aamc.org does not support this web browser.
  • AAMCNews

    A nightmare approaches: Hospitals painfully prepare for life and death decisions

    As COVID-19 spreads, ethicists at academic medical institutions are updating guidance around the allocation of scarce medical resources in the event they have to ration care.

    A patient receives oxygen in the hospital

    If a patient suffering from COVID-19 is deteriorating, should doctors remove their ventilator and give it to someone with a better chance of survival?

    If a physician can secure enough blood for only one of two people stricken by the disease, should she favor a mother of toddlers over a childless homeless man? A teenager over an octogenarian?

    Does the doctor who is caring for the patient have to make the decision?

    These are among the nightmare dilemmas that front-line doctors and administrators at hospitals around the nation are contemplating as the spread of COVID-19 threatens to outstrip their resources.

    “We’ve been hearing incredible distress from physicians and hospital presidents,” says Douglas White, MD, director of the Program on Ethics and Decision Making in Critical Illness at the University of Pittsburgh School of Medicine (UPSOM). Their bottom-line question: “What on Earth are we supposed to do here?”

    To provide the answers, bioethicists in academic medicine are guiding hospitals and other institutions to develop policies and procedures that are ethical and practical. Although they vary in detail, the policies being developed build on shared foundational, written guidelines and prioritize several similar principles, including:

    • Save the most lives, even at the expense of some.
    • Treat all patients equally, rather than valuing one life over another.
    • Base decisions on clinical data.
    • Assign the decisions to someone other than the caregivers.

    A pilot test being run by UCHealth, affiliated with the University of Colorado School of Medicine, shows a typical way that medical institutions plan to carry out those principles.

    “We’ve been hearing incredible distress from physicians and hospital presidents.”

    Douglas White, MD
    University of Pittsburgh School of Medicine

    Matthew Wynia, MD, director of the university’s Center for Bioethics and Humanities, says that each day, triage teams there get sequential organ failure assessment (SOFA) scores about every inpatient. The higher the score is on a scale of 1 to 8, the less likely the person will benefit from critical care. If a lack of resources requires the hospital to deny critical care to someone, the team will base its decision on that score.

    It’s a distressing but necessary plan, Wynia says.

    “Let’s say you have five patients for every one ventilator,” he says. “That’s an incredibly tragic and difficult, Sophie’s Choice-type of decision.

    “You have to decide. You can’t put that off.”

    A new ethical challenge

    The “fast and furious” planning, as Wynia puts it, seeks to avoid what happened in Italy, where news reports said some physicians were left to decide when to withdraw care for their own patients in order to shift resources to others. A medical society eventually issued guidelines that prioritized steering limited resources to those with the highest chances to survive.

    Although institutions and government agencies in the United States have long had guidelines for working through disasters such as hurricanes and viral outbreaks, ethicists say that COVID-19 has required those guidelines be revised.

    “This is a new ethical challenge,” says Arthur Derse, an emergency physician and director of the Center for Bioethics and Medical Humanities at the Medical College of Wisconsin.

    Among the reasons, he says, is that the coronavirus is not contained to a region (unlike a hurricane), and its fast and highly fatal spread could exhaust resources nationwide with few opportunities to replenish in time. Hospital leaders tell Derse they envision this scenario: “Patients are dependent on this life-sustaining medical treatment but they’re deteriorating or not improving significantly, and others need these resources. Should the patients who are unlikely to survive have that treatment discontinued?

    “That, we’ve never faced before.”

    Health care systems are using or amending existing guidelines, like those from UPSOM (which have been adopted by the UPSOM-affiliated hospitals, among others) and government agencies (such as the state of Washington), and conferring with each other. They hope to achieve basic uniformity, so that patients don’t feel they will be treated differently at one hospital than at another. 

    While the plans will differ in operational details, some principles are common among them:

    Save the most lives

    “The first thing to make clear when there is a public health emergency,” White says, “is that the goal shifts from an unwavering focus on the well-being of individual patients to focus on doing the greatest good for the greatest number.”

    Scarce resources would go to victims who are most likely to survive because of the treatment. A patient whose prognosis is poor might not get a ventilator, because all ventilators are being used by patients whose prognoses with treatment are better. Also, a ventilator might be removed from one patient whose prognosis is poor and given to another who has better chances of survival.

    “This is a complete reversal” of priorities for health care providers, Derse says, because their mission is to provide the best care possible for each patient in accordance with the wishes of the patient or family. “Our normal professional obligations to one patient are, in this pandemic, superseded by our obligations to everyone. That is the biggest hurdle for physicians.”

    “Let’s say you have five patients for every one ventilator. That’s an incredibly tragic and difficult, Sophie’s Choice-type of decision.”

    Matthew Wynia, MD
    University of Colorado Anschutz Medical Campus

    Treat patients equally

    The criteria about who gets resources should not consider factors such as the patients’ social status, wealth, citizenship status, or perceived value of their lives. Last month, the Office of Civil Rights within the Department of Health and Human Services issued a bulletin reminding institutions that they cannot make COVID-19 treatment decisions based on “judgments about a person’s relative ‘worth’” because of a disability.

    In addition, Derse says, the public must know about the standards for them to trust health care systems.

    “People need to know that everyone, no matter what their stature — the mayor or an unemployed person — is being treated the same way,” he says. “Social worth, status, [and] privilege are not factors. If people know they [the standards] are being applied fairly to everybody, they’re more willing to accept that.”

    That’s why the triage team at UCHealth in Colorado would make its decisions without visiting the patients or getting information beyond specific medical conditions, Wynia says. “You walk into someone’s room, you see race, you see a child, or a minister,” he says. “Those are nonclinical factors that should not come into play.”

    Nevertheless, nonclinical factors might come into play when the conditions of patients are equal, forcing decision-makers to rely on other information to break the tie. One tiebreaker, Wynia says, could be the “multiplier effect” — when saving the life of one person might save other lives, because the person is a health care provider or an emergency responder. And although ethicists say policies should not favor parents over nonparents, Wynia can envision a triage team allocating scarce medical care to a single parent because “if you lose that parent, it will harm the children.”

    Perhaps the most complicated element is age. While ethicists say resources should not be withheld based on age alone, age often correlates with other factors. Wynia notes that older people are more likely to have comorbidities and weaker immune systems, which would affect their survivability and the length of their lives after treatment. Derse notes that some groups have proposed that, when other factors are equal, “younger patients who haven’t experienced as much life should have some priority over older patients. That is a controversial position.”

    The guidance that White created at UPSOM takes that position for tiebreakers, saying that “younger individuals receive priority because they have had the least opportunity to live through life’s stages.”

    “People need to know that everyone, no matter what their stature – the mayor or an unemployed person – is being treated the same way.”

    Arthur Derse, MD
    Medical College of Wisconsin

    Shield care providers from resource decisions

    Forcing doctors to ration scarce resources among needy patients “would put them in the impossible position of trying to advocate what is the best thing for the patient and the best for society,” White says. His plan says the triage teams promote objectivity in decision-making, avoid conflicts of commitments that clinicians might have for some patients and not others, and “minimize moral distress” among caregivers.

    To achieve those objectives, here is how the teams would plan to operate at UCHealth, according to Wynia:

    • Each team is composed of three to five people, including leadership (such as a chief medical officer or someone representing them), staff with specific expertise (such as respiratory care), and perhaps people from different perspectives (such as ethicists and patient advocates).
    • Several teams would rotate around the clock so that one is always available.
    • When called upon to decide about a particular patient, team members will get the patient’s SOFA score and critical clinical information, but they will not receive any identifiable information, such as age and gender, unless such information is later needed for tiebreakers.
    • The teams can confer electronically or in person, and it may take hours to make decisions.

    Christine Mitchell, executive director at the Center for Bioethics at Harvard Medical School, says that if a triage team decides to withdraw medical support from a patient, that withdrawal may be carried out by medical professionals other than the clinicians who have been caring for that patient, although the caregivers might want to be present to medicate and comfort the patient.

    That way, Mitchell says, “the health care provider who is best known to the patient or family can support the patient and family and doesn’t have to be involved in the very sad and often tragic process of withdrawing life support,” Mitchell says.

    While Mitchell says the triage team should communicate a denial or withdrawal of care decision to the family, the guidelines from White at UPSOM say the patient’s caregiver should have the option of delivering the message. 

    Mitchell adds that the establishment of the teams and the clear standards for their decisions also benefits patients and their families, because people need to know that the choices were made based on clinical factors rather than personal preferences.

    Providers hope they don’t have to activate these processes. The prospects look frightening, but might not come to pass in some parts of the country. Where they do, hospital leaders hope that putting procedures in place now will help allay some of the stress for health workers and the public.

    “Physicians should be alarmed by the call on resources that will be needed and the difficult choices that lie ahead if we don’t act as forcefully as we can,” Derse says.

    “The people in the health professions are doing everything they can to avoid reaching this point. … I hope and pray we do not.”