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Who Lives And Who Dies If Hospitals Run Out Of Ventilators? And Who Decides? NY State Report Offers Clues
By
Gwynne Hogan
and
Fred Mogul
Published Apr 2, 2020
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Lorraine Carita / Gothamist
By
Gwynne Hogan
and
Fred Mogul
Published Apr 2, 2020
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With an ever-increasing number of critically ill COVID-19 patients, Governor Andrew Cuomo and Mayor Bill de Blasio have repeatedly refused to lay out plans for decision-making if New York runs out of ventilators.
But for many hospitals and doctors, it’s not a question of “if” but “when.” They are already consulting a 2015 document created by a state task force for precisely this situation, and waiting for the state to signal that its guidelines are in effect.
As of Wednesday, more than 12,000 people statewide were in hospitals with the virus, and 3,000 of them were in intensive care units, which often means they are on ventilators. Ventilators are also used for other types of serious respiratory illness.
In New York City, there were 2,213 people in ICU beds, including COVID and non-COVID patients, according to the state health department. There were only 352 ICU beds left in New York City as of Wednesday afternoon, according to the state.
“There’s no protocol” for when hospitals run out of ventilators, Cuomo said at a press conference Tuesday**.** De Blasio was asked about it on Wednesday.
"Honestly, I think talking about these horrible choices and contingencies just distracts from the mission, which is to protect every life and save every life we can," he said.
But for some health-care professionals, that moment is coming up fast.
A memo obtained by the Wall Street Journal to doctors at NYU Langone hospital urged them to be more critical of who gets a ventilator and to "withhold futile intubations." The Washington Post reported doctors at other hospitals had been allowed informally override a patient's desire for life saving intervention.
Listen to Gwynne Hogan & Fred Mogul's radio story for WNYC:
A nurse at a Manhattan hospital said she recently discussed end-of-life care for a COVID patient who also has cancer. WNYC is withholding the nurse’s name at her request because she did not have permission to speak from her employer.
“[My patient] opted to be on a ventilator. I relayed this to the ICU team, and they said we might have to override that,” she said. “As terrible as it sounds, if I had a loved one who was 40 and not very ill, I would prefer that he got the ventilator over someone who is 60 or 70 and has a 99 percent chance of never being weaned off the machine. It becomes a little utilitarian.”
At Maimonides Hospital
Lorraine Carita / Gothamist
Dr. John Marshall, the chief of emergency medicine at Maimonides Hospital in Brooklyn, said the pace of the coronavirus outbreak is forcing everybody’s hand.
“Any organization that has not thought through the possibility of running out of ventilators is not being responsible both to their staff members or to their patient populations,” he said. “We’re thinking about how to maximize the benefits to our patients while also minimizing the trauma to our staff, none of whom want to have to do this.”
In 2015, a state task force released a 266-page document, the result of nearly a decade of deliberations, with public input weighed by medical, ethical, and legal experts. It offers a step-by-step guide for how to allocate ventilators when they run out. It uses a flu pandemic as its worst-case scenario.
The main criterion for decision-making is to maximize the number of lives saved.
“Prioritizing individuals based on their chances of survival during an emergency is the most equitable, as it does not consider non-clinical factors, such as race, ethnicity, sexual orientation, socio-economic status, education, religion, or quality of life,” the report reads. “The most effective use of scarce resources is to allocate them to patients who have the highest likelihood of survival with the use of the scarce resource.”
The report lays out a three-step process where a designated hospital triage officer or committee evaluates each patient based on their likelihood of survival, developing a score for six organ systems: lungs, liver, brain, kidney, blood clotting, and blood pressure. The choice is largely taken away from attending doctors so they don’t have to decide between patients.
If you’re relatively healthy with a very low score, you are unlikely to need a ventilator in the first place. If you have a very high score and a very low likelihood of surviving, you don’t get one. People in the middle are approved for ventilators. If there aren’t enough ventilators for all those people, then they’re assigned by lottery.
Old age is explicitly not a factor in the criteria, said Susie Han, who was the Deputy Director of the task force and helped write the guidelines.
“How do you say a 79-year-old versus an 80-year-old, where do you draw that line? You can’t use age as a hard number,” Han said. “But this is how age indirectly works — age just by nature is going to affect your organ systems.”
New York City requested 15,000 ventilators; this is one of 400 that arrived on March 24, 2020.
Scott Lynch / Gothamist
The guidelines say if all the clinical evaluations are equal, doctors are allowed a “tie-breaker” to give priority to children under the age of 18.
All of the allocations are re-evaluated at different time intervals to see if a patient’s condition is improving or getting worse. At any one of those points, a ventilator could be reallocated to someone else who has a greater chance of survival.
“Any plan is still better than no plan,” said Han. “Is what we have perfect? No, but it’s a good starting point.”
Doctors and nurses on the ground say the state needs to authorize use of the guidelines soon.
“Currently we are doing everything for every patient, but at some point, we’re going to run out of this equipment,” said Dr. Michael Redlener, an emergency room doctor at Mount Sinai. “Thankfully, we’re not there yet to think about these things. Those who work on the front lines will be thankful when there's specific guidance.”
Others are still holding out hope New York might somehow acquire enough ventilators from across the globe to avoid having to choose who gets one.
“We are making life and death decisions over the phone, talking to families,” said Dr. Hugh Cassiere, the director for respiratory therapy services at North Shore University Hospital. ”It’s just heart-wrenching. But we haven't been put in the situation where I have a 20-year-old who needs a vent and I have a patient who’s dying who needs a vent. That has not occurred yet, and I’m praying that it doesn’t.”
Tagged
COVID-19
bioethics
coronavirus
hospital
Gwynne Hogan
Gwynne Hogan is a former Gothamist reporter.
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Fred Mogul
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Gothamist is funded by sponsors and member donations
Gothamist is funded by sponsors and member donations
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