory, according to a report on the exercise. Citing “institutional racism in the health care system,” they were concerned that the metrics for some groups, like African-Americans and immigrants, would be skewed because they had not received the same quality of care.
There were similar findings in Maryland, where researchers at Johns Hopkins engaged residents across the state in deliberations over several years.There were similar findings in Maryland, where researchers at Johns Hopkins engaged residents across the state in deliberations over several years.
The researchers presented them with several options. Hospitals could assign ventilators on a first-come, first-served basis. Some thought that could disadvantage people who lived far from hospitals. A lottery struck other participants as more fair.The researchers presented them with several options. Hospitals could assign ventilators on a first-come, first-served basis. Some thought that could disadvantage people who lived far from hospitals. A lottery struck other participants as more fair.
Others argued for a more outcome-oriented approach. One goal could be saving the highest number of lives, regardless of factors like age. A different goal could be saving the most years of life, a strategy favoring younger, healthier patients. Participants also considered whether those playing a valuable role in a pandemic, like medical workers who risked their lives, should be made a priority.
After the project ended, the Hopkins researchers designed a framework that assigns scores to patients based on estimated probability of short- and long-term survival. The latter was defined by whether the person had a pre-existing life expectancy of at least a year. Ventilators would be provided, as available, according to their ranking. The framework recommends a lottery for lifesaving resources when patients have identical scores. Stage of life may also be used as a “tiebreaker.” Decisions should be made by designated triage officers, not individual doctors caring for patients, and there should be a limited appeals process in cases of resource withdrawal, the protocol said.
Updated June 22, 2020Updated June 22, 2020
A commentary published this month on the website of the British Journal of Sports Medicine points out that covering your face during exercise “comes with issues of potential breathing restriction and discomfort” and requires “balancing benefits versus possible adverse events.” Masks do alter exercise, says Cedric X. Bryant, the president and chief science officer of the American Council on Exercise, a nonprofit organization that funds exercise research and certifies fitness professionals. “In my personal experience,” he says, “heart rates are higher at the same relative intensity when you wear a mask.” Some people also could experience lightheadedness during familiar workouts while masked, says Len Kravitz, a professor of exercise science at the University of New Mexico.A commentary published this month on the website of the British Journal of Sports Medicine points out that covering your face during exercise “comes with issues of potential breathing restriction and discomfort” and requires “balancing benefits versus possible adverse events.” Masks do alter exercise, says Cedric X. Bryant, the president and chief science officer of the American Council on Exercise, a nonprofit organization that funds exercise research and certifies fitness professionals. “In my personal experience,” he says, “heart rates are higher at the same relative intensity when you wear a mask.” Some people also could experience lightheadedness during familiar workouts while masked, says Len Kravitz, a professor of exercise science at the University of New Mexico.
The steroid, dexamethasone, is the first treatment shown to reduce mortality in severely ill patients, according to scientists in Britain. The drug appears to reduce inflammation caused by the immune system, protecting the tissues. In the study, dexamethasone reduced deaths of patients on ventilators by one-third, and deaths of patients on oxygen by one-fifth.The steroid, dexamethasone, is the first treatment shown to reduce mortality in severely ill patients, according to scientists in Britain. The drug appears to reduce inflammation caused by the immune system, protecting the tissues. In the study, dexamethasone reduced deaths of patients on ventilators by one-third, and deaths of patients on oxygen by one-fifth.
The coronavirus emergency relief package gives many American workers paid leave if they need to take time off because of the virus. It gives qualified workers two weeks of paid sick leave if they are ill, quarantined or seeking diagnosis or preventive care for coronavirus, or if they are caring for sick family members. It gives 12 weeks of paid leave to people caring for children whose schools are closed or whose child care provider is unavailable because of the coronavirus. It is the first time the United States has had widespread federally mandated paid leave, and includes people who don’t typically get such benefits, like part-time and gig economy workers. But the measure excludes at least half of private-sector workers, including those at the country’s largest employers, and gives small employers significant leeway to deny leave.The coronavirus emergency relief package gives many American workers paid leave if they need to take time off because of the virus. It gives qualified workers two weeks of paid sick leave if they are ill, quarantined or seeking diagnosis or preventive care for coronavirus, or if they are caring for sick family members. It gives 12 weeks of paid leave to people caring for children whose schools are closed or whose child care provider is unavailable because of the coronavirus. It is the first time the United States has had widespread federally mandated paid leave, and includes people who don’t typically get such benefits, like part-time and gig economy workers. But the measure excludes at least half of private-sector workers, including those at the country’s largest employers, and gives small employers significant leeway to deny leave.
So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.
Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.
A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.
The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.
States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.
Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.
If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)
If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.
If you’re sick and you think you’ve been exposed to the new coronavirus, the C.D.C. recommends that you call your healthcare provider and explain your symptoms and fears. They will decide if you need to be tested. Keep in mind that there’s a chance — because of a lack of testing kits or because you’re asymptomatic, for instance — you won’t be able to get tested.If you’re sick and you think you’ve been exposed to the new coronavirus, the C.D.C. recommends that you call your healthcare provider and explain your symptoms and fears. They will decide if you need to be tested. Keep in mind that there’s a chance — because of a lack of testing kits or because you’re asymptomatic, for instance — you won’t be able to get tested.
Others argued for a more outcome-oriented approach. One goal could be saving the highest number of lives, regardless of factors like age. A different goal could be saving the most years of life, a strategy favoring younger, healthier patients. Participants also considered whether those playing a valuable role in a pandemic, like medical workers who risked their lives, should be made a priority.
After the project ended, the Hopkins researchers designed a framework that assigns scores to patients based on estimated probability of short- and long-term survival. The latter was defined by whether the person had a pre-existing life expectancy of at least a year. Ventilators would be provided, as available, according to their ranking. The framework recommends a lottery for lifesaving resources when patients have identical scores. Stage of life may also be used as a “tiebreaker.” Decisions should be made by designated triage officers, not individual doctors caring for patients, and there should be a limited appeals process in cases of resource withdrawal, the protocol said.
The public input led the Hopkins researchers not to incorporate most exclusion criteria.The public input led the Hopkins researchers not to incorporate most exclusion criteria.
Dr. Lee Daugherty Biddison, one of the effort’s leaders, said that was because most participants were uncomfortable excluding patients with underlying health issues. Preconditions don’t always predict survival from respiratory viruses, and having chronic diseases like diabetes, kidney failure and high blood pressure often tracks with access to medical care. Rationing based on these conditions would be “essentially punishing people for their station in life,” Dr. Biddison said.Dr. Lee Daugherty Biddison, one of the effort’s leaders, said that was because most participants were uncomfortable excluding patients with underlying health issues. Preconditions don’t always predict survival from respiratory viruses, and having chronic diseases like diabetes, kidney failure and high blood pressure often tracks with access to medical care. Rationing based on these conditions would be “essentially punishing people for their station in life,” Dr. Biddison said.
The Hopkins group published a description of the framework last year, and doctors from other Maryland hospitals are teleconferencing twice a day to prepare to implement the plan if conditions grow extreme. Dr. Biddison has also been sharing the recommendations with doctors across the country.The Hopkins group published a description of the framework last year, and doctors from other Maryland hospitals are teleconferencing twice a day to prepare to implement the plan if conditions grow extreme. Dr. Biddison has also been sharing the recommendations with doctors across the country.
In Pennsylvania, Dr. Douglas B. White, chairman of ethics in critical care medicine at the University of Pittsburgh School of Medicine, is using the Hopkins protocol to help prepare hospitals in his state.In Pennsylvania, Dr. Douglas B. White, chairman of ethics in critical care medicine at the University of Pittsburgh School of Medicine, is using the Hopkins protocol to help prepare hospitals in his state.
In Colorado, Dr. Matthew Wynia, a bioethicist and infectious disease doctor, is working on a plan that would also assign a score. In his rubric, the first considerations are odds of survival and expected length of treatment. He said there was wide agreement among planners “not to make decisions on perceived social worth, race, ethnic background and long-term disability status,” which some fear could happen if doctors had to make seat-of-the-pants judgments without guidelines.In Colorado, Dr. Matthew Wynia, a bioethicist and infectious disease doctor, is working on a plan that would also assign a score. In his rubric, the first considerations are odds of survival and expected length of treatment. He said there was wide agreement among planners “not to make decisions on perceived social worth, race, ethnic background and long-term disability status,” which some fear could happen if doctors had to make seat-of-the-pants judgments without guidelines.
He is also trying to ensure that patients on admission to Colorado hospitals are asked whether they would forgo a ventilator if there were not enough for everyone. “One thing everyone agrees on is that the most morally defensible way to decide would be to ask the patients,” Dr. Wynia said.He is also trying to ensure that patients on admission to Colorado hospitals are asked whether they would forgo a ventilator if there were not enough for everyone. “One thing everyone agrees on is that the most morally defensible way to decide would be to ask the patients,” Dr. Wynia said.
He supports the idea of reassigning ventilators in certain cases. “If things are clearly getting worse, it’s really hard to justify a stance of once you’re on a vent, you own it, no matter how many people have to die in the meantime,” Dr. Wynia said.He supports the idea of reassigning ventilators in certain cases. “If things are clearly getting worse, it’s really hard to justify a stance of once you’re on a vent, you own it, no matter how many people have to die in the meantime,” Dr. Wynia said.
Unlike in Italy, where age has been used in rationing treatment, some people developing protocols elsewhere have de-emphasized it. “There are arguments about valuing the young over the old that I am personally very uncomfortable with,” Dr. Pagel, the British researcher, said, including that young people should be a higher priority because they have more life ahead of them.Unlike in Italy, where age has been used in rationing treatment, some people developing protocols elsewhere have de-emphasized it. “There are arguments about valuing the young over the old that I am personally very uncomfortable with,” Dr. Pagel, the British researcher, said, including that young people should be a higher priority because they have more life ahead of them.
“Where is your threshold? Is a 20-year-old really more valuable than a 50-year-old, or are 50-year-olds actually more useful for your economy, because they have experience and skills that 20-year-olds don’t have?”“Where is your threshold? Is a 20-year-old really more valuable than a 50-year-old, or are 50-year-olds actually more useful for your economy, because they have experience and skills that 20-year-olds don’t have?”
As Hurricane Sandy intensified outside Bellevue in 2012, Dr. Evans referred to New York State guidelines, since updated — which some hospital leaders have said they will follow if overwhelmed by the coronavirus — on how to allocate ventilators in a pandemic using a scoring system that tries to estimate someone’s chance of survival. She pulled together an ad hoc committee of doctors, ethicists and nurses. “Having a system and procedures gave us a sense we had some control of the situation,” she recalled.As Hurricane Sandy intensified outside Bellevue in 2012, Dr. Evans referred to New York State guidelines, since updated — which some hospital leaders have said they will follow if overwhelmed by the coronavirus — on how to allocate ventilators in a pandemic using a scoring system that tries to estimate someone’s chance of survival. She pulled together an ad hoc committee of doctors, ethicists and nurses. “Having a system and procedures gave us a sense we had some control of the situation,” she recalled.
For those about to lose electricity, she and her colleagues stationed two staff members at the bedside of all patients who relied on ventilators, preparing to manually squeeze oxygen into their lungs with flexible Ambu bags.For those about to lose electricity, she and her colleagues stationed two staff members at the bedside of all patients who relied on ventilators, preparing to manually squeeze oxygen into their lungs with flexible Ambu bags.
Looking back, Dr. Evans feels the patients and their families had the right to know that their machines would lose power, but in the crisis they hadn’t been told. The doctors also did not think to ask whether any patients or their families might volunteer to give up a power outlet so that it could be provided to someone else. “It wasn’t even on my radar,” Dr. Evans said.Looking back, Dr. Evans feels the patients and their families had the right to know that their machines would lose power, but in the crisis they hadn’t been told. The doctors also did not think to ask whether any patients or their families might volunteer to give up a power outlet so that it could be provided to someone else. “It wasn’t even on my radar,” Dr. Evans said.
In the end, it was improvisation that prevented tragic rationing at Bellevue. The generator fuel pumps failed, but a chain of volunteers hand-carried diesel up 13 flights of stairs. Dr. Evans’s patients were all maintained on backup power until they were transferred to other hospitals.In the end, it was improvisation that prevented tragic rationing at Bellevue. The generator fuel pumps failed, but a chain of volunteers hand-carried diesel up 13 flights of stairs. Dr. Evans’s patients were all maintained on backup power until they were transferred to other hospitals.
“I remember it really vividly,” she said of the experience. “It’s going to stay with me my entire professional career.”“I remember it really vividly,” she said of the experience. “It’s going to stay with me my entire professional career.”
David D. Kirkpatrick and Andrew Jacobs contributed reporting.David D. Kirkpatrick and Andrew Jacobs contributed reporting.