As COVID-19 spreads in the United States, some physicians and hospitals are confronting a difficult and unprecedented situation — the need to choose which patients should receive the limited supply of critical care resources, such as ventilators and intensive care unit (ICU) beds when not all patients can.
Researchers at the University of Pittsburgh School of Medicine have developed a new framework that helps hospitals ethically allocate scarce critical care resources during this pandemic. The framework is described today in the Journal of the American Medical Association (JAMA) and hundreds of hospitals nationwide have adopted these guidelines or are in the process of doing so. A model hospital policy is freely available and can be adapted by health care organizations for their specific needs.
“In a pandemic like this, public health policy focuses on doing the greatest good for as many people as possible. This dramatically changes how hospitals must prioritize critical care resources,” said Douglas White, M.D., M.S., professor in the Pitt School of Medicine’s Department of Critical Care Medicine, and director of the department’s Program on Ethics and Decision Making in Critical Illness. “Our policy offers health care organizations a new guideline that has been developed with the input of community members, ethicists and physicians, and ensures all patients are eligible for critical care if they need it,” said White, who developed the new policy and co-authored the JAMA viewpoint.
White and his colleagues at the University of California, San Francisco (UCSF) began the process of developing a new framework in 2008 and subsequently worked with collaborators at Johns Hopkins University to gain the input of diverse community groups, ethicists and disaster medicine experts.
Guidelines for allocating ventilators and ICU beds during a public health emergency were published in 2014 by the American College of Chest Physicians but contain ethically problematic provisions like excluding certain groups of people by default, like those with chronic heart failure and the very elderly. White said.
The new guidelines differ from existing professional society recommendations in two ways:
• They do not exclude any individual or groups from eligibility for critical care.
• They prioritize patients most likely to receive benefit from ventilator support, both in terms of the likelihood of surviving the hospitalization and longer-term survival. This approach is similar to rules for allocating lungs for transplantation, which incorporate patients’ likelihood of long-term survival after transplantation.
The allocation framework uses a tool that integrates multiple criteria to arrive at a score from one to eight, where lower scores indicate those who are more likely to benefit from critical care.
“No single measure adequately captures all the values we want to take into account when making such decisions, so we need to incorporate multiple criteria as we determine how to achieve the greatest benefit to the greatest number of patients,” said White.
The policy also recommends that a triage committee, not the treating physician, make decisions about allocating ventilators and ICU resources. It explicitly prohibits the allocation of ventilators on the basis of gender, race, religion, intellectual disability, insurance status, wealth, citizenship, social status or social connections.
“These recommendations ensure that we don’t put physicians who are in the middle of caring for patients in a position where they have to make morally difficult decisions about which of their patients should receive care,” said White.
The policy is designed to be adapted quickly as new information becomes available, for example if new clinical findings are published that help physicians identify patients who are very unlikely to survive. “This is designed to be a living document,” said White. Another advantage of the approach of not excluding any patients from being eligible for ICU care is that an increase in the availability of ventilators — as could be expected as manufacturers ramp up capacity — allows more patients to benefit overall.
“Although it’s critically important that hospitals have an ethical framework to make these tragic choices, the real goal is to make sure that we never need to make these decisions in the first place,” said White. “The only way to do that is by social distancing and other measures to decrease the volume of cases over a short period of time. There is no magic factory that will instantly produce more ventilators, and we should do everything in our power to slow the spread of this epidemic.”
White discussed the policy and the viewpoint in a live interview with JAMA’s editor at 1:00 p.m. ET, Friday, March 27.
Bernard Lo, M.D., of UCSF was a co-author of the JAMA viewpoint. The policy development was by National Institutes of Health grant K24HL148314.