'There's nothing about it that will feel right': Hospitals are gearing up to choose which patients to save if they run low on crucial equipment

• Ethicists are working around the clock to draft guidance for hospitals about how to ration scarce resources like ventilators if they run short because of the coronavirus.
• Governors are making sure healthcare workers won't be held liable for the tough decisions ahead, like taking away one patient's ventilator and giving it to someone else with a better shot at surviving.
• Experts at Johns Hopkins and the American Medical Association are fielding lots of calls from hospitals, doctors and public health officials about what to do.
• Those tasked with the administration of allocation programs are feeling the pressure. "If this has to happen, there's nothing about it that will feel right. And there's all kinds of ways in which it will feel wrong," one coordinator told us.
• New York could be the first state to see ventilator allocation, but hospitals in Washington State, Colorado, Maryland, Nebraska and Wyoming are gearing up for it, too.
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Hospitals are preparing to make difficult decisions about which patients to save and how to ration care should they be overwhelmed by the novel coronavirus.

Experts caution that hospitals in the US are at risk of running out of workers, beds, and protective equipment. By one estimate, the US could require up to 400,000 more ventilators in the next month or two - but it has no more than 20,000 left in the national stockpile. Earlier this week, New York Gov. Andrew Cuomo said states were competing to buy ventilators in bidding wars.

"That's literally what we're doing," he told reporters on Tuesday.

Providers in Colorado, Nebraska, Wyoming, Maryland, New York, New Jersey, and Washington State have been working closely with ethicists in recent weeks to gear up for the worst-case scenario. Some are drafting system-wide rules specifically for the pandemic, while others are dusting off old ones made for handling disasters like terrorism, severe flu outbreaks, and large-scale fires.

But they all deal with similar questions of what's fair to individuals when resources are scarce, and others are dying.

"The models only give you a range. And the range goes from very, very bad to just pretty bad," said Mark Tonelli, a pulmonary and critical care specialist and bioethicist at UW Medicine in Seattle, in an interview. "We're preparing for every eventuality."

'My world has blown up'

During a crisis, doctors will generally try to save the greatest number of lives, but that can require brutal decisions - like taking away one person's ventilator and giving it to someone else with a better chance at surviving.

States like New York and New Jersey have taken steps to protect healthcare workers from liability for actions like that. Others, such as Maryland, are expected to follow.

The US Department of Health and Human Services issued a stern warning over the weekend to hospitals, reminding them not to discriminate against patients as they make these decisions.

HHS told hospitals to "keep in mind their obligations under laws and regulations that prohibit discrimination on the basis of race, color, national origin, disability, age, sex," including in the allocation of healthcare services during the pandemic.

Some guidelines recommend that hospitals care for the young before the old and the relatively healthy above the chronically ill, if only in tie-breaking scenarios. But HHS said that providers can't discriminate against people by age or disability.

Johns Hopkins is working to finish its guidelines for rationing ventilators and other medical care with this notice in mind, according to one of the lead authors, Jeffrey Kahn, the director of the Berman Institute of Bioethics. The guidelines build off Maryland's framework from 2017.

They outline a point system that gives some priority to people who are most likely to survive. "Triage teams," like juries of healthcare workers, are tasked with deciding who gets ventilators, blood, and items that may be in short supply.

Written by a team of ethicists, physicians, nurses, lawyers, scientists, and anesthesiologists, as well as folks in emergency medicine, disaster preparedness, and pediatrics - the frameworks are being coordinated among the hospitals and the state of Maryland, according to Kahn.

But if outside interest is any indication, they could be widely adopted. Kahn has been fielding calls and emails from academic medical centers around the country with growing frequency, he said in an interview.

"My world has blown up in the last week over this," Kahn said. "I've been doing nothing but talking for ten straight days."

Last week, an article in the New England Journal of Medicine described ethical values underlying resource allocation, like maximizing benefits and treating people equally. The American Medical Association also published recent guidance.

Dr. Audiey Kao, the chief editor of the AMA's ethics journal, said he's getting constant questions from institutions, physicians, and public officials trying to address a variety of pandemic-related issues.

"The ethics that apply to a public health emergency are very different than in normal care," Kao said in an interview. "Not only are you looking at potentially limited resources. You're also trying to care for individual patients while at the same time trying to maximize the number of lives saved."

Scoring systems, categories, and machines

Though HHS' warning has thrown some rules into question, according to Kahn, many systems still plan to make decisions based on an algorithm that predicts mortality called the sequential organ failure assessment, or SOFA. New York's guidelines, for instance, use SOFA scores to help prioritize ventilators.

At UCHealth, a project is underway to evaluate a patient's chances in the short-term using artificial intelligence, said Matthew Wynia, director of the Center for Bioethics and Humanities at the University of Colorado and developer of allocation policies for the health system. The idea is to improve on the data available to the triage team.

"My hunch is we can do better than that today," Wynia said in an interview.

Computers will consider data points from electronic medical records like diagnosis, age, and relevant comorbidities. For those with the novel coronavirus, the AI will factor in markers of blood clotting and energy-producing enzymes thought to impact survival.

One of the goals is precision. Another is working around the implicit biases of human beings on the triage teams, who won't see the patient's file.

But there's still no right way to do this, Wynia said. UCHealth's guidelines for rationing supplies and care are not yet complete, Wynia said, and the AI system's output will be just one consideration of many.

At UCHealth and elsewhere, families won't be there when loved ones pass away, due to restrictions on visitors. They'll be notified through videos and phone calls.

Patients with COVID-19, the disease caused by the coronavirus, will be asked upon admission if they'd like to be treated for as long as possible, or give up their ventilators to someone else if they take a turn for the worst.

"It's stressful. It's really stressful," Wynia said. "If this has to happen, there's nothing about it that will feel right. And there's all kinds of ways in which it will feel wrong. We're kind of burning the candle at both ends right now because we need to do this in the best way we can."

Canary in the coal mine

New York will probably be the first state to reckon with ventilator rationing, though hospitals have not yet reported total depletions to their supply.

Physicians in the city are steeling themselves should they run out of the machines.

"Probably within the next week we're going to get to that point," said Benjamin Wyler, an assistant professor of emergency medicine in the Mount Sinai Health System, referring to the city's capacity limit as a whole.

Even though triage teams make the final decision, it's likely that bedside physicians will remove the patients from ventilators and notify the families.

"I think it's going to be really hard, but my feeling is that I'm prepared to follow this policy," Wyler said.

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