Too Many COVID-19 Patients, Too Few Ventilators: An Ethical Framework to Guide Hospitals
For U.S. Hospitals The Worst Case Scenario Is Imminent: Too Many COVID-19 Patients for Too Few Ventilators.
Jeffrey Kahn, PhD, MPH, the Andreas C. Dracopoulos Director of the Johns Hopkins Berman Institute of Bioethics, discusses the ethics of allocating lifesaving equipment and a Hopkins-led project to guide hospitals through such difficult decisions.
How are hospitals grappling with these issues?
There has been lots of discussion among our colleagues nationally about what approach people are using. Nationally, many hospitals are looking to a Maryland project as a model. It was started after the H1N1 pandemic by a group at Johns Hopkins to develop a plan of rationing care in a public health emergency. A statewide community engagement process gathered public input on the fairest, most ethically acceptable way to allocate medical resources. Last year, that project published a framework to guide the allocation of scarce mechanical ventilators.
What are the ethical underpinnings of this framework?
It’s based on a balancing of values, characterized in the project’s report by a “multi-principled approach ... that strives to save the most lives, preserve the most life years, prioritize evidence-based decisions, and show compassion to non-recipients.”
In the framework, what factors are used to determine how ventilators will be allocated?
The Sequential Organ Failure Assessment (SOFA) score is used in the Maryland project, to predict the likelihood of short- and long-term survival of people who need to go on ventilators, combined with prioritizing points based on our understanding of the COVID-19 infection so far and who's most likely to fare worst and fare best.
How does a triage team figure in decisions on access to ventilators and other medical care?
The team implements the framework in a consistent way across the institution and removes triage decisions from the physicians caring for individual patients. Those decisions could conflict with their role to provide appropriate care, and it’s just not fair to put them in such an untenable position, not to mention the increased moral distress it would bring.
After someone is on a ventilator, for example, how long does it take to have a clear sense of whether someone will actually improve or not—a week, 14 days? 21 days? There will need to be assessments made at stages of care to decide whether continued use is appropriate. Another scenario is two patients, one ventilator, same score, same set of facts. How to decide? It may then come down to a lottery. These are unthinkable decisions for Americans to be facing, but that is the nature of this public health emergency.
Besides ventilators, what other resources for treating COVID-19 patients could be in short supply?
ICU beds and Extracorporeal Membrane Oxygenation (ECMO), which is a potential last-resort lifesaving procedure if ventilation isn’t successful. [An ECMO machine pumps and oxygenates a patient's blood outside the body.]
You hear about the demand for ventilators because the need is a direct result of COVID-19. But the crisis has also affected the blood supply because donors are staying home.
If health care rationing becomes necessary, what would you tell people who are concerned that well-connected and wealthy patients will always get preferential treatment no matter what?
Among the commitments highlighted by the Maryland project is that any process must be public and transparent, so that those sorts of concerns are addressed clearly and directly. I think everyone’s fervent hope is that with strong public health interventions we won’t have to confront these questions.
