Doctors, lawyers, and bioethicists to decide “who lives and who dies.”– Dr. Ezekiel Emanuel, oncologist and chairman of the University of Pennsylvania’s department of medical ethics and health policy
‘Who lives and who dies’: Hospitals’ tough ethics choices
SPECIAL COVERAGE |
Hospital sets up ‘triage tents’ in parking lot
Mar 24, 2020
MyEasternShoreMD – CHESTERTOWN — University of Maryland Shore Regional Health has set up a triage tent here and at its other emergency center locations in Cambridge, Easton and Queenstown to prepare for a potential surge in patient volume due to the novel coronavirus pandemic, according to a spokesperson for the health care provider.
Trena Williamson said the tent at UM Shore Medical Center at Chestertown, located adjacent to the parking lot for doctors and near Washington College, has not been used.
In an email Sunday, March 22, Williamson, regional director of communications and marketing for UM Shore Regional Health, said the tents will allow the four emergency centers “to gain additional space for patients ahead of any significant influx.”
“The goal for COVID-19 vigilance is to quickly evaluate and treat patients for fever and upper respiratory symptoms. This additional space will allow our system hospitals a greater level of capacity to care for patients during this pandemic,” Williamson said.
Hospital admissions and emergency department visits are down throughout UM Shore Regional Health, President and CEO Ken Kozel said in an email Saturday, March 21.
He attributed this largely to messaging through the media instructing patients to contact their primary care provider when they are not feeling well or have a slight temperature … Read more.
March 22, 2020
USA TODAY – It’s a scenario few health-care leaders want to contemplate much less discuss:
What if the ranks of desperately ill patients overwhelm the nation’s ability to care for them?
With respiratory illness caused by the novel coronavirus rapidly spreading, nowhere is that potential more evident than the nation’s limited supply of mechanical breathing machines called ventilators.
“The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama’s “death panel” so his bureaucrats can decide, based on a subjective judgment of their ‘level of productivity in society,’ whether they are worthy of health care. Such a system is downright evil.” – Sarah Palin, Facebook, August 7, 2009
Desperate scenes are playing out in Italy, where a spike in COVID-19 cases have overwhelmed the medical system and doctors have reported shortages of staff and equipment.
More than 4,800 people have died there, surpassing China in total deaths.
Because the worst cases of COVID-19 rob a person of their ability to breathe, patients die unless they get life-sustaining oxygen from machines.
But there are fewer than 100,000 ventilators in the United States and millions of patients struggling to breathe might need such care.
Other machines can deliver oxygen to help those with mild or moderate forms of the disease, but the most critically ill patients need powerful airway pressure that only ventilators can deliver.
Federal and state officials are urging people to follow measures to prevent the spread of the respiratory virus that causes the disease.
Both California and New York have adopted strict limits on travel and commerce and urged people to stay home and eliminate nonessential travel.
These measures aim to slow the pace of new infections and ease demands on hospitals without the intensive care unit beds, protective gear or ventilators to handle an unprecedented surge of patients.
In a worst-case scenario of ventilator shortages, physicians may have to decide “who lives and who dies,” said Dr. Ezekiel Emanuel, an oncologist and chairman of the University of Pennsylvania’s department of medical ethics and health policy.
“It’s horrible,” Emanuel said. “It’s the worst thing you can have to do.”
‘First come, first served doesn’t hold true’
Government public health experts have planned for a scenario in which there are too many patients and too few ventilators.
In a July 2011 report completed by a U.S. Centers for Disease Control and Prevention ethics subcommittee, planners said the “principle of sickest first” for critical care might no longer apply during a severe pandemic because it “may lead to resources being used by patients who ultimately are too sick to survive … ” Read more.
COVID-19 Triage: Who Lives, Who Dies, Who Decides?
When push comes to shove, special committees could take emotional burden off individual clinicians
March 23, 2020
MedPage Today – Triage committees deciding which patients get ventilators in a potential ventilator shortage during the COVID-19 coronavirus outbreak in the U.S. may serve as a valuable buffer to protect individual clinicians from emotional damage from making the decision themselves, experts argued.
Committees made up of experts with no clinical responsibilities for patient care can ensure these decisions are based on which patients are most likely to benefit, and may help to spare clinicians from crippling emotional distress, argued Robert Truog, MD, of Harvard Medical School in Boston, and colleagues.
Writing Monday in a Perspective article in the New England Journal of Medicine, the authors cited states like New York, which has developed rationing guidelines, defined as “saving the most lives, as defined by a patient’s short-term likelihood of surviving the acute medical episode.”
Mechanical ventilation is the most “problematic” of medical care to be rationed, they said, noting projections that the U.S. supply of ventilators could fall short of demand by a factor of 10 to 100.
The authors pointed to data from Italy, where 10% to 25% of hospitalized COVID-19 patients required ventilation. Among 21 critically ill hospitalized patients with COVID-19 in Washington state, 15 had mechanical ventilation initiated, with acute respiratory distress syndrome observed in all 15.
To cope with such demands in areas experiencing large numbers of severe COVID-19 cases, Truog and colleagues recommended appointing triage officers or committees, who would perform triage in three steps:
With these repeat assessments, the authors noted, “patients whose condition is not improving are removed from the ventilator to make it available for another patient.”
A triage committee not only can adjust its criteria based on an increase or decrease in the supply of ventilators, but the committee’s existence “removes the weight of these choices from any one individual, spreading the burden among all members of the committee.” Committee members would also be encouraged to tell the family of these decisions, Truog and colleagues said.
“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,” they wrote … Read more.
Family speaks out while man fights COVID-19 in ICU; wife sick in quarantine
PONCA CITY, Okla. (KFOR) – Geoffrey Cowan is fighting for his life in an Oklahoma ICU after testing positive for COVID-19.
His wife is also sick at home, as she sits in isolation.
The couple’s daughter spoke to News 4, hoping to get the word out about how this virus is threatening her entire family.
“We have a group text, and every time I type something, I am like, ‘Oh, I wonder what dad is going to say,'” Christy Yousefi said. “Then I realized, ‘Oh, he can’t respond.'”
Christy Yousefi’s dad is now at the mercy of COVID-19.
The 69-year-old is breathing through a ventilator in the ICU at AllianceHealth Hospital in Ponca City.
“People think this is a two or three day thing, and it’s not,” Yousefi said.
It’s day 19 for Geoffrey and his sick 64-year-old wife, Steffi.
She is at home in quarantine, facing a fever and cough, but Steffi hasn’t been tested for coronavirus yet.
Doctors told her to stay home in isolation, and if she gets worse, to come to the emergency room.
The two have been sick for about three weeks.
“All of us are heartbroken and we can’t be near our mom,” Yousefi said. “She’s crying and lonely and we can’t do anything.”
Christy is only able to wave to her mom through a window, and she has only been able to see her dad once. Read more.