Rationing health care and advanced directives — do not intubate

Despite what Americans like to believe, there has always been rationing of health care. In our country, most of the rationing that patients experience has to do with one’s ability to pay rather than a lack of equipment or professionals. But even before this crisis, there have always been common procedures where there is a temporary shortage for one reason or another and thus those types of decisions that must be made. The most obvious example is with organ transplants. Not everyone who needs a transplant gets a transplant. In order to address this shortage, we have tried to encourage people to become organ donors. But even then, there isn’t always enough. So, we ration the organs based on a few factors including a match between donor and recipient, distance from donor hospital, pediatric status, medical urgency, etc.

With this current pandemic crisis, we have already faced rationing of tests; with most states prioritizing tests for those who are severely ill or health care providers. We anticipate needing to ration hospital beds — and more severely — ICU beds and ventilators. Decisions will need to be made. These can be made based on likelihood of survival, age, or other factors (such as wealth).

I don’t have an easy answer to this very difficult decision. Geography will be, unfortunately, the first point of triage. Someone in a better equipped area without as great a current need will have a greater likelihood of being able to receive full treatment than someone in an area that is stretched well beyond capacity.

Wealth and status oughtn’t be a point of triage. I would argue it is unethical for it to be one. That said, I am concerned that fear of litigation and/ or fear of bad press will put pressure on decision makers to more aggressively treat those of means than the rest of us.

First come, first served is one way to make such a determination of who gets scarce medical resources. But that is not how triage typically works, especially when there are many waiting. Even under normal circumstances in a busy emergency department, people aren’t taken in order that they arrive. Urgency of treatment is a key determinant in those situations. For COVID-19, age is the easiest way to make a decision; but one can be older with better underlying health (and thus a better chance of recovery) than someone who is younger. A better way to make the determination would be to examine a patient’s health history and likelihood of recovery. That said, it is possible that providers will be stretched too thin to be able to do this in a timely manner — especially if the shortage of ventilators is severe.

I should note that there are some attempts at trying to mitigate the shortage of ventilators, either from a hitherto untested method of adding tubing to allow for multiple patients to be on one ventilator as well as having companies that don’t make ventilators make them now in this moment of crisis. The former is untested and the latter, at least in the US, is being done by eliminating any liability from the part of the manufacturer. So while there might be more ventilator capacity on paper; we do not yet know if there will be more quality ventilator capacity. If the new or jerry rigged ventilators are faulty, then the rationing is based on luck more than anything else. That is, does one get the tested ventilator made by experts or the one that might not work as planned?

I do think we, as individuals and potential patients, can do something here….

I don’t want to get sick — and I hope I don’t. But I know that I also don’t want to die alone. Unfortunately, everyone who goes into the hospital with this condition must go alone (for the safety of the providers, other patients, and to preserve the number of personal protective equipment and not give those to loved ones of the ill). I have made it known to my loved ones that if I get sick enough to require intubation; I would rather be sent home. And yes, I know that there is a chance that the ventilator would save a life — otherwise we wouldn’t be concerned about the shortages. Nevertheless, save that ventilator for someone else, someone more brave than I.

While I am not encouraging others to create advanced directives to save ventilator capacity, I do encourage everyone to think about their wishes now to avoid putting medical professionals and/or loved ones in the position of making that decision for us. Pandemic or not, it is best to have these kinds of conversations before any such decision has to actually be made. I would recommend checking out The Conversation Project for some useful tools in this regard.

Let it be clear, the fact that we are having this discussion at all is problematic. Had we been better prepared, the discussion over who should and shouldn’t get treated might have been avoided. And if not avoided, at least the severity could have been minimized. We are not just facing a severe shortage in regard to ventilators — and more recently the drugs needed to intubate patients. There is rationing of non-urgent surgery, rationing of personal protective equipment (which is another problem altogether), rationing of testing for COVID-19. While some patients in the US have long experienced a shortage of care due to lack of adequate insurance or lack of doctors in rural areas; we have not witnessed this kind of large scale shortage with the exceptions of shortages in localized or regional crises such as an earthquake or hurricane. We need to make sure that we plan for urgent national crises while doing all we can do to prevent them from occurring. And in the meantime, let us do what we can do as individuals and make our health decisions known to our loved ones while we are still healthy.

Photo by Frederick Tubiermont on Unsplash

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