Dr. John Sy, an emergency medicine doctor in Savannah, has made decisions all his career about how to save lives. What he has never done is decide who will live — and who won’t. Now, looking at the damage from the spreading coronavirus, he’s afraid he might have to.
The last line of defense for some of the most serious COVID-19 patients are ventilators, the machines that keep people breathing when they can’t do that for themselves. And for what’s coming, there aren’t enough.
Georgia has perhaps 2,400 to 3,000 on hand. When the outbreak peaks later this month, it will place a tremendous strain on the state’s supply of ventilators, computer models show. With the supply now on hand, hospitals in Fulton County could fall short by the beginning of next week, emergency management officials warned Wednesday. In the worst case, the Fulton hospitals could be short more than 100.
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That raises the wrenching possibility that in the near future, a care team will be faced with one available ventilator and more than one patient who needs it — and the team will have to choose.
Georgia isn’t yet at that point, and all concerned hope it never will be. But hospital officials and some of the bioethicists who advise them on end-of-life decisions are already drawing up guidance for such decisions. They consider if or when age should be a factor. The likelihood of full recovery. Certainly not wealth or prominence, but what about contributions someone has made to society? Or should it be first come, first served?
A group of doctors writing in the New England Journal of Medicine last week suggested that for patients with similar prospects, a lottery was the only fair way to decide.
As they wait for guidance, Georgia doctors have asked Gov. Brian Kemp for protection from liability if they have to deny someone a ventilator. And family members and mental health professionals are bracing for the mental fallout among health care workers if they have to make such choices.
Dr. Ann Groover, a psychiatrist in Rome, has already seen health care workers in her office in tears at dealing with the outbreak there: frazzled and exhausted at the work they’ve done, and still racked by wondering if they could have done more. To actively decide not to do more for a patient — or at least to feel like it was your decision — could be devastating for some, she said.
If it comes to rationing ventilators, “It’s going to be awful,” she said. “Doctors are going to feel like they’re killing patients instead of saving them. And it’s a very unfair situation to put physicians in.
“But we haven’t ever faced a crisis like this as a nation. And many many people are facing situations that they are going to find extremely hard to live with going forward.”
Planning ahead
A week ago, the Georgia-based Healthcare Ethics Consortium, started posting guidance on its website for hospitals and doctors trying to figure out how to approach the issue. One of the most detailed documents is a draft for Emory Healthcare, where Kathy Kinlaw, the consortium’s director, also works.
That guidance has some signal principles. First and foremost, each patient’s chances for the ventilator should be evaluated based on medical scores indicating whether they are likely to survive. Only if choosing between patients of similar health, it says, does age become a possible, second-tier consideration. In that case, clinicians may take into consideration “support for an equal opportunity to live through the various phases of life.”
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Another principle is not to write off a class of people, such as the disabled. The U.S. Department of Health and Human Services released a bulletin this weekend reminding hospitals it would enforce federal protections from discrimination based on age, disability, national origin or similar factors.
Hospitals should also draw up guidelines well before hand, as an institution, so that doctors don’t feel they’re making decisions alone or on the fly, the draft recommends. Connected to that is the recommendation that the patient-by-patient decisions be made not by the patient’s own doctor, but by a designated team at the hospital.
The patient and their family should have input. But they don’t make the final call.
Kinlaw advocates for transparency not just with the patient and their family but with the public; and from the very beginning, long before such decisions are on a patient’s doorstep.
"We haven't ever faced a crisis like this as a nation. And many many people are facing situations that they are going to find extremely hard to live with going forward." —Dr. Ann Groover, a psychiatrist in Rome
The medical journal article says patients should be made aware of the possibility of rationing at admission.
Emory’s drafted guidance doesn’t pretend that a ventilator shortage is impossible, and it is blunt about what is at stake. In a crisis shortage, Emory’s draft guidance reads, “It is unavoidable that not all who desire ventilation will receive it.”
Sy said that at his hospital, Memorial Hospital in Savannah, medical workers had started to have conversations, and he was eager to read the draft by Emory and others.
Faced with an 85 year old and an 18 year old in similar respiratory condition, “It’s easy to say, ‘oh well you only have one open ventilator and there’s one 18 year old and one 85 year old’,” he said. “But I’m the one that’s going to have the conversation with the 85-year-old’s family and let them know.”
“It would challenge the mental well being of physicians to essentially have to give out death sentences, to have to make decisions to not put someone on a ventilator or take someone off a ventilator that might need it if there are not enough ventilators,” he added. “The first thing you learn is, do no harm. There’s no training in medical school on how to ration out medical care in the U.S.”
Shifting resources?
These agonizing decisions could be avoided if enough ventilators can get to the hospitals that need them.
The U.S. Department of Health and Human Services on Tuesday said it had put in orders to increase the national stockpile by 20,000 ventilators. But they won’t arrive until a month after the outbreak peak is expected to be past in Georgia.
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The department also suggested that a state transfer equipment from regions not experiencing outbreaks to those that are. But hospital professionals said that transferring equipment is not workable, because any hospital that loses ventilators to a growing surge knows they’re not coming back, even if they are hit by a surge of their own. And when a patient arrives needing ventilation, there’s no time to get it back anyway. Physicians have described COVID-19 patients going into a dire state unexpectedly fast and needing ventilation.
Another suggestions was to use one ventilator for two patients, but only as “an absolute last resort.” Doing that can have adverse health effects, including infections and damage to patients’ lungs.
At his press briefing Tuesday evening, President Trump said the federal government had distributed some ventilators to needed areas, and was holding on to about 10,000 of the machines in order to more quickly deploy them to needed areas.
Dr. Henry Siegelson practices emergency medicine in Atlanta. In his three decades as a physician, he said never before have short supplies forced him to decide who lives and who dies. He’s frustrated there hasn’t been more planning.
“We talk about it all the time,” Siegelson said. “Some people will get ventilators and some people won’t. It’s awful.”
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