The Growing Conversation and Controversy on Rationing Urgent Care in the COVID-19 Pandemic — A Teaching-Learning Resource

My last article for EducatingNurses.com, “What Happens When Hospitals Run Out of Ventilators and Other Emergency Rescue Equipment,” joined the growing conversations about the prioritizing of ICUs, ventilators, oxygen supplies, etc. This article provides a review of published discussions around this current COVID-19 pandemic health care crisis. The article is designed as a source of discussion and debate by faculty and students to sharpen and clarify the issues around the necessity of rationing ventilators and other scarce emergency supplies.

Fortunately, New York Governor Andrew Cuomo says that ICU admissions are declining right now, meaning that rationing ventilators in New York may not be necessary. This news may bode well for the rest of the country if we plan for adequate deployment and timely supply of ventilators where and when they are needed. Avoiding the need to ration ventilators is the goal, but preparedness for rationing is still necessary. A nurse from New York gives an up-close account of what it is to care for critically ill COVID-19 patients who are separated from their families and even separated from caregivers due to the necessary personal protection equipment:

 

Journalist Liz Kowalczyk reviewed the local Massachusetts hospital guidelines in her article on April 8th in the Boston Globe titled, “Who gets a ventilator? New gut-wrenching state guidelines issued on rationing equipment.” Preference given to medical personnel, healthy people, younger is a good starting point for our discussion:

“I have a number of friends in New York and New Jersey and what I have heard is they are pushed right up to the brink but have not yet had to refuse ventilation,” said White, the Pittsburgh physician. “It’s likely that in at least some pockets of the US, we will have to ration ventilators. We hope it’s pockets and they are temporally separated so that resources can be allocated to Boston and then reallocated elsewhere.” Goralnick said the Brigham conducted a series of webinars over the weekend to educate providers about the Partners’ recommendations around possible rationing of equipment. He said that it is important to have a transparent method for making those types of decisions — before hospitals become overwhelmed. He believes “it is likely we will have to implement crisis standards of care. The hope is that we don’t have to implement this. But the reality is we should be ready. These are the choices people faced in Italy and they are the choices people are now facing in New York.”

 

Giving young, healthy health care providers preference in the allocation of respirators has created a storm of controversy among ethicists and clinicians. For example, see a Washington Post article by Ariana Eunjung Cha and Laurie McGinley, April 7, 2020: “Who gets a shot at life if hospitals run short of ventilators? States, hospitals scramble to set guidelines that could prioritize pregnant women, health-care workers — and even some politicians”:

Recognizing their sacrifices — as well as their essential role — Pennsylvania officials recently adopted new guidelines giving doctors, nurses and others fighting covid-19, the disease caused by the novel coronavirus, preferential access to scarce ventilators in a shortage.

But the idea makes some uncomfortable. A Maryland panel rejected the priority access, arguing those sick enough to need the life-sustaining machines would be unlikely to return to their jobs anytime soon and that defining who is and who is not a health-care worker in a crisis is too morally fraught… Pregnant women would get extra priority “points” in most if not all plans, U.S. hospital officials and ethicists say. This is not controversial. There also has been some discussion about whether high-ranking politicians, police and other leaders should be considered critical workers at a time when the country is facing an unprecedented threat.  The elderly, people with terminal cancer and those with chronic conditions, on the other hand, fare poorly in many plans, as do people with disabilities.

U.S. hospital officials, bioethicists and doctors involved in the closed-door discussions for drafting plans at their institutions say many critical details are still being debated even as the number of people on ventilators climbs higher each day.  Catholic groups have called on hospitals to treat pregnant women as two lives instead of one. AARP, formerly the American Association of Retired Persons, has decried age cutoffs for ventilator access in some plans. Last month, the Arc, a disability rights group, filed multiple complaints with the Department of Health and Human Services objecting to plans that disadvantage those with “severe or profound mental retardation” or dementia.

Some bioethicists have called for a national plan for rationing that would resolve disagreements and prevent “hospital shopping” by patients seeking care in a place that might favor their survival. But others believe a single standard is an impossible ask, given the nation’s deep ideological and religious divisions on life-or-death issues.

Bioethicist Brendan Parent, who worked for a New York state task force that developed a highly regarded framework for rationing, sees hospitals and states following two paths:
One group takes a utilitarian view of doing “the greatest good for the greatest number,” giving preference to those with the best chance of surviving the longest. Others are more focused on ensuring social justice and ensuring vulnerable groups have an equal chance.

Parent said there may be acrimony over various plans but that the alternative of treating everyone exactly the same — for instance, by using a lottery system — is not compatible with saving the most lives. Calling the plans “blunt instruments,” he said they cannot imagine every scenario that might arise so judgments will ultimately be left to individual doctors and nurses.

“Their use and utility will butt up against some very real, very difficult human problems with regard to how clinicians who are in the trenches are making real-time decisions,” he said…

At Ronald Reagan UCLA Medical Center in Los Angeles, patients with a life expectancy of one year or less — such as some with advanced cancer, or severe heart failure combined with other conditions — would be assigned a lower priority than those with a longer life expectancy, according to the documents.

Robert Cherry, chief medical and quality officer for UCLA Health, said that while the plan doesn’t list a specific age as a benchmark, age is “an indirect marker for chronic illness. The older you get, the more you are likely to have heart disease and other things that impact your survival.”

UCLA’s plan goes to great lengths to avoid possible discrimination, stating that medical teams may not consider a long list of criteria for ventilator allocation including gender, disability, race, immigration status, personal relationship with hospital staff or “VIP status” — an important reminder given the medical center’s proximity to Hollywood. Cherry said it would be irresponsible to not have a framework in place for making difficult decisions.

In UCLA’s plan, front-line health-care workers and administrators may be given priority access to lifesaving treatment, when their return to work means more people are likely to survive the crisis. If all the allocation criteria are applied and there’s still a shortage of medical resources, then care should be allocated on the basis of a lottery, the document says. Patients who do not receive required care would be categorized as “Do Not Resuscitate,” with palliative care provided, according to the documents.

In Virginia, Inova Health’s draft plan follows similar criteria, except those with chronic conditions face a more severe penalty in the rankings — which makes it less likely that they would get a ventilator even over someone who is sicker from covid-19, according to the plan. Steve Motew, chief clinical officer for Inova, said discussions are ongoing but that the hospital system wanted to use numerous components to try to capture the likelihood of success of intubation.
“With all candor, these types of question are something none of us want to or have imagined having to think about,” he said.
UCLA, as an extra precaution against bias, calls for decisions to be made by a special triage officer or team, rather than the group that cares for a patient, with demographic information “blinded” when it is passed on to the decision-makers….

Ezekiel J. Emanuel, chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania, and his colleagues argued that ventilators should go first to front-line health-care workers who care for “ill patients and who keep critical infrastructure operating.“

“These workers should be given priority not because they are somehow more worthy, but because of their instrumental value,” they wrote in the New England Journal of Medicine.

Douglas White, a University of Pittsburgh bioethicist and critical-care doctor whose framework was used by Pennsylvania, expressed similar sentiments in JAMA the following week. In his model — co-written NO SPAC Ewith Scott Halpern, a bioethicist at the University of Pennsylvania — he emphasized it would not be appropriate “to prioritize front-line physicians and not prioritize other front-line clinicians (e.g., nurses and respiratory therapists) and other key personnel (e.g., maintenance staff that disinfects hospital rooms).”

“Most of us are sheltering at home while there is this group of people going toward the danger. We have a reciprocal moral obligation if they suffer from their efforts,” White said in an interview.

These front-line discussions, occurring now, offer students, at all levels, stimulating and urgent learning opportunities for dialogue, debate, critical, creative and ethical thinking.

A prescient article entitled “Critical care experts tackle disaster preparation, surge capacity, and rationing,” written May 13, 2008 by Lisa Schnirring and Robert Roos, calls attention to neglect in preparing adequately:
“Provision of essential rather than limitless critical care will be needed to allow many additional community members to have access to key life-sustaining interventions during disasters,” the report states. It stresses that hospitals should use limited, essential critical care, or “emergency mass critical care (EMCC),” only in overwhelming events.
The task force says that EMCC should include the following:
• Mechanical ventilation
• Intravenous fluid resuscitation
• Vasopressor administration
• Antidote or antimicrobial administration for specific diseases
• Sedation and analgesia
• Select practices to reduce adverse consequences of critical illness and critical care delivery
Optimal therapeutics and interventions, such as renal replacement therapy and nutrition for patients unable to take food by mouth, if warranted by hospital or regional preference. The report states that every hospital with an intensive care unit should plan to provide EMCC and should coordinate with regional hospital planning efforts in doing so.

In a prophetic vision of our current situation, this report goes on to recommend what most hospitals are currently doing in the COVID-19 Pandemic:
The task force suggested several strategies that healthcare groups could use to augment critical care staffing:
• Physicians willing to serve in intensivist roles could be encouraged to join critical care teams.
• Critical care nurses could help mentor noncritical care caregivers.
• Noncritical care nurses and pharmacists could become responsible for medication delivery to all of the critical care patients.
• Paramedics could help maintain airways of critical care patients.
• Respiratory therapists who specialize in critical care could oversee groups of their noncritical care colleagues who could quickly ramp up their skills with just-in-time training materials.
• Pharmacists from regional health systems could help redistribute scarce pharmaceutical resources.

 

Most experts agree that in a time of significant shortages, we will have to move to a population-based health care approach. Most discussions of rationing have referred to managing costs in Health Management Organizations for population-based health care. A focus on population-based health care is not new, of course, but clinicians and ethicists care for individual patients and families. Most of our ethical considerations function at the individual level, and we have relatively untried and un-experienced demands for rationing at the population level. This is brought home by the following interview with a physician on finding a way to talk about rationing with individual patients:

I believe we need a national consensus and guidelines, but these must be informed by local discussions in ethics committees and clinician dialogues that are occurring in front-line care, as the crisis unfolds. The military has been dealing with mass casualties and limited medical resources extensively. Military writing on rationing is instructive. In the article, “The Dynamics and Ethics of Triage: Rationing Care in Hard Times” in Military Medicine in 2005, Maj. Thomas B. Repine and colleagues wrote:

Triage requires that a single person make rapid decisions
of tremendous impact. These decisions cannot be made by committee to ensure fairness, because of the speed at which they are made. Triage done by a single person, unfortunately, is clearly open to criticism of bias and inequality. To ensure that justice is being applied in these situations, oversight of the person performing triage must be instituted. Clinical guidelines are one approach to enforcing good ethical practice by a triaging physician. The Geneva Convention, for example, dictates that injured patients be triaged according to medical necessity, to the exclusion of nationality or even status as an ally or enemy. This can be quite difficult to explain to an American soldier watching as the insurgent who just killed one of his comrades is treated. Only by understanding the grander intent of the Geneva Convention can the soldier see why this is so important. Without clear, concise, explicit guidelines, triage is often perceived as inadequate and poorly organized by patients and the public. Guidelines for triage, however, do not supersede the judgment of the physician in triage situations.

The ultimate decision-making authority and subsequent responsibility always fall on an individual, who cannot be controlled from without but must be taught to follow ethical principle from within. It is impossible to guarantee justice through an external influence in any triage situation, but it can be ensured after the fact through appropriate review.

 

This view of triage acknowledges the exigencies of front-line care and advocates for review and improvement in ethical and clinical decision-making based upon front-line review and revision instead of providing an appeals process that may be too cumbersome during a surge of patients.

Many hospitals have already set up an appeals process for rationing decisions. Patrone and Resnik (2020) point out inherent limits and appeals processes because of the urgency, and surge demands that exceed health provider capacities during a time of crisis:

Existing pandemic preparedness plans should be developed to include ventilator specific guidelines and procedures. These should include measures aimed at improving surge capacity as well as at providing explicit guidance for implementing triage criteria and procedures. The adoption of clear, objective, and easily measurable clinical triage criteria in these plans helps to minimize potential injustices and errors, and reduces the need for individual physician judgment in triage decisions, thus further relieving pressures to include potentially dangerous appeals processes. Transparent and well-articulated national guidelines reflecting these suggestions should be proposed, and state and local legislation drafted to ensure protections for both patients and healthcare providers in case of disputes over particular decisions. Plans should adopt a competent and regular retrospective review of triage decisions and allow for revisions to triage protocol in light of those reviews. If these steps are taken, pandemic planning efforts can reasonably and ethically justify not including individual appeals processes and the potential problems threaten to create. These suggestions may hopefully help chart a way for discussions toward more actionable pandemic planning which is sensitive to the attractiveness of the idea of appeals processes in medical rationing policy, but which, at the same time, recognizes the potential dangers and difficulties that appeals processes pose under severe pandemic conditions for both patients and those who must care for them

 

American society values individual autonomy and rights in health care. An appeals process is often used to enhance justice and provide a sense of entitlement in health care. However, a surge in demand may make it administratively impossible to meet the requirements of an appeals process. In that case, it becomes imperative that health care providers and hospital systems review, evaluate and improve clinical and ethical decision-making during an ongoing crisis. This accomplished, as events occur with institutional feedback and records kept towards a goal of continual improvement.
The goals are to fuel debate, discussion, and thinking about this unprecedented crisis in the U.S., where life and death rationing decisions may have to be made. The following questions are offered to start the discussion:

Critical Questions for Debate and Critique

1. Should national guidelines be developed for rationing ventilators and other life-saving equipment and facilities such as ICUs during the COVID-19 pandemic?
2. What should be the criteria for deciding who gets a ventilator, when there are not enough to go around?
3. How should quality control and continuous quality improvement be designed to improve equity and quality of care?
4. Should there be an appeals process for rationing decisions that deny access to ventilators. Why or why not?
5. What kinds of conversations, counseling, and information-giving should occur in discussing the need for rationing for a particular patient?

 

References:
Repine, T.B.,Lisagor, P., Cohen, M.C. (2005) “The dynamics and ethics of triage: Rationing Care in Hard Times.” Military Medicine. , 170, 6:505, 2005

Annotated Bibliography

American Nurses Association: Nurses ethics and the response to the covid-19 pandemic.

“During pandemics, nurses and their colleagues must decide how much care they can provide to others while also taking care of themselves. They must be supported in these heart-wrenching decisions by the systems in which they provide care and by society.” 

Click here to view report

This three page paper from the American Nurses Association has excellent guidance.
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Cathcart, Thomas (2013) The Trolley Problem Or Would you throw the fat guy off the bridge? A Philosophical Connundrum.
This book will clarify the philosophical and ethical issues involved in health care rationing, where the life of one might be sacrificed to save the lives of many. This book can be augmented by viewing Michael Sandel’s first lecture in his Harvard College course on Justice (justiceharvard.org). This “philosophical” conundrum presented by Thomas Cathcart is enlivened by the real-live situation of Daphne Jones of Oakland, who according to the courts set a “dangerous precedent” by switching the course of a trolley that was sure to kill at least 5 people in its tracks, by routing the trolley so that it killed only one man, Chester Farley of San Francisco. This clarifying and complexifying exploration resonates with the central issues of life and death health care rationing. I encourage you to stretch your thinking by considering the issues adroitly and clearly articulated by Thomas Cathcart in this provocative book. The Growing Conversation and Controversy on Rationing Urgent Care in the COVID-19 Pandemic.

Christian, Michael D. MD, FRCPC, FCCP, Sprung, Charles L., MD, FCCP,  King, Mary A. MD, MPH, FCCP, Dichter, Jeffrey R. MD, Kissoon, Niranjan MBBS, FRCPC, Devereaux, Asha V. MD, MPH, FCCP, Gomersall, Charles D. MBBS “Triage Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement.” © 2014 The American College of Chest Physicians. October 2014Volume 146, Issue 4, Supplement, Pages e61S–e74S Published by Elsevier Inc.

This article gives extensive guidelines for managing and rationing critical resources in a time of high demand and crisis. The focus is on events such as natural disasters or a terrorism attack, pandemics, or any circumstance that results in a large number of critically ill or injured patients. A must-read for understanding critical variables in delivering health care during extreme shortage.

Cohen, Glenn JD1; Crespo, Andrew M. JD1; White, Douglas B. MD, MAS2 (April 1, 2020) “Potential Legal Liability for Withdrawing or Withholding Ventilators During COVID-19Assessing the Risks and Identifying Needed Reforms” JAMA. Published online April 1, 2020. doi:10.1001/jama.2020.5442

This article discusses the ethical conflict and legal liabilities of removing a ventilator from one patient who is not progressing well and giving that ventilator to another patient who is more likely to benefit. Given that predicting who will survive on ventilator support and who will not is fraught with uncertainty, and withdrawing or withholding a potentially life-saving treatment creates a legal and ethical conundrum legislation is needed similar to the one in Maryland. A Maryland statute in place since 2004 indicates that “A health care provider is immune from civil or criminal liability if the health care provider acts in good faith and under a catastrophic health emergency proclamation.” The authors recommend that other states adopt such a law to protect health care providers from lawsuits related to rationing when acting in good faith and under circumstances of a crisis of lack of medical supplies.

Daniels, Norman & Sabin, James E. (2002) Setting Limits Fairly. Can we Learn to Share Medical Resources. New York, N.Y., Oxford University Press. These authors draw on Daniel Callahan’s classic book published in 1987: “Setting Limits: Medical Goals in an Aging Society (Callahan, 1987).

Daniels and Sabin address the problems associated with a lack of consensus in U.S. Democracy about distributive principles for health care. Do these authors ask the questions about what priority should society give to the most seriously ill patients? The articulate the multiple values and perspectives that can shape the answers given in a pluralistic Democratic society offering some lessons learned from the Oregon universal health care system. The authors argue for fair processes of rationing health care services “must enable public deliberation and democratic oversight for health care limits (p.4),” Daniels and Sabin place legitimacy (the problem of how to set limits to the use of scarce health care resources) at the center of discussions of rationing limited health care resources. Improving accountability for reasonableness in rationing scarce health care resources can increase legitimacy or the decision-making and plan for the rationing of health care. But this legitimacy rests on the transparency of the deliberation and planning for fairly distributed resources. The authors compare nations’ willingness to be transparent in the decision-making process for limiting scarce health care resources. They point out that only Oregon has openly discussed and set standards for limiting health care resources. This book was written before the COVID-19 pandemic, but it effectively sets the stage and articulates the ethical and social-political issues related to reasonable, fair rationing of health care services.

Emanuel, E. (Host) , Moreno, J.  (2020,  April 2).  Making the Call  [Audio podcast]. Retrieved from :  Click here to go to podcast 

“COVID-19 is overwhelming our healthcare system. As cases increase exponentially across the United States, it’s clear we just don’t have enough resources to go around. Doctors in the United States aren’t used to dealing with scarcity. Now they’re being forced to make tough decisions about rationing care. How do you decide who gets the ventilator, when there aren’t enough for every patient who needs one?”

Emanuel, Ezekiel, Persad, Govind, Upshur, Ross, Thome, Beatriz, Parker, Michael, Glickman, Aaron, Zhang, Cathy, Boyle, Connor, Smith, Maxwell, Phillips, James P. “Fair allocation of scarce medical resources in the time of Covid-19.” Sounding Board, NEJM, 10.1056/NEJMsb2005114, March 23, 2020

This article predicts that rationing of ICU beds and ventilators will likely occur during the Covid-19 pandemic. They also predict a shortage of health care workers. They recommend that front-line health care workers get priority in receiving ventilator care and ICU beds because they are essential to caring for patients stricken with the Corona Virus. The authors recommend that rationing be based upon “four fundamental values: maximizing the benefits produced by scarce resources, treating people equally, promoting and rewarding instrumental value, and giving priority to the worst off.” An individual’s wealth should not determine life or death, and the goal is to save the most lives, or most life-years, by giving priority to patients most likely to survive.  The authors give examples of how these four values can be implemented.

Truog RD, Mitchell C, Daley GQ . “The toughest triage: allocating ventilators in a pandemic. N Engl J Med.” Published online March 25, 2020. doi:10.1056/NEJMp2005689

Pointing out that withdrawing or withholding a ventilator is truly a life or death decision for most COVID-19 patients in respiratory distress. New York guidelines for “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, such that patients whose condition is not improving are removed from the ventilator to make it available for another patient.” These authors recommend developing a formal triage committee to buffer front-line health care workers from having to make these decisions alone. They argue for flexibility, for example, when circumstances and the development of local expert knowledge in handling difficult decisions related to ventilators.

Making The Call  COVID-19 1. Who gets the ventilator? April 8, 2020
Click here to go to podcast

 

White, Douglas B. MD, MAS, Lo, Bernard MD. (2020) “A Framework for Rationing Ventilators and Critical Care Beds During the COVID-19 Pandemic” JAMA. Published online March 27, 2020.
doi:10.1001/jama.2020.5046

This article describes a framework for rationing ventilators during the COVID-19 score pandemic. The authors recommend using a “score-based system that incorporates patients’ likelihood of surviving to hospital discharge and beyond and their role in the public health response to the outbreak.” Their system does not recommend a blanket rejection of ventilators for all patients with “class III or IV heart failure, severe chronic lung disease, end-stage renal disease, and severe cognitive impairment.” The authors recommend a “Multiprinciple Allocation Framework. Under this allocation framework, all patients who meet usual medical indications for ICU beds and ventilators are eligible and are assigned a priority score using a 1 to 8 scale (lower scores indicate higher likelihood of benefit from critical care), based on (1) patients’ likelihood of surviving to hospital discharge, assessed with an objective measure of acute illness severity; and (2) patients’ likelihood of achieving longer-term survival based on the presence or absence of comorbid conditions that influence survival. Also, individuals who perform tasks vital to the public health response are given heightened priority by subtracting points from their priority score. In the event that there are ties in priority scores between patients, life-cycle considerations are used as a tiebreaker, with priority going to younger patients, who have had less opportunity to live through life’s stages.”

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