Our overwhelmed, or soon to be overwhelmed hospitals, face rationing precious life-saving equipment, such as ventilators. Our national lack of preparedness for a global pandemic will, in the near future, force local physicians and nurses to ration ventilators and oxygen delivery equipment, for patients and Personal Protective Equipment (PPE) for caregivers. How do health care providers make decisions about who gets a ventilator when their survival statistic range in the 10% to 20% range (See Stanford Article https://www.kqed.org/news/11808531/what-happens-when-the-ventilators-run-out). This is an unprecedented large-scale ethical and human challenge for U.S. health care workers. As Dr. Jessica Zitter, a palliative care doctor at Stanford University Health Care, states:
“I don’t know that this can be as much of a two-way conversation and a back and forth as it has been in this crisis period, because we just don’t have the resources. When you don’t have something, you don’t have it.”
In a research study of “Care of Wounded Warriors,” the interview data contain many heart-wrenching stories of nurses, and physicians who care primarily for “enemy combatants” and civilians (Benner, Halpern, Gordon, Kelley, In Review)—due to the state of the art military transport system that evacuates the U.S. and Allied Warriors to hospitals out of the war zone within 24 hours (often from 6-12 hours). Consequently, U.S. war zone facilities that offer highly technical care to local patients face the dilemma of transferring local patients to facilities ill-equipped to care for those patients, especially those on ventilators. When no other options exist, the nurses and physicians (against all military rules) usually left the necessary ventilators for civilians and enemy combatants, to continue the tenuous life-saving care of those patients with multiple injuries require. These military health care providers simply could not be the one to remove the ventilator when it meant sure death. These “front line” interventions are direct and personal for the health care provider. Guidelines must mitigate this burden, even though they cannot completely not remove the anguish of required death-producing rationing. Such extreme deprivation and scarcity are not a situation that military nurses and physicians had ever faced in their hospitals at home. Now in the COVID-19 pandemic, with rapidly rising morbidity and mortality rates, health care workers must prepare to make heart-wrenching rationing decisions because of the acute shortage of ventilators. This crisis is made more difficult by uncertainty and misinformation about federal and state reserves of ventilators.
David Magnus, a biomedical ethics professor at Stanford University and a member of the ethics committee at Stanford Hospital says that if care needs to be rationed, the guiding principle will be around who is most likely to benefit from the care. Patients with a less than 1% chance of benefitting from ventilator support, will not get it. The more difficult decisions are for patients who have a 10%, 15%, or 20% chance of benefitting. For these categories, doctors and researchers are turning to data from other countries hit by the virus, scouring the electronic medical records of patients to learn what characteristics of their health profile make them more or less likely to recover. “The early data does seem to indicate that patients who have more than one organ system down are less likely to benefit, especially if they’re older,” Magnus says.
Local ethics committees are engaged in writing ethical guidelines for rationing ventilators. The goal is to prevent the physicians and nurses from having to make solo decisions in the middle of the night, where they individually face the burden of making unimagined rationing decisions. The weight of this responsibility cannot be left to the last minute, and must not leave individual health care workers to face this crisis alone. Thus, the need is urgent for ethics committees to set guidelines for rationing ventilators. But while local guidelines are necessary, they are not sufficient. A national set of guidelines is needed to ensure that the distribution of ventilators and other urgent life-saving equipment, such as oxygen delivery, is fair. It would be a travesty to have patients move across state lines in a scramble to get the best chance of getting use of a ventilator, or even worse, to have vulnerable people try to buy a ventilator in order to prepare for an uncertain eventuality. This situation is made more urgent by the experience-based evidence that early use of ventilators saves lives. As stated from Stanford Health Care: “First, COVID-19 patients tend to “crash” quickly, and it appears they may need ventilators sooner to be effective.” (See Stanford Article https://www.kqed.org/news/11808531/what-happens-when-the-ventilators-run-out).
David Magnus further notes that the use of oxygen delivered by nasal cannula, put health care providers at additional risk: “That is very dangerous for everybody in the environment because you’re essentially aerosolizing their [patient] droplets and shooting them up into the atmosphere.” (See Stanford Article https://www.kqed.org/news/11808531/what-happens-when-the-ventilators-run-out).
Dr. Magnus points out the broader transmission concerns related to nasal cannula oxygen as compared to ventilators. This broader context of possible higher transmission rates with the use of nasal cannulas, and recommendation for earlier use of ventilators, will increase the need for more ventilators.
Developing new ways of deciding and communicating about end-of-life care in a time of rationing.
Jessica Zitter, palliative care doctor at Stanford University Health Care, who is often in the position of communicating with patients and families about end-of-life care, points out that communicating about end-of-life care brings unprecedented rationales, and decisions born of lack of ventilators.
Dr. Zitter states, “We’ve never done this before. This is completely uncharted territory.” Dr. Zitter notes that end-of-life decisions have never been primarily about the availability of life-saving equipment. She points out that end-of-life conversations are normally meant to empower patients to make their own decisions, now the rationing of ventilators will be more focused on the public good.
Rationing end-of-life care conversations will need to be transparent, honest, and delivered with compassion. In such a conversation fraught with tension, issues of trust, coerced choices born of scarcity, it will be tempting while fraught with breach of ethical, relational communication, to present the information as only a mandated external choice. Though rationing will be a mandated choice, born of scarcity, the communicator must stay open, curious, and responsive through active listening and compassion to maintain an essential safe and humane conversation with the patient/family. Such communication provides the only possibility for the patient and family to participate in and contribute to what will often be an inordinately difficult and essentially mandated choice.
Zitter notes that some physicians are considering ways to open the conversation of choosing, in advance of a crisis, to not go on ventilators: This amounts to, “Really assessing if people are willing to voluntarily say, ‘Look, I don’t want to take up that resource.’ Or, ‘Look, I understand I may not get that resource, and I’d rather really highly prioritize and focus on comfort,’” Zitter says.
Group discussions, and “town hall” type meetings, exploring these difficult conversations and decision-making contexts, could help. Therefore, articulating the concerns, the necessity of rationing, and enriching our understanding of the ways people are thinking about and articulating the range of issues associated with necessary rationing. Such conversations could give us the sense that, more basic than our status as individuals, separate from others, we are members and participants in many and more extensive social groupings, i.e., society, family, associations, churches, neighborhoods, and so on. Unless we can flatten the curve through social distancing, the numbers of ventilators cannot match the demands generated by the respiratory distress caused by COVID-19. I hope that these extraordinary demands will continue to stimulate a sense of belonging to one another, and a sense of our shared humanity. Nurses, physicians, first responders, service workers, and every one of us who wear masks and practice social distancing contributes to the well-being of others as well as our own. Standing together with respect and compassion is an essential moral source at a time when our country has been polarized into “political camps” that colonize thinking and trust. In the face of this shared crisis, we must make every effort to restore trust and faith in one another. In such a time of crisis, we dare not lead with suspicion, enmity, and blame. We really are all in this together!