Imagine the unthinkable: Doctors at a hospital overwhelmed by the coronavirus outbreak are left with one ventilator but multiple patients unable to breathe without it. Who gets care?
Government officials stress that New Jersey hospitals are not currently facing this moral dilemma. But if that time comes — and COVID-19 patients overburden the state’s health care system — they want clear and ethically sound plans in place to help frontline caregivers navigate these painful choices.
Health care leaders are now working with state officials to create decision-making ethics tools designed to maximize ventilators and other resources, while saving as many lives as possible. An ethics subcommittee of the Medical Society of New Jersey submitted draft guidelines to the state Department of Health on Friday.
“We are — all of us and all of our teams — committed to saving every single life we can in this state,” Gov. Phil Murphy said Friday at the state’s daily media briefing. But “we would be abrogating our responsibilities not to prepare for that awful potentiality” of scarce medical resources, he added.
Refocusing on needs of public
In fact, doctors, nurses and other clinicians are already being forced to rethink how they provide treatment, shifting from their traditional patient-centered focus to a broader approach that must also consider the needs of the public at large. Experts agree this is challenging for medical providers, who are trained to do all they can to save the patient in front of them.
“When the resource is scarce, the goal is to save the most lives with the resources available,” explained Dr. Hannah Lipman, a gerontologist and director of the Center for Bioethics at Hackensack University Medical Center, part of Hackensack Meridian Health. “When resources aren’t scarce, those two goals are not in tension.”
Hospitals around the nation are required to have some form of ethics committee or consultant group, but these entities typically help patients, their families and clinicians with end-of-life decisions specific to one individual, experts said. But with the COVID-19 pandemic — which has now infected more than 16,600 New Jerseyans, including 198 who died — these providers must now wrestle with the potential need to ration some aspects of care, should efforts to slow its spread and ramp up hospital capacity not be enough.
Ethical decisions allocating limited medical resources are highly complex and involve many variables — like age and underlying conditions — but experts said they generally center on survivability. While data on COVID-19 is still limited, patients with respiratory failure may need to remain on a ventilator for 10 days or more, they note.
“When we’re talking about access to that limited resource, the big threshold is survivability. Will this benefit you such that you can go on it, and recover enough so that you can come off it,” said Nancy Berlinger, a research scholar with The Hastings Center, a 50-year-old nonprofit focused on bioethics.
If doctors choose a patient who is unlikely to endure the treatment over one that is stronger, “you create bad outcomes for two people,” Berlinger added. The Hastings Center created a series of slides to help hospitals update their ethics policies in the current crisis.
Dealing with demographic disparities
Medical ethicists acknowledge that this approach raises difficult questions about demographic disparities, given the higher prevalence of certain underlying conditions — like asthma and diabetes — among African Americans. Advocates for disabled individuals also fear these citizens could be passed over when it comes to allocating scare resources.
These disparities are real and worrisome, Berlinger and other experts agree, but they can’t be resolved through ethics policies designed to allocate medical resources in an epidemic. “We have to be very honest about the inequalities we have tolerated,” she said. “But this is not a great opportunity to make comprehensive social justice.”
That said, ethicists stress that public trust in the health care system is essential and people need to know they won’t be turned away if they are elderly or suffer from underlying health conditions. “The goal of saving the most lives requires consideration of the patient’s prognosis. Considerations of characteristics such as race, ethnicity, religion or sexual orientation are irrelevant,” Hackensack’s Lipman said.
Some decision-making ethics tools, like a model outlined last week in the New England Journal of Medicine, also prioritize treatment for health care professionals. Experts note this makes sense, given the critical role they now play in responding to the outbreak, but underscore the need to think carefully about who is included in this group; doctors, nurses and clinicians alone can’t operate a hospital without those who clean the floors, connect the equipment and transfer patients, for example.
New Jersey’s 71 acute-care hospitals are now required to provide the DOH daily reports on bed space, staffing levels, ventilators and stocks of personal protection equipment, or PPE, the gowns, masks and other critical supplies needed to protect frontline workers. The state is working to add bed space — reopening one closed hospital and setting up temporary facilities at three sites — and seeking to amass more PPE and ventilators from closed surgery centers and a federal stockpile.
DOH Commissioner Judith Persichilli said Monday she remains concerned about the supply of PPE and trained staff; the state is also working with professional organizations to expand workforce capacity. But while the impact of the state’s strict social-distancing measures is still being assessed, she remains confident there will be enough beds to accommodate the surge of patients expected to need hospital care in the coming weeks.
Ventilators remain in short supply
But New Jersey does not yet have enough ventilator units, officials said. Federal officials have provided at least 300 units, but Murphy requested 2,300 total and State Police are now working to purchase as many as 2,000 in case the Trump administration doesn’t fill the full order. Persichilli said they are also considering strategies to use one ventilator for multiple patients — an emergency protocol approved by federal officials — or converting anesthesia machines to instead provide breathing support.
“We just want to be prepared,” Persichilli said Monday. “We are preparing for the worst and hoping for the best.”
Berlinger, with The Hastings Center, said putting two patients on a single ventilator is clearly a “workaround” and not a long-standing approved protocol; other workarounds are underway when it comes to the use of PPE, with clinicians re-using some items or opting for less protection than they would normally use, with federal approval. “You see a lot of ingenuity and you see a lot of heroism” in these situations, she said, “but at some point you have to say, ‘What if this doesn’t work’?”
That’s why state officials want a strategy in place to make sure the equipment is used to save as many lives as possible. The DOH declined to say when statewide guidance based on the MSNJ recommendations might be ready for distribution, but it is now working with retired state epidemiologist, Dr. Eddy Bresnitz, on models to help hospitals allocate scare resources and deliver care as safely as possible during the crisis.
“We want to make sure that no matter what we do, that we give safe care,” Persichilli said.
The effort is greatly appreciated by hospital leaders, according to Cathy Bennett, president and CEO of the New Jersey Hospital Association, which has worked closely with the state to assess and allocate resources. “Our healthcare system has a responsibility to plan for all scenarios in a public health emergency like COVID-19,” Bennett, a former state health commissioner, said. “We hope these crisis plans will not be needed, but appreciate that thoughtful and reasoned discussions are under way by medical ethicists.”
Hospitals have already been forced to adjust a host of operational policies in light of the coronavirus epidemic, restricting family visits and rethinking discharge or transfer plans to ensure patients with COVID-19 don’t further spread the disease. But ethicists said it made sense to have statewide guidance, so that public access to care is the same for all New Jerseyans.
“When you have a pandemic, it shouldn’t matter what hospital you go to,” said MSNJ president Larry Downs. “We might not get there, but there’s a chance we could.”