Who gets a ventilator in the COVID-19 crisis?
TORONTO -- Imagine a scenario where there are two patients with COVID-19 who are having difficulty breathing. They’re both in desperate need of a ventilator to help them breathe, but the hospital only has one machine available.
One of the patients is a 12-year-old child, while the other one is a 74-year-old doctor.
While some might assume the machine should be given to the younger patient, health-care professionals say it’s not that simple.
Timothy Christie, a medical ethicist and the regional director of ethics services for Horizon Health Network in New Brunswick, presented this theoretical scenario to demonstrate some of the fraught ethical dilemmas Canadian health-care systems could be faced with should the COVID-19 pandemic overwhelm hospitals.
“We might be in a situation where we might not have the resources to save someone that we would normally be able to save if we weren’t in a pandemic situation,” he told CTVNews.ca during a telephone interview from New Brunswick on Friday.
Although this hasn’t happened yet in Canada, Christie is sharing these hypothetical scenarios with the Horizon Health Network’s ethics board to explain the potential magnitude of such a problem and to stress the need for health authorities to prepare for it.
Christie cited hard-it areas such as Italy and New York City as examples of places where the sudden outbreak of COVID-19 overwhelmed hospitals and forced frontline workers to ration life-saving resources.
“They’re just hit with a tsunami all at once,” he said. “They’re making things up as they go, and they're doing the best they can on the front lines.”
According to a recent study in the New England Journal of Medicine, there have been reports out of Italy describing physicians “weeping in the hospital hallways because of the choices they were going to have to make.”
In Canada, provincial governments have been reassuring people they have enough ventilators and intensive care unit (ICU) beds to respond to the current crisis and they’re in the process of ordering more should the demand require it.
However, according to a preliminary study from the University of Toronto, University Health Network and Sunnybrook Hospital, Ontario could encounter a shortage of ventilators and beds by the end of April.
Even in a best-case scenario, which includes the province adding more than 2,000 beds and 600 ventilators, the models suggest Ontario’s health-care system would still face a shortage in two months.
The shortage of equipment in Ontario could come even sooner, according to Dionne Aleman, an associate professor of industrial engineering at the University of Toronto who develops models to predict the spread of a virus in a pandemic.
She said that based on the current trajectory of infections and published numbers of ICU and ventilator usage by COVID-19 patients in Ontario, the province could face a shortage in as little as two weeks if nothing else changes.
“The latest numbers I have seen are that 25 per cent of ventilators are now used by COVID-19 patients, and around 20 per cent of COVID-19 patients end up requiring this advanced care, which is very concerning,” she said in an email to CTVNews.ca on Tuesday.
Aleman said the infection rates and equipment usage rates aren’t exact, however, because only patients with moderate to severe illness are tested in the first place.
Ontario’s numbers may not be good news for the rest of the country, either, because the province has a slightly higher number of ventilators in proportion to its population than the national average, Aleman said.
Aleman said the hope is that Canadians will be able to flatten the curve through self-isolation and physical distancing so that hospitals aren’t overwhelmed all at once and there is enough equipment for everyone.
Dr. David Migneault, an emergency medicine specialist and bioethicist at Vancouver Coastal Health, said he’s cautiously optimistic that some of Canada’s early actions will have an effect on the course of the pandemic.
“I'm not ready to celebrate, but I think that we will have an effect of the curve,” he told CTVNews.ca during a telephone interview from Vancouver on Tuesday.
Migneault said this week will be telling to see whether public health measures, such as self-isolation and physical distancing, have made a difference. He also said that health-care providers are already making difficult decisions, including delaying other surgeries, to respond to the outbreak.
“We are already making difficult choices in order to accommodate the potential of worst choices to come,” he explained.
“We all hope we're not going to end up in a situation where we have to make these extremely difficult [decisions] where we have to choose between one individual and another one.”
WHO LIVES? WHO DIES?
In the hypothetical case of the 74-year-old patient in need of a ventilator, Christie said that person could still live for another 15 to 20 years and that age, alone, should not be the only consideration when health-care workers are faced with these difficult decisions.
In fact, the medical ethicist said there isn’t going to be one clear set of guidelines outlining what factors will be taken into account to decide who gets to live and who gets to die during a pandemic.
“I don’t think there's going to be any formula that everyone’s going to be able to live with,” he explained.
Importantly, Christie said health-care providers can’t base their decisions on discriminatory reasons, such as age, race, religion, sex, prejudices, and arbitrary criteria, such as the patient’s influence or who they know.
Instead, the medical ethicist said it will most likely have to come down to outcomes and who is more likely to survive for longer if they receive the treatment. It’s a departure for health-care workers who typically consider the patient’s values and goals.
For example, Christie said doctors may provide ventilation to a terminally ill patient with cancer because that person wants to live long enough to see their daughter get married, even though they know they won’t be able to cure the disease.
“In a pandemic, I think we’re going to be in a situation where if we’re not going to be able to prevent death for you, regardless of what your life goals are, we might have to give that resource to someone for whom we can get a better outcome,” he said.
Migneault said that health authorities try to be fair to everybody and consistent in the sense that they treat similar situations the same way every time. However, in a health emergency, information can quickly change and Migneault said health-care workers have to be able to adapt on the fly.
“We say one thing one day and the next day we learn something, say something else so within all that ethical framework, you have to be flexible with it and try to adapt yourself as things move along,” he said.
In the U.S., health authorities across the country are developing strategies with the general principle to provide the most benefit to the greatest number of people and prioritize those with the best chance of recovery.
Dr. Douglas White, from the University of Pittsburgh, has developed a framework for rationing ventilators and critical care beds during the COVID-19 pandemic. He said categorically excluding groups of people, based on their age or other underlying health issues for example, from receiving care is ethically problematic.
Instead, White recommends that all patients be assigned a priority scale based on a number of factors including their likelihood of surviving hospital discharge and their longer-term survival. He also said individuals who perform tasks vital to the emergency response, such as doctors and nurses, should receive extra points.
In the event of tie in priority scores, White said the younger patient should be given priority because “they have had less opportunity to live through life’s stages.”
While some American hospitals have already adopted White’s framework, Christie said Canadian health authorities still have time to look at best practises and confer with their ethical committees to develop their own strategies if they’re faced with supply shortages. He said by planning ahead of time, health authorities can increase their capacity to treat as many patients as they can and prevent frontline health-care workers from having to make these difficult decisions.
“We’re doing all that planning now, so that we can delay these tragic choices as much as we can,” he explained.
Part of that planning includes the distribution of personal protective equipment (PPE) to protect health-care workers, Migneault said.
“We talk a lot about ventilators, but it actually goes way beyond ventilators,” he said. “You can have as many ventilators as you want, but if you don't have the human resources to provide the care, for example, if you don't have the nurses to provide the care, then you're not providing the care.”
Migneault said health authorities have to co-ordinate the distribution of resources on a provincial level to ensure hospitals have the supplies they need to respond to the pandemic.
“It’s important to pay attention [to] where are the ventilators, who has access to the ventilators, or critical care resources, and you don't want to forget people that may have more challenging access to them,” he said.
With The Canadian Press and The Associated Press