Bracing for a surge of Covid-19 patients and facing shortages of the resources necessary to keep the sickest patients alive, hospitals and governments are grappling with the reality of having to answer an unimaginable question: If ventilators and intensive care unit beds must be rationed, who should get them?
Several states have already issued guidance recommending that hospitals exclude certain patient groups from such care, such as those with late-stage cancer or Alzheimer’s disease — and in doing so, sparked a storm of criticism, as well as federal civil rights investigations. Professional societies and academic bioethicists are also putting forward alternative ethical guidelines. One, in particular, is gaining traction.
That framework, developed by bioethicists at the University of Pittsburgh Medical Center, argues that no patient groups should be automatically denied access to scare ventilators and ICU beds. Rather, the guidance suggests, medical resources should be allocated to patients according to how they score on an eight-point scale that takes into account their odds of making it out of the hospital, as well as whether they have certain life-limiting medical conditions.
“It is a serious ethical concern for any framework to send a message that there are some lives that are not worth saving. And we think exclusion criteria send that wrong message. So the approach we have taken is that everyone who is normally eligible for intensive care remains eligible,” said Douglas White, a UPMC critical care physician who led the team that developed the framework.
Several hundred hospitals are adopting or considering putting UPMC’s guidelines in place as their policy, including Yale, Pennsylvania State University, and Kaiser Permanente. The state of Pennsylvania is expected to soon endorse the framework for its 300-some hospitals, though a spokesperson for the state’s health department noted that the state has not yet issued final guidance. And several other states are considering following suit, White said.
The UPMC approach stands in contrast to more restrictive guidelines that have been proposed. Alabama’s plan for the emergency period recommends that hospitals withhold ventilators from people with metastatic cancer; it also says that people with “severe or profound mental retardation” or “moderate to severe dementia” ought to be considered “unlikely candidates for ventilator support.” Washington state’s guidance advises that hospitals consider whether a patient has severe congestive heart failure or severe liver disease when deciding whether to transfer them to receive palliative support instead of intensive care. Michigan’s Henry Ford Health System faced criticism after a letter from the hospital about its plan for rationing in a “worst case scenario” was shared on Twitter. The letter said in the event of dire shortages, patients with terminal cancers, severe trauma, or severe heart, lung, kidney, or liver failure would likely not be eligible for ICU care or a ventilator.
The UPMC priority score is measured on a scale from 1 to 8, with lower scores meaning that a patient gets higher prioritization to receive intensive care.
The first four points are allocated based on how likely it is that a hospitalized patient will die before going home. One way of assessing that is with the patient’s SOFA score — short for sequential organ failure assessment, which is calculated based on factors like how much oxygen a patient is taking in, their blood platelet count, and several measures of their body’s waste output.
The next four points are allocated based on whether patients have certain conditions that tend to decrease the odds of long-term survival, sometimes even beyond one year. The UPMC framework names a few such medical conditions, though it’s not meant to be an exhaustive or definitive list. Among them: Alzheimer’s disease, late-stage heart failure, and, in patients over age 75, end-stage renal disease.
The framework calls for a triage committee of non-frontline physicians at each hospital to assess the scores and make decisions about allocating resources. That’s designed to avoid the conflicts that could arise if bedside physicians were asked to decide for their own patients. If there’s a tie and a rationing decision must be made, the framework prioritizes younger people and frontline health care workers. All frontline workers are treated equally under the guidelines, whether they be a physician, a nurse, a respiratory therapist, or a member of the maintenance staff that disinfects hospital rooms.
“It’s a simple matter of fairness,” White said.
While some bioethicists have called for prioritizing parents with young children who rely on them, the UPMC framework steers clear of considering any such factors.
“You can be young, and not have children, as many people are, and view their life to be filled with equal meaning to that of parents,” White said.
“This is a framework that is grounded in medical principles of survival, with no judgment of whether one’s broad social worth, with no inclusion of consideration of individuals’ perceived social worth,” White said. “Our framework treats as equal a homeless person and a hospital president.”
White and his team originally started work on the framework in 2008, after the avian flu and SARS outbreaks of the mid-2000s sounded the alarm about the potential for a devastating respiratory pandemic that could lead to shortages of ventilators or other supplies. When White and his team looked at existing guidelines and state laws concerning allocation of scarce resources, they found that many of them had blanket exclusions for certain patient groups — a feature they felt was “unjust and probably illegal,” White said.
So they set to work on a new approach. They proposed an initial version of the framework in 2009 and, over the next few years, vetted it with the help of community members, ethicists, and disaster medicine experts.
But around 2015, with the prospect of a respiratory pandemic far from center stage, the intensity of the effort diminished and the work went quiet.
That changed at the start of this year, as the novel coronavirus emerged in China and then forced painful rationing decisions in Italy.
“Sixteen hours a day for the last two weeks,” White said, “I’ve been on the phone with hospitals and health systems and state representatives to help them think through how to allocate scarce resources ethically.”