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Ventilator Rationing During Covid-19 Pandemic
1.
Perspective The NEW ENGLAND
JOURNAL of MEDICINE n engl j med nejm.org 1 T he Covid-19 pandemic has led to severe shortages of many essential goods and ser- vices, from hand sanitizers and N-95 masks to ICU beds and ventilators. Although rationing is not unprecedented, never before has the American public been faced with the prospect of having to ration medical goods and ser- vices on this scale. Of all the medical care that will have to be rationed, the most problematic will be mechanical ventilation. Several countries, but not the United States, have already experienced a shortage of venti- lators. Acute care hospitals in the United States currently have about 62,000 full-function ventilators and about 98,000 basic ventilators, with an additional 8900 in the Centers for Disease Control and Prevention (CDC) Strategic Nation- al Stockpile.1 The CDC estimates that 2.4 million to 21 million Americans will require hospital- ization during the pandemic, and the experience in Italy has been that about 10 to 25% of hospital- ized patients will require ventila- tion, in some cases for several weeks.2 On the basis of these es- timates, the number of patients needing ventilation could range between 1.4 and 31 patients per ventilator. Whether it will be nec- essary to ration ventilators will de- pend on the pace of the pandemic and how many patients need ven- tilation at the same time, but many analysts warn that the risk is high.3 Although shortages of other goods and services may lead to deaths, in most cases it will be the combined effects of a variety of shortages that will result in worse outcomes. Mechanical ven- tilation is different. When patients’ breathing deteriorates to the point that they need a ventilator, there is typically only a limited window during which they can be saved. And when the machine is with- drawn from patients who are ful- ly ventilator-dependent, they will usually die within minutes. Un- like decisions regarding other forms of life-sustaining treatment, the decision about initiating or terminating mechanical ventila- tion is often truly a life-or-death choice. Many states have developed strategies for rationing during pandemics. The New York Guide- lines target saving the most lives, as defined by the patient’s short- term likelihood of surviving the acute medical episode.4 Rationing is performed by a triage officer or a triage committee composed of people who have no clinical re- sponsibilities for the care of the patient. Triage proceeds in three steps: application of exclusion cri- teria, such as irreversible shock; assessment of mortality risk us- ing the Sequential Organ Failure Assessment (SOFA) score, to de- termine priority for initiating ven- tilation; and repeat assessments over time, such that patients The Toughest Triage — Allocating Ventilators in a Pandemic Robert D. Truog, M.D., Christine Mitchell, R.N., and George Q. Daley, M.D., Ph.D. Allocating Ventilators in a Pandemic The New England Journal of Medicine Downloaded from nejm.org at San Raffaele del Monte Tabor - Milano on March 24, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved.
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PERSPECTIVE 2 Allocating Ventilators in
a Pandemic n engl j med nejm.org whose condition is not improving are removed from the ventilator to make it available for another patient. Anticipating the need to allo- cate ventilators to the patients who are most likely to benefit, clini- cians should proactively engage in discussions with patients and fam- ilies regarding do-not-intubate or- ders for high-risk subgroups of patients before their health dete- riorates. Once patients have al- ready been placed on mechanical ventilation, decisions to withdraw it are especially fraught. Less than 50 years ago, physicians argued that withdrawing a ventilator was an act of killing, prohibited by both law and ethics. Today, with- drawal of ventilatory support is the most common proximate cause of death in ICU patients, and with- drawal of this support at the re- quest of a patient or surrogate is considered an ethical and legal obligation. Withdrawal of a ven- tilator against the wishes of the patient or surrogate, however, is primarily done only in states and hospitals that permit physicians to unilaterally withdraw life sup- port when treatment is determined to be futile. Decisions to withdraw ventila- tors during a pandemic in order to make the resource available to another patient cannot be justi- fied in either of these ways: it is not being done at the request of the patient or surrogate, nor can it be claimed that the treatment is futile. Even though the chances of survival may be low, in the ab- sence of the pandemic the treat- ment would be continued. Where- as this type of rationing may not be unusual in countries that tragi- cally have a chronic shortage of essential ICU care, it is unprece- dented for most physicians who practice in well-resourced coun- tries. Reports from Italy describe physicians “weeping in the hospi- tal hallways because of the choices they were going to have to make.”5 The angst that clinicians may experience when asked to with- draw ventilators for reasons not related to the welfare of their pa- tients should not be underestimat- ed — it may lead to debilitating and disabling distress for some clinicians. One strategy for avoid- ing this tragic outcome is to use a triage committee to buffer cli- nicians from this potential harm. We believe that such a committee should be composed of volunteers who are respected clinicians and leaders among their peers and the medical community. Advantages of this approach are that it allows the physicians and nurses caring for the patients to maintain their traditional roles as fiduciary advocates, including the opportunity to appeal the initial decision of the committee when appropriate. While working to- gether to ensure consistent and unbiased decisions across patient groups, the committee also has the flexibility to consider factors that may be unique to a given sit- uation. As circumstances change and the availability of ventilators increases or decreases, the com- mittee can adjust its rationing cri- teria to produce the best outcomes. Finally, when 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 indi- vidual, spreading the burden among all members of the com- mittee, whose broader responsi- bility is to save the most lives. In addition to removing the responsibility for triage decisions from the bedside clinicians, com- mittee members should also take on the task of communicating the decision to the family. The treating clinicians may be moti- vated to try to comfort the family by telling them that mechanical ventilation is not being provided because it would be futile and by reassuring them that everything possible has been done. Though well intentioned, such inaccurate representations could ultimately undermine public trust and con- fidence. Having the committee members communicate these deci- sions would ensure that the mes- sage is clear and accurate, helping to prevent confusion or misunder- standings. Similarly, the physicians, nurs- es, or respiratory therapists who are caring for the patient should not be required to carry out the process of withdrawing mechan- ical ventilation; they should be supported by a team that is will- ing to serve in this role and that has skills and expertise in pallia- tive care and emotional support of patients and families. Pain and suffering at the end of life can be controlled, and these patients de- serve the best that palliative care can provide. In the weeks ahead, physicians in the United States may be asked to make decisions that they have never before had to face, and for which many of them will not be prepared. Though some people may denounce triage committees as “death panels,” in fact they would be just the opposite — their goal would be to save the most lives possible in a time of unprec- edented crisis. Creation and use of triage committees, informed by experience in the current pan- demic2 and prior written recom- mendations,4 can help mitigate The New England Journal of Medicine Downloaded from nejm.org at San Raffaele del Monte Tabor - Milano on March 24, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved.
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PERSPECTIVE 3 Allocating Ventilators in
a Pandemic n engl j med nejm.org the enormous emotional, spiritual, and existential burden to which caregivers may be exposed. Disclosure forms provided by the au- thors are available at NEJM.org. From the Center for Bioethics (R.D.T., C.M.), the Department of Global Health and Social Medicine (R.D.T., C.M.), the Of- fice of the Dean of the Faculty of Medicine (G.Q.D.), Harvard Medical School, and the Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital (R.D.T.) — both in Boston. This article was published on March 23, 2020, at NEJM.org. 1. Ventilator stockpiling and availability in the US. Baltimore:Johns Hopkins Bloom- berg School of Public Health, Center for Health Security, February 14, 2020 (http:// www.centerforhealthsecurity.org/resources/ COVID-19/200214-VentilatorAvailability -factsheet.pdf). 2. Società Italiana di Anestesia Analgesia Rianimazione e Terapia Intensiva (SIAARTI). Raccomandazioni di etica clinica per l’ammissione a trattamenti e per la loro so- spensione, in condozioni eccezionali di squilibrio tra necessità e risorse disponibi- li. March 6, 2020 (http://www.siaarti.it/ SiteAssets/News/COVID19%20-%20 documenti%20SIAARTI/SIAARTI%20-%20 Covid19%20-%20Raccomandazioni%20 di%20etica%20clinica.pdf). 3. Kliff S, Satariano A, Silver-Greenberg J, Kulish N. There aren’t enough ventilators to cope with the coronavirus. New York Times. March 18, 2020 (https://www.nytimes.com/ 2020/03/18/business/coronavirus-ventilator -shortage.html). 4. Ventilator allocation guidelines. Albany: New York State Task Force on Life and the Law, New York State Department of Health, November 2015 (https://www.health.ny.gov/ regulations/task_force/reports_publications/ docs/ventilator_guidelines.pdf). 5. Ferraresi M. A coronavirus cautionary tale from Italy:don’t do what we did. Boston Globe. March 13, 2020 (https://www.boston- globe.com/2020/03/13/opinion/coronavirus -cautionary-tale-italy-dont-do-what-we-did/). DOI: 10.1056/NEJMp2005689 Copyright © 2020 Massachusetts Medical Society.Allocating Ventilators in a Pandemic The New England Journal of Medicine Downloaded from nejm.org at San Raffaele del Monte Tabor - Milano on March 24, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved.
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