It is hard to imagine a topic more sensitive, and a situation more difficult, than deciding who gets to live and die in the time of a pandemic. Yet this is the reality of the COVID-19 outbreak and the resource shortage it has caused.
In particular, the insufficient number of ventilators very quickly came to the world’s attention, as highlighted by physicians and hospital managers from across the world, including Italy, India, and the United States.
Due to the lack of critical care resources, healthcare professionals, patients, and families around the world must live with the consequences of withdrawing life support from one person for the benefit of another.
Such decisions are so fraught, both emotionally and ethically, that the phrase “fair allocation” of a ventilator may seem inappropriate. These decisions can never truly be “fair.”
Stay informed with live updates on the current COVID-19 outbreak and visit our coronavirus hub for more advice on prevention and treatment.
However, fairness is what frontline hospital workers must strive for in such circumstances. This Special Feature looks at some of the difficulties posed by such decisions and the criteria involved in making them, as explained and recommended by doctors and bioethicists.
Although it is a very difficult thing to calculate, data and analytics company GlobalData estimated on March 23, 2020 that approximately 880,000 more ventilators would be needed globally to tackle the COVID-19 outbreak.
According to the same report, the U.S. had a shortage of 75,000 ventilators, while France, Germany, Italy, Spain, and the United Kingdom collectively lacked 74,000 ventilators.
The Society of Critical Care Medicine recently highlighted that calculations of this type are “gross estimates” because there are many unknowns underpinning them, one of which is the pacing of the pandemic. Our success in “flattening the curve” will affect the extent of the demand for ventilators at any given point in time.
“Ventilator shortages are a crucial reality as the COVID-19 outbreak continues to worsen globally. All ventilator manufacturers have full order books and hold little in stock — receiving orders not only from regular customers such as hospitals, but also directly from governments.”
– Tina Deng, a medical devices analyst at GlobalData
In the context of this scarcity, there are many concerns. Not least of all is the fact that some people, who may not have died had there been enough ventilators, may now perish as a result of this scarcity of resources.
One of the other main concerns is the clinicians’ burden of choosing who gets a ventilator. The psychological distress of having to make such a decision is hard to overestimate.
Dr. Robert Truog — the director of the Center for Bioethics at Harvard Medical School in Boston, MA — and colleagues reflect on the point that less than 50 years ago, doctors argued that taking someone off of a ventilator was an act of killing, and that it was both illegal and unethical.
Today, however, withdrawal from a ventilator is the most common immediate cause of death in an intensive care unit (ICU), and many people see it as an ethical act and a legal obligation.
What makes the COVID-19 crisis very different for these same doctors is that the two ways of justifying such decisions no longer apply. Indeed, “it is not being done at the request of the patient or surrogate, nor can it be claimed that the treatment is futile.”
To help ease the toll that such decisions can take on a person’s mental health, Dr. Truog and colleagues recommend that a “triage committee” should make these decisions — not the clinician.
“[S]uch a committee should be composed of volunteers who are respected clinicians and leaders among their peers and the medical community,” write the authors, adding that such a committee could help “buffer” the clinicians from the potential harm to their mental health.
This kind of committee would also help healthcare workers such as physicians and nurses continue to maintain their roles as “fiduciary advocates” and appeal the committee’s decision when necessary.
Also, having a dedicated committee would enable those in it to constantly adjust their rationing criteria according to the changing situation — for example, should more or fewer ventilators become available — and allow them to consider each individual situation on a case-by-case basis.
“[W]hen a hospital is placed in the unavoidable but tragic role of making decisions that may harm some patients, the use of a committee removes the weight of these choices from any one individual, spreading the burden among all members of the committee, whose broader responsibility is to save the most lives.”
– Dr. Robert Truog, et al.
Dr. Truog and colleagues recommend that the triage committee should also take on the task of accurately and sensitively communicating their decisions to the patients’ families. This would help prevent misunderstandings and inaccuracies.
Finally, they suggest that the healthcare workers who take care of the patients in question “should not be required to carry out the process of withdrawing mechanical ventilation; they should be supported by a team that is willing to serve in this role and that has skills and expertise in palliative care and emotional support of patients and families.”
Although a triage committee would help alleviate clinicians’ burdens, the question remains: What are the ethical values that such a committee would need to base their decisions on?
In the state of New York, such a committee is already in place. A “triage officer or a triage committee composed of people who have no clinical responsibilities for the care of the patient” is responsible for rationing ventilators, write Dr. Truog and colleagues.
The rationing criteria in the state of New York aim to “save the most lives” by prioritizing “patients for whom ventilator therapy would most likely be life saving.”
Such criteria mean that both pati