‘Who lives and who dies’: In worst-case coronavirus scenario, ethics guide choices on who gets care

It’s a scenario few health-care leaders want to contemplate much less discuss: What if the ranks of desperately ill patients overwhelm the nation’s ability to care for them?

With respiratory illness caused by the novel coronavirus rapidly spreading, nowhere is that potential more evident than the nation’s limited supply of mechanical breathing machines called ventilators.

Desperate scenes are playing out in Italy, where a spike in COVID-19 cases have overwhelmed the medical system and doctors have reported shortages of staff and equipment. More than 4,800 people have died there, surpassing China in total deaths.

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Because the worst cases of COVID-19 rob a person of their ability to breathe, patients die unless they get life-sustaining oxygen from machines. But there are fewer than 100,000 ventilators in the United States and millions of patients struggling to breathe might need such care. Other machines can deliver oxygen to help those with mild or moderate forms of the disease, but the most critically ill patients need powerful airway pressure that only ventilators can deliver.

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Federal and state officials are urging people to follow measures to prevent the spread of the respiratory virus that causes the disease. Both California and New York have adopted strict limits on travel and commerce and urged people to stay home and eliminate nonessential travel. These measures aim to slow the pace of new infections and ease demands on hospitals without the intensive care unit beds, protective gear or ventilators to handle an unprecedented surge of patients.

In a worst-case scenario of ventilator shortages, physicians may have to decide “who lives and who dies,” said Dr. Ezekiel Emanuel, an oncologist and chairman of the University of Pennsylvania’s department of medical ethics and health policy.

“It’s horrible,” Emanuel said. “It’s the worst thing you can have to do.”

‘Tying to be prepared’ in Seattle, home of Patient One.

Respiratory therapists, who take care of patients who struggle to breathe, are aware of the pressures that comes from a swift, sudden need for ventilators.

“This is something that we have thought about most of our careers,” said Carl Hinkson, director of Providence Regional Medical Center’s pulmonary service line.Providence, in Snohomish County just north of Seattle, treated the nation’s first known patient with COVID-19, a 35-year-old man who became ill in January after returning from Wuhan, China. The hospital brought the man to health through a combination of oxygen and medications.

At the time, Hinkson and his team of respiratory therapists realized they were soldiers in a war against a virus that might last months. The Seattle metro area has the most U.S. fatalities from COVID-19 so far, a cluster of 35 deaths at Life Care Center in Kirkland, adding to Washington’s state’s 83 deaths.

Patients like the Snohomish County man recover after getting care at well-equipped hospitals such as Providence and Harborview Medical Center in Seattle. The key is to manage the flow of patients so the hospital and its staff aren’t overwhelmed.

Providence has a roster of 44 ventilators, and the staff is “using a good portion of that capacity right now,” Hinkson said.

Still, Hinkson is optimistic his hospital can handle a surge of COVID-19 patients. His staff has worked long hours, but the hospital contracted with a private company that provides traveling respiratory therapists on a temporary basis. It allowed Hinkson to give time off to one therapist who worked 20 of the last 24 days.

Hinkson is aware of the hard decisions doctors in Italy are making about how to prioritize treatment of desperately ill patients.

“We’ve done a good job of planning and trying to be prepared so that we will avoid those problems,” Hinkson said. “Planning and social distancing should help us not having to make those decisions.”

‘First come, first served doesn’t hold true’

Government public health experts have planned for a scenario in which there are too many patients and too few ventilators.  In a July 2011 report completed by a U.S. Centers for Disease Control and Prevention ethics subcommittee, planners said the “principle of sickest first” for critical care might no longer apply during a severe pandemic because it “may lead to resources being used by patients who ultimately are too sick to survive.”

When there’s a severe shortage of life-saving medical resources “priority is given to those who are most likely to recover,” the report said.Medics in war, for example, might first treat wounded soldiers more likely to return to health. Or emergency workers managing a cholera outbreak in a refugee camp will first give limited IV fluids to moderately dehydrated people because they are more likely to recover than sicker patients.

When these decisions have to be made, however, “health care workers should be the top priority,” Emanuel said, because they “save other people and put themselves purposely in harm’s way to save others.”

The goal is to “save the most lives and the most life years,” he said. “First come, first served doesn’t hold true. It’s not because you’re not a worthy person.”
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