What if four patients in respiratory distress need a ventilator to keep them alive, but a hospital has just one available? Who makes that call? And how?
Public health and community leaders are contemplating excruciating dilemmas just like that before demand for medical help in the coronavirus crisis peaks in coming weeks.
They’re updating protocols, called “crisis standards of care,” for the most urgent medical decision-making possible, guidelines to determine, as resources get scarce, who gets care and at what level and who does not.
“You have to have thought this through in advance. You can't just make that decision at the last second on an ad hoc basis,” said Dr. Matthew Wynia, the Director of the Center for Bioethics and Humanities at the University of Colorado. “So that's what we're planning for right now, hoping we don't ever need to use it. But that's why we're planning.”
Wynia likened these shattering ethical choices, brought on by a tsunami of cases swamping the hospital system, to the kinds of scenes most have only witnessed in movies.
“Crisis standards of care is not a decision point. It is thrust upon you. You have to make decisions. These are forced choice,” he said. “This is like Sophie's Choice kind of decisions where you've got two, three, four people, all of whom are likely to die without a ventilator. And you’ve only got one ventilator left in your hospital.”
Triage in crisis is well known to first responders. In mass casualty situations, like the Aurora theater shooting, the first people on scene with medical training are forced to quickly prioritize the wounded by assessing who is most likely to be saved through rapid intervention. Others, who are less seriously injured, have to wait, and some may not be treated at all because they are judged too far gone to be saved.
But hospital settings are different. There, the coronavirus is like a slower-moving mass casualty incident, forcing physicians to confront fundamental changes to the way care is delivered with dwindling resources.
The crisis standards are defined as a “substantial change in usual healthcare operations and the level of care it is possible to deliver.” They’re prompted by catastrophes like pandemics, earthquakes and hurricanes or a blizzard or train derailment. Business as usual, where medical professionals strive to provide the highest level of care possible, gives way to something more like those battlefield, triage conditions.
Decision-making becomes “how to do as best we can with what we've got,” Wynia said. Under that scenario, some patients “will not be able to get even very basic life saving treatments.”
In Italy, the pandemic forced doctors to essentially decide which lives to save first; they prioritized young and otherwise healthy over older patients deemed less likely to recover. In New York, physicians are preparing for similar pressures. That state has 10,000 ventilators, life-saving machines that help sick patients breath, but it may need three times that many or more.
Colorado has had crisis standards in place for years, most recently adopted in May 2018 under John Hickenlooper. But those guidelines are now being tailored to the current crisis. A statewide work group set up by the health department will make recommendations to another group that advises the governor during a public health threat, called the Governor’s Expert Emergency Epidemic Response Committee.
The GEEERC, as it’s called, could revise and would likely adopt the plan, potentially as soon as next week, and send it on to Gov. Jared Polis. Under his current emergency powers, he could enact the crisis standards as soon as the health system appeared to be on the verge of getting overwhelmed by COVID cases.
The committee is racing the clock as academic models predict peak hospitalizations, and competition for resources, reaching Colorado on April 17.
“We're all running pretty fast here” due to the urgency of the crisis, said Dr. Eric France, the state’s chief medical officer. “We know there's a strong demand from our hospitals to get these standards of care out, so that they can be using our recommendations in the work that they're doing to those standards for their institutions.”
France said Colorado has never taken this step.
“It would be unprecedented.”
Wynia said Washington state, the first U.S. COVID epicenter, is preparing a similar crisis plan, but hasn’t instituted it yet. And he said during Hurricane Sandy, a New York hospital swamped by the storm almost, but narrowly, averted moving, to crisis protocols. In that case, fearing electricity would go out, hospital workers lugged gasoline up multiple flights of stairs to power a generator for multiple patients on ventilators.
“One of the real advantages of planning for crisis standards of care is that it causes you to become creative,” Wynia said. “It causes you to start saying, ‘really if we had to do that, would we find some other solution?’”
New York state recently okayed technology allowing two patients to share one ventilator, in an effort to address the urgent need as the number of hospitalized coronavirus patients shot up.
Under a draft proposal still in the works, France described a four- tiered scoring system that would assign patients points to help predict which had the best chance for survival. It would consider things like how serious a patient's illness is and if they have comorbidities, other additional health conditions that might make them less likely to survive, or to return to decent health.
The point system envisions considering factors like whether a patient is a child or pregnant or a first-responder like a firefighter or a nurse.
“It's extremely important we try to make these decisions in as blind a process as possible,” France said. “So we're only looking at the factors that are predictive of outcome and we don't know anything that is irrelevant to those questions.”
In the current draft, level four, France said, is a lottery, something like a coin toss or a drawing of straws.
“We would find ourselves just using a lottery to decide which of these persons is the right one to receive the scarce resources," he said.
France stressed that so far these are preliminary recommendations and any final decisions would be made by the GEEERC, and ultimately the governor.
He said the plan would call for individual hospitals to establish their own independent decision-making triage teams on site. They should include an ethicist, a physician that understands intensive care, a nurse and hospital director or leader. These brutal, life-or-death decisions would be out of the hands of frontline providers.
“We don't think that the frontline physicians and caregivers should be making these decisions,” he said. The team would not know about characteristics he described as “irrelevant” to someone’s potential health outcome. Age, race, ethnicity, sexual orientation and other characteristics would not be part of the decision process.
“It is very important to have clear guidelines that all hospitals can follow that are non-discriminatory and to start having these difficult community conversations,” said Julie Reiskin, executive director with Colorado Cross-Disability Coalition, which advocates for disability rights.
Reiskin is consulting the committee and serves on a second group that will be engaging the community to educate about the new standards, if they were implemented.
If these crisis care "rationing" guidelines have to be implemented they must be done “without bias about disability that is not relevant to the real and immediate ability to survive,” she said via email. Conditions like “cerebral palsy, Down Syndrome, blind, Deaf, wheelchair user, schizophrenia, brain injury, etc. should not be taken into consideration when determining access to critical care.”
Reiskin said if the disability has a direct bearing on ability to survive COVID-19 (for instance if someone has severe COPD and over 70) or someone who is actually terminally ill (like stage 4 cancer and eligible for hospice care) that is different.
“We do not want to go ahead of others but do not want to be left behind,” she said.
As physicians are forced into macabre discussions in the face of the pandemic, families should be having them too, said Sara Froelich, Executive Director of the Chronic Care Collaborative.
"Our main message to all Coloradans is now is the time to have important conversations with your family and your care team about your health and your medical wishes. All people should have a current advance directive and medical durable power of attorney," Froelich said. "If you have a medical issue that requires hospitalization during this time, your care team may not be able to be with you due to restricted visitation policies. People who get COVID-19 can experience rapid declines in their health, regardless of age or preexisting condition and we hope all are prepared."
France said the plan was to have the state issue different standards on different topics, should the crisis require it.
“So one might be access to ventilators, one might be personal protective equipment, another might be around palliative care,” France said.
Part of the reason for discussing the potential protocols is to alert the community to the seriousness of the crisis, in hopes mitigation measures like social distancing take hold and they would never need to be enacted.
“When we talk about flattening the curve, the entire reason for that is to keep the volume from overwhelming the Colorado health care system and the hospitals,” said Julie Lonborg, spokeswoman for the Colorado Hospital Association.
She said the standards could be necessary to make “unthinkable decisions.”
Konnie Martin, the CEO of San Luis Valley Health, said her team has been preparing for a surge of patients for weeks and hoping these most urgent measures wouldn’t be needed. “If the time came that we had to make those decisions, we would at least have some background information and understand how other communities or organizations made those decisions for themselves. But we're not there yet,” she said.
Another key element of adopting crisis standards of care is to protect providers and institutions forced by circumstances into extraordinary decisions they’d never make under normal conditions. Crisis standards of care provide some level of legal protection and coverage, “so that you feel empowered to really do your best and not to feel like, even if it's a worse outcome, at least I won't get sued if I do X instead of Y,” Wynia said.
“You want people in those circumstances to make the very best decision they can. You don't want them making decisions based on fear of a lawsuit," he said.
Emergency department physicians said they welcomed the guidance if the situation does indeed progress to the point where the protocols are needed.
“It’s not something I ever thought I might have to face,” said Dr. Emmy Betz, an emergency room physician at University of Colorado School of Medicine.
She said as a front-line provider, guidelines or policies “or even someone else making the decision” would be helpful.
“We’re trained to do whatever we can for a patient, as medically appropriate and in line with what that patient wants. So even the thought of having to decide which patient gets a resource — of having to ‘triage’ resources — is terrifying," Betz said.
The crisis standards would help in these “unprecedented times” to make sure medical decisions are as ethical and fair as possible, and ease the already intense pressure on physicians, said Dr. Katie Sprinkel, the associate medical director in the emergency department of The Medical Center of Aurora.
She said emergency providers are used to dealing with death and making complex decisions in the heat of the moment. But, she said, the crisis frameworks developed by a group, not in the heat of the moment, “are not only the best thing for patients, but would go a long way to mitigate the emotional trauma of physicians that have to carry them out.”
Ultimately, crisis standards of care, if enacted, come down to something resembling a utilitarian calculation, seeking decisions that get the most benefit to the most people, while others simply can’t get the life-saving help they normally would expect.
But Wynia said decision-makers won’t escape unscathed.
“There is no good way to make these kinds of decisions. Every decision you make is going to be incredibly painful and the people who make these decisions live with those for the rest of their lives,” he said. “If you talk to people who had to do military triage, they're scarred by deaths and I expect we may see a generation of physicians who had to make these decisions and carry that burden with them for the rest of their lives.”