When Grace Taylor was in her first year of medical school, she took an ethics class with this hypothetical: You have two ventilators and three patients who need them. Who gets one?
“I remember thinking that was a classroom situation that would never come up in the real world,” says Taylor, who is now a third-year physician resident at San Francisco General Hospital. “And I really didn’t expect that that situation could be looming the way it is now.”
These are the kinds of decisions local and state officials are trying to avoid by ordering people to stay at home to slow the spread of the coronavirus. But just as hospitals across the Bay Area are preparing their supplies and facilities for a surge in sick patients, hospital ethics committees are still writing guidelines for the kinds of worst-case-scenarios that will arise when medical resources, especially ventilators, become scarce.
“So that no individual doctors or providers are making decisions about rationing, in the middle of the night, alone,” Taylor says, “both because it takes the moral distress off of the individual and also because it decreases the possibility of bias taking place.”
The U.S. ventilator supply was already limited before the coronavirus began to spread, with 70% to 80% of them already being used for flu, cancer and other patients, says David Magnus, a biomedical ethics professor at Stanford University and a member of the ethics committee at Stanford Hospital.
“Then you have this thing that comes along that might double or triple the number that are needed,” he says.
The coronavirus attacks the lungs, making it very difficult to breathe for some patients. Magnus says clinical data indicates these patients need to be put on ventilators sooner in the disease process than flu patients, further straining the supply. Intubating earlier happens for two reasons. First, COVID-19 patients tend to “crash” quickly, and it appears they may need ventilators sooner to be effective. Second, other types of intermediary respiratory support that health care providers usually turn to before ventilators, like oxygen delivered through a nasal cannula, put health care workers at risk of getting sick.
“That is very dangerous for everybody in the environment because you’re essentially aerosolizing their droplets and shooting them up into the atmosphere,” Magnus says.
Magnus says we will very likely reach the point where ventilators need to be rationed. This is a difficult concept for Americans in the U.S. health care system, who are used to getting whatever care they ask for, even at the end of life, when drastic treatments will not help at all.
“If families tell us, ‘We’re not ready to stop yet,’ even though the chances of a good outcome are really terrible, we will put patients on ventilators, send them to the ICU and essentially prolong the dying process in ICUs often for days, or weeks, sometimes even for months,” Magnus says. “But in circumstances of extreme scarcity, then we don’t do that.”
Magnus says, 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 benefiting 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.
The biggest ethical responsibility for hospital staff will be communicating with patients and their families about exactly how and why certain decisions are being made. At Highland Hospital in Oakland, a lot of those conversations will fall to palliative care doctor Jessica Zitter.
“We’ve never done this before,” she says. “This is completely uncharted territory.”
Conversations that are normally meant to empower patients to make their own decisions will be more focused on the public good.
“Ultimately, we want our conversations to be as filled with compassion and support and validation and reflection as we can for people and their families,” she says. “But 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.”
Some ethicists in the U.S. are also considering talking to people who are in the category of 10% to 20% chance of benefit from treatment, early, right when they arrive at the hospital, to see if some of them might be willing to forego certain treatment.
“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.
But Zitter desperately wants to avoid having these conversations. She pleads with the public, everyone young and old, to stay home. Help slow the spread of this virus so doctors aren’t forced to make these difficult decisions.