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Rationing Life Saving Treatments in the Setting of COVID Pandemics: A Podcast with Doug White and James Frank



You are caring for two adults with COVID-19.  One who is a previously healthy 70 year old. One is 55 with multiple medical comorbidities.  Both are now requiring mechanical ventilation, but there is only one ventilator left in the hospital and all attempts to transfer the patients to another hospital for care have failed.  Which patient would you give the life saving treatment to and why?

On today's podcast with talk with Doug White, Professor of Critical Care Medicine at the University of Pittsburgh, and James Frank, Professor of Medicine and fellowship director for the UCSF Pulmonary and Critical Care Medicine Fellowship, about this type of tragic choice that we may soon be making if we do not flatten the curve on the COVID-19 pandemic (for more on that, check out our last podcast with Lona Mody).  If you don't think that would be even remotely possible, just read this quote from a NEJM article that came out yesterday:
Though the physicians I spoke with were clearly not responsible for the crisis in capacity, all seemed exquisitely uncomfortable when asked to describe how these rationing decisions were being made. My questions were met with silence — or the exhortation to focus solely on the need for prevention and social distancing. When I pressed Dr. S., for instance, about whether age-based cutoffs were being used to allocate ventilators, he eventually admitted how ashamed he was to talk about it. “This is not a nice thing to say,” he told me. “You will just scare a lot of people.”
In our podcast we reference a fair amount of articles and resources.   Here are links for them:
We also want to share this summary of the allocation framework that more than 100 hospitals (and counting) across the country are using, which is grounded in the framework we discussed on the podcast. Per Dr. White, it has gone through extensive vetting in the form of 3 years of community engagement in Maryland.  And per Dr. White, the result is an ethically grounded, operationally feasible allocation strategy that has also been extensively vetted with citizens.  If your health system wants to use it, please contact Dr. White as they have a fully prepared hospital policy document that hospitals can simply adopt for their purpose.
And, if you have other resources on resource allocation, send them to me (eric.widera@ucsf.edu) and I'll add them to the google drive folder linked above.

  


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TRANSCRIPT

Eric: Welcome to the GeriPal podcast. This is Eric Widera...

Alex: This is Alex Smith.

Eric: And Alex, we have two very special guests with us today.

Alex: We do. In studio, we have James Frank who is Professor of Medicine at UCSF and the program director for the Pulmonary and Critical Care Fellowship. Welcome to the GeriPal podcast, James.

James: Thank you.

Eric: And we have somebody on Skype.

Alex: And on Skype, we have a returning guest. We have Doug White who is Professor of Critical Care Medicine at the University of Pittsburgh School of Medicine. Welcome back to the GeriPal podcast, Doug.

Doug: Hello. Thanks for having me.

Eric: And so this is the second podcast that we're going to do on Coronavirus. We just had and published one with Lona Mody on the epidemiology and what we know so far about coronavirus. This one is thinking ahead more and in the next couple of weeks if things happen, thinking about how we think about resource allocation. Doug White wrote a really great article several years back that we will have in our show notes on the GeriPal blog.

Eric: Lots of links too, but before we even talk about that, we're going to be talking about how do we prevent ourselves from getting that situation. But before you even talking about that, we always start off with a song request. Do you have a song request for Alex, Doug?

Doug: I do. Space Cowboy.

Alex: And why this song, Doug?

Doug: This was a dinner conversation with my family, three adolescent children and my wife, and we were thinking, what is both a beautiful song and has something relevant to the public health measures we'll be talking about today.

Alex: Great.

Eric: Great. And Alex, we're going to ask you to do about 20 seconds. So if people want to-

Alex: No, no, no. That's a different song.

Eric: It was this one too.

Alex: Okay. This one too. We'll try it out. We're just going to do the chorus.

Alex: [singing]

Doug: Wow. Bravo.

James: Wow. That was great.

Doug: Very nice

Eric: Social distancing folks.

Doug: Social distancing. You can have your space.

Eric: Well, I'm going to start off both with James and Doug. Maybe, you can start off Doug. How are you thinking right now about this coronavirus outbreak coming from a critical care perspective?

Doug: Well, we are sobered by seeing what's coming out of Italy and what came out of China, this feels like... to put it mildly, the horses out of the barn in terms of a containment and we're just trying to prepare for what will likely come in the coming weeks and months.

Eric: Yeah. It sounds like we're about two weeks before Italy right now. I'm one of those optimistic folks. I actually think that hopefully, we're starting up a little bit earlier and can prevent some of this. And I think I'm seeing in the hospitals, we're learning lessons so I'm truly hopeful. But it's also about a good palliative care phrase hoping for the best and also planning for the worst.

Doug: Yep. I agree.

Eric: James, how're you think about this?

James: I like that last comment. I too, I'm an optimist. I'm hoping that with maybe slightly earlier intervention here, we may avoid the worst fate, but we are absolutely planning as best we can for the worst. And really for the first time in my career, we are very seriously thinking about, “Will we have enough ventilators and things like that where in the past that's felt more theoretical?”

Alex: Yeah. I just heard Zeke Emanuel was on NPR this morning, and he said he's concerned that this is very likely to happen in some pockets of the country. That in some pockets of the country, there will not be enough resources for every person in particularly ventilators.

Eric: Before we get into resource allocation and that word rationing, what are some simple things? Let's just remind people of the simple things that we can do to flatten that curve. And if you want to learn more about why flattening the curve is important, listen to our last podcast with Lona. Simple things that we can do.

Doug: Alright. Yeah. So this is the perfect place to start the podcast because it is really all about flattening the curve. And as I've talked to people about this, I think there's a real misunderstanding about what we're trying to achieve when we flatten the curve. A lot of people say, well, we go into all these public health prevention measures to get this thing over with more quickly and get it behind us.

Doug: But in reality, all of the things we're about to talk about are meant to make it last longer and be less intense. And so, the curves that you'll see... I think you guys are going to post them on the show notes, really show not only decreasing the peak of the incidents of cases, but also spreading it out over time. I think that's really sobering because when we think about how long we're going to be dealing with this, this is not something that's going to be over in two or three weeks. We're really looking into July, August, September, October that we're going to be faced with this.

Eric: Yeah. I also think that over the next couple of weeks, it's also about trying to create a scenario where we can actually develop good testing where we can actually make things hand sanitizers, face masks, things that we actually need. So, instead of having that huge peak up front, we're actually slowing it down. Hopefully we can have some of these resources including things ventilators instead of actually using them all at one burst and having to run into rationing resource allocation decisions.

Alex: And I just add that Joanne Lynn emailed us and encouraged us to promote the public health message that we need to engage each other in advanced care planning so that we have prepared for scenarios where we have respiratory distress, and how would we want to be treated in such circumstances. What do we prioritize? What do we value? What are our goals? In view of serious respiratory health illness?

Doug: Yeah. You guys talked about this, it sounds on a prior podcast, but I think it's worth saying, the really critical things are, number one, aggressive social distancing, and that's what... canceling school, canceling large public events, looks people are working from home. This is going to be critical to just slow things down. Number two, aggressive and at scale testing for the virus, and then following up those cases with quarantine and then tracking down contacts.

Doug: And then something that I think it's really important to talk about before we talk about what to do when there aren't enough resources is, how can we actually increase our ability to care for patients, for example, who are critically ill with the resources we have. And this is the concept of surge capacity, which is to say, increasing the number of... for example, critically ill patients that any given hospital can care for.

Doug: There are a lot of different ways to do this. I sent you guys a couple infographics about it. But the way I think about it is we need to figure out, how can we more effectively leverage staff space and staff. So staff means, trying to ensure that we have as many clinicians as we'll need, and more than we normally do to take care of critically ill patients. Space means, opening up more... for example, ICU beds to take care of these patients. For example, if a hospital has a mothballed wing as many hospitals actually do now, re-purposing that to be an ICU.

Doug: Actually UPMC is looking at reopening one of the hospitals that we had shut down a couple of years ago and making it fully focused on critically ill patients. And then the thing is the staff part of it. And that's broadly construed all of the healthcare technology and medications that will be needed to treat these patients. And that's things ventilators, ventilators sockets, medications, oxygen, PPE, Personal Protective Equipment, et cetera.

Doug: And you may not know this, but a lot of hospitals do have stores of ventilators and other things that they can pull out in the event of crisis. Most States also have stockpiles, and then the federal government has what's called, the Strategic National Stockpile, and they have about 10,000 ventilators mothballed in a warehouse that they can iteratively send to different places around the country if ventilators are in shortage.

James: Right. That sounds spot on for the experiences that we've been having here in the last couple of weeks. Thinking about how we might cohort patients, repurpose wards. Conceivably, one of the hospitals using what is normally the recovery room from the operating room as a makeshift ICU and planning for these contingencies with reserve ventilators and personal protective equipment for our staff.

Eric: Are you right now more worried about... because it sounds from the equipment standpoint, we should be okay. Who's going to man all this equipment, if people are sick?

James: Absolutely. That's a great point. So we really are already changing the way we're thinking about staffing our ICUs, where I would say historically, there's a high priority obviously on patient care, but also on the education of the people who are training on the ICU team. Now, it's really more of a focus on, “How do we have the fewest number of providers see each patient each day and still provide the best quality care?”

James: And what that looks is, we have more of a skeleton crew in the ICU at a lot of the time, and attending staffing. We've rearranged so that we've got first line, second line, third line, like a hockey team or something like that.

Doug: I don't know. This morning I listened to an interview, a New York Times interview podcast with an intensive care physician in Italy in Bergamo-

Eric: We'll have the link to that podcast because I listened to it too and it was amazing. So we'll have the link to that on our GeriPal blog as well with our show notes.

Doug: Yeah. It was incredibly sobering to hear him talk. What really jumped out at me is, he said that they are every day having 50 to 70 cases of patients coming in with acute respiratory failure, requiring mechanical ventilation. Every day, 50 to 70 cases, and they have no capacity for that. Although he didn't really address how they were making decisions, it's very clear that they were not able and continue to not be able to provide critical care to all the patients who need it to survive.

Eric: Yeah. They said there was about a thousand bed hospitals. Just imagine that, if you're 1000 bed or if you're 500 bed hospital divided by two, that's where if we follow this curve for Italy, we will be out in two weeks. And they also alluded to making decisions based on age. If you're at a certain age, you may not be getting those particular resources in addition to other things.

Eric: I think one of the things that they were hoping for is some idea of, Who's going to benefit from the most, and having some objective score around that because they feel, they're making these tragic decisions, it sounds like by themselves and they're having a very hard time with that.

Doug: Yup. Yup. Yup. And this is all to just remind everyone, Europe is very different in how decisions get made around ICU end of life decisions than the United States, there's much more comfort with physicians taking a much more directive role in saying, “It's time to stop.” I think that they're having trouble with it is a real eyeopener because will be an even bigger shift for us.

James: Right. I agree with that. I think it's important to acknowledge that most intensivists are used to the idea of triaging ICU beds, but the principles that we think about really are more having the sickest patients in the highest level of care. And we really don't think about the resources being limited.

Alex: Yes. This maybe is a good entry point to talk into how ought we. If we face this terrible choice, if we are in a situation where we don't have the capacity to provide ventilators for people who are coming in with serious illness due to COVID-19, what are the key considerations? How should we think about this in terms of ethical principles or guidelines? And are there specific rules we might adopt? And should those rules be applied uniformly across the country? Or is this within each healthcare system? That's like 18 questions that could take us two hours.

Eric: Let me give you one minute to answer all of those [laughter].

Alex: Doug, where would you to start with this? And then we'll go to James?

Doug: I do think that the right place to start is just to talk about the context. The normal way we do in acute care hospitals is really a patient centered focus, a clinical ethics focus, which is, we're working to prioritize the wellbeing of the individual patient. Let's just call that standard usual care and business as usual. If there is an overwhelming public health emergency, which is really what we're talking about here, things will shift to a very different ethic.

Doug: And that is an ethic that's focused on public health domains. And so it shifts from prioritizing the wellbeing of the individual patient to the traditional moniker of public health ethics, which is accomplishing the greatest good for the greatest number. And I think that distinction moving from a patient focus, clinical ethic to a public health efficacy is a really important first starting point.

Doug: And what that requires, there are some legal aspects to this that are probably worth talking about a little bit. It does require a declaration of a public health emergency and this happens both at the federal level and at the state level. It would be the governor declaring or the legislature declaring a public health emergency. And that's when this new ethic would kick in.

Alex: And that's happened in California, right?

Doug: Yeah.

Alex: Has Trump declared a state of emergency?

Doug: Yeah.

Alex: He did. So we are there?

Doug: Yeah.

Alex: Right. So we are moving into this public health ethic. Any other broad considerations that we should get into before we get into specifics from you or James?

Eric: We're not there yet on scarcity though, right? Currently, I think the good news is, all hospitals are getting ready for a surge. But as far as I know, no hospitals are in a surge right now, which is a... I'm going to stay optimistic. I'm open, except in places Italy who knows what's going in Iran. But it sounds like they're actually in what sounds like, at least from that New York Times podcast today, in a surge with a triage resource allocation and rationing.

James: One other important point I wanted to touch on, you brought up Alex, is the federal versus state versus even more hyper-local considerations. Typically, we think about this being very different locally. And even at the hospital level, for example, with an ethics committee weighing in on these kinds of decisions in a hospital by hospital way.

Alex: I guess one other point I want to emphasize is, in order to prevent critical care docs being in this position or ethics committees coming to this without having thought of it beforehand. The reason we're having this podcast now and trying to push it out in advance is to help people start the process of thinking through this so that they can prepare in advance and have some sense of what ethical considerations are at stake here, and how they might triage patients within their facility.

Alex: Onto having an understanding of what guidelines are in place for whatever health system they're in, Kaiser or VA or whatnot. Because the worst thing is if you get there and you haven't prepared, and you're making decisions at random or gut instinct, A, it's not fair to patients. It doesn't provide the best care. And B, these clinicians are going to be terribly morally distressed by these decisions they have to make. As much as we can to support them with a thoughtful process upfront.

Eric: There's plenty of examples out there of rationing decisions that are probably not that well thought out or thought through. I think going back to the 70s with the God committee from Swedish Medical Center, and resource allocation of dialysis machines early on when there weren't many dialysis machines, there were a lot of people that stage renal disease, and how did they make decisions and part of their decision making was around social worth. Like, “Oh, this person went to Church every day. They run a business, they employ people. They should get the dialysis machine.”

Doug: Exactly. Yeah. I think you guys said it really well that the whole goal here is to think about it enough in advance. That, at a minimum we can make sure that ethically irrelevant considerations are not what's driving allocation decisions.

Eric: Doug, could you give us some idea of what are some of the ethical considerations that people think about and the ones that we should potentially think about when we're making these decisions or hopefully win a public health perspective, they're thinking through these allocation decisions?

Doug: Sure. There are a lot of different principles. Let me give a little streamlined view of one way to think about it. That really, it starts from the principle of doing the greatest good for the greatest number, right? If that's the mindset you have, there are a number of ways that you can specify that, but certainly the first would be a focus on maximizing the number of lives saved. Just for context, I do think it's important to sort of.... let's give an example of what we're talking about.

Doug: We're talking about people who are coming in just for this thought experiment with acute respiratory failure, who if they don't undergo mechanical ventilation will die of acute respiratory failure. Okay? Let's assume that you have... just to keep it simple, two people. You have a 55 year old with several life-limiting comorbidities, and who comes in with septic shock and acute respiratory failure, and has maybe a 50% chance of survival.

Doug: And then let's say you have an 80 year old who comes in with no comorbidities and just relatively mild respiratory failure but still needing a ventilator, and probably has a 70 or 80% chance of survival. So all of a sudden, even with just these two patients, you're seeing that there are several considerations that might be relevant. Is it relevant, who has a better chance of surviving to hospital discharge?

Doug: Is it relevant, who is likely to be able to live longer? Which is to say the number of life years that could be saved. Is it relevant, how old the person is in terms of whether they've had more or less of a chance to live through life stages. And then finally, if you want to really make it a little more complicated, let's say one of those two people is the head of vaccine manufacturing for COVID or Corona virus at one of the pharmaceutical companies. Does that matter?

Eric: Doug, let's just say, all of this stuff, it reminds me... what's the TV show? The Good Place. Everybody hates moral philosophy professors, forget about all that. I'm just going to do a lottery. Random. This is my egalitarianism. Everybody is equal. All of this stuff falls through. I'm just going to draw straws. Whoever gets the biggest draw gets the ventilator. There, solved.

Doug: Solved. First, I totally agree with you that The Good Place and the scene of the trolley problem with the blood splattering up has been running through my head as I've been thinking about these issues over the last couple of weeks. So yes, if your specification of justice or fairness is that everyone is treated equally in the moment, then a random lottery would be one way to go.

Doug: The problem is that the public health ethic is not merely to treat everyone equally, it's to try to maximize the greatest good for the greatest number. And so I think that's where the random allocation strategy fails.

Eric: So one of those patients happen to have widely metastatic cancer, maybe a prognosis of two weeks. Treating that person equally as a 20 year old, otherwise healthy person with a really good chance of surviving till hospital discharge probably is not actually a fair allocation of resources.

Doug: Correct. Under the public health ethic, and I think under the way that many would argue for this, exactly.

James: The question that I have about maximizing the life you've saved is that, on the one hand our ability to predict short term outcomes like survival, the is charge is reasonably okay. But our ability to predict the longer term prognosis for a patient is associated with a lot more uncertainty, especially in the moment in the ICU.

James: In the case that you described, the two patients, it sounds like maybe the 55 year old has these comorbidities, but there's a lot of uncertainty about, could they be managed, could there be things done to alter that prognosis, which I bring up only because it makes the decision making in the moment more difficult.

Doug: Absolutely. Operationally, trying to parse this too narrowly is problematic for all the reasons James just said. That said, I do think you can put people in big buckets of life limiting comorbidities. For example, someone who is entirely healthy or has very mild, well-controlled, non-life limiting comorbidities could be in one category.

Doug: People with very advanced end-stage diseases, class 4 CHF, widely metastatic cancer, COPD on six liters home oxygen. You can start to make distinctions between people in terms of the likelihood or the number of life years they're likely to have to live even under ideal non-critical care circumstances.

Alex: And how does the interaction of this particular virus, COVID-19, with comorbid conditions play into this? For example, my understanding is that people with congestive heart failure or people with diabetes are at increased risk of death from the virus itself.

Doug: That's right. It does appear that people, both older individuals and people with cardiopulmonary comorbidities do tend to have a worse prognosis. And what we don't have is a COVID-19 specific risk prediction model for hospital survival. Presumably, there those patients clinical status, and the worst clinical status they have would be reflected in our standard measures of severity of illness like the SOFA score, the sequential organ failure assessment. But right now, that's a big unknown of whether the SOFA score or something like it will accurately predict hospital survival.

Alex: Right. And full disclosure, Eric and I of course are involved in EAP prognosis, which has longterm prognostic calculators. The challenge is that, if you're trying to estimate somebody's remaining life years, you would do that based on how they are outside of the hospital. And you're not seeing them outside of the hospital. You're seeing them when they're critically ill and need a ventilator.

Alex: You would have to retrospectively think back to, “Okay, what was this person four weeks ago? What was their function at that point?” In order to enter their information into a prognostic calculator that estimated long term life expectancy.

Doug: That's exactly right. That's exactly right, Alex. That's what this, this step... if we were to consider life years, that's what this step would entail. It would entail some history taking or it would entail some chart biopsying to really figure out, “What do we really objectively know about this patient's baseline health status?”

Eric: All right. I got a question. So I'm just going to break it down because I want to focus on these key principles, And then we can talk about how to do that. We talked a little bit about egalitarianism, treat everybody equally. We talked about some of the issues with that. We've broached issues. Going back to the good place of utilitarianism is, save the most amount of people that you can, most amount of benefits.

Eric: So we talked a little bit about the issue around disease severity, right? Or number of lives saved. So just try to treat as many people as possible, which is an issue because it doesn't count for longterm prognosis. We've just talked about prognosis as far as life you've saved, and maybe it sounds like we're broaching some of the issues with that. Do you want to say anything else about that?

Doug: I just to point out that even under... if your guiding principle is utilitarianism, more maximizing benefit, there are different ways to specify that. Just as you said, you can specify that by saying, “We're going to maximize survival to hospital discharge.” That's specification of a utilitarian framework. Alternatively, you could say, “We're going maximize some balance of survival to hospital discharge and maximizing the number of life years saved.” Both of those would generally fit under a utilitarian frame.

Eric: Great. A couple of other principals favoring the worst off, what's that called again?

Doug: It's a kind of prioritism.

Eric: What are some things we should consider there? Like...sickest first, right?

Doug: Yeah. Just to cut to the chase on the prioritarian focus, although it's not typically how we think about this. In some ways the young are the worst off.

Eric: Tell me more.

Doug: In the sense that young people say an 18 year old has the least of something that I think we can all agree is what we cherish, which is the ability to live life and to live through the normal progression of life stages. To be an adolescent, to be a young adult, to be a middle aged person.

Doug: Whether that means having a family or pursuing interests that we find meaningful, late in life, to be elderly and then to die. That's at some level what we all hope for. We hope to have a normal life arc and life cycle. And so the young are the worst off in terms of achieving that. And those at the extremes of old age are paradoxically the best off.

Eric: And my understanding too is when you do focus groups, it sounds like people are also okay with this as a potential guiding or a potential principle as we think about putting this together. Is that right?

Doug: Correct. Yeah. There have been a number of studies that have focused on community engagement around allocation principles. What's come up in those is that, yes, people do generally endorse that the young should be given some priority. What I think scares people... and what I think rightly should, is that, that could end up looking or feeling a lot discrimination against the elderly or saying, the elderly are just not-

Eric: Ageism.

Doug: ... they're less worthy.

Alex: Right. This is the GeriPal podcast. We should talk about this. Yeah.

Doug: We should talk about this. This is hugely important. Yeah, I totally agree. I think this prioritarian frame can say everyone has equal moral worth, and we're focusing on trying to lessen the imbalances across the age span.

Alex: James, you want to jump in here?

James: I like this idea of trying to consider all of these multiple variables and then applying the principles equally to each person and not using something straight forward is maybe just an age cut off. But as we've talked about, it's sometimes a tricky to put the appropriate weight on different factors that you're trying to consider. I also wanted to take the Doug's bait on the instrumental value argument and whether or not that applies in an epidemic like this one.

James: You had hypothetically suggested that one of the patients worked for a biotech company or something like that. Is it conceivable that they would actually recover and then be able to produce more therapy later or does that not apply in a situation this? How do we think about that?

Doug: Right. Remember, one of the things we talked about at the beginning of the podcast was that this flattening of the curve not only decreases the peak, but it's meant to really extend the length of this thing. And so we're looking at this as something for this particular coronavirus pandemic. We're looking at this as playing on unfortunately over the next year or two years, right?

Doug: Even after the first wave of people get infected, probably more than half to two thirds of the U.S. population won't have been infected and will still be at risk. So when we think about instrumental value, the question is, “Will these people were identifying as having a narrow social value to achieve the public health goals, will they get back on the work line in time to actually affect that value?”

Doug: And that's the question. In the 2009, the analyst paper, I think we got it wrong honestly in the sense that, we basically said, listen, a pandemic is likely to be very short lived and therefore we don't think we should be prioritizing individuals because of instrumental value. And now as we've been really thinking about what it means to extend out a pandemic to flatten the curve, I think we need to look about whether the instrumental value could be achieved. And if so, it should be considered.

Eric: Yeah. That, that seems so hard. Because even as San Francisco is being locked down to only essential businesses, now, everybody's arguing what's an essential business? The person who is stocking the grocery store, how do you compare their instrumental value? Because now people can get food versus the value of A, let's say, James Frank who's working in the ICU.

Eric: And is it the only people with power, let's say, people who are working in the ICU are making these decisions. They're obviously going to choose the person that work in the ICU versus the person who is also important like the delivery driver who's delivering food to-

Doug: Yeah. I totally agree. And this is something that requires really careful specification by not neutral parties because I don't think there's such a thing, but by multiple perspectives. And so, one way to think about this is that it's not just the nurses and doctors in the hospitals. It's also the the maintenance staff who disinfect rooms after a patient dies or is discharged.

Doug: You guys have probably all experienced the crush in the hospital even during normal working time when there are no rooms because they haven't been able to turn the room over... quote-unquote, in terms of cleaning it. And so when we think about this, I do think that we have to really look at, what is the chain of people that are crucial to the public health response and not inappropriately identify them. Its not just doctors and nurses.

Eric: Can I ask you about... Going to your paper, 2009, 2011 the allocation of ventilators in the a pandemic?

Doug: 2009.

Eric: 2009. You actually decided on three principles. Save the most lives, so SOFA score. Save the most life years. So prognosis for longterm survival, which included things like severe co-morbidities, death likely within one year, and life cycle principal. We will have this figure on our GeriPal website with also the links. And there was a point system. You tally up the points, you make your triage decision there. Is that a good summary of what you-

Doug: Yeah.

Eric: ... recommended back then?

Doug: Well, with a caveat, we proposed that approach as a way to illustrate how it... it's at least theoretically possible to incorporate multiple allocation principles into the decision making. And so, the table three (3) that you'll probably put up in the show notes, we went to great lengths to say, “Listen, this is just a very, very simplistic non-weighted theoretically possible way to balance and incorporate multiple things.”

Doug: There are a lot of different things that you could do with how you weight certain criteria, whether you hierarchically order them, but big picture, we just proposed it as a way, look, it's possible theoretically operationally to incorporate multiple considerations into how we make decisions.

Eric: And the other link, we'll have is, chest guidelines from 2007 on definitive fair critically ill patients in a disaster. And they also had guidelines to exclusion, inclusion criteria. And New York state has a more recently 2015, they convened a task force to come up with guidelines for how to deal with epidemics like this. And they're, they decided explicitly not to consider age as a criteria and longterm lifespan because they felt it would discriminate against the elderly.

Alex: Except in the sense that they prioritize children as a tie breaker. People who are less than 17, if there are two individuals who are similar otherwise in terms of their short term survival as characterized by the SOFA score. It seems to me, my read of the literature, this is where one of the major disagreement points, but I'm interested to hear from James, you and Doug, whether you have a sense of where institutions are at, States are at in terms of these guidelines.

Alex: Do they differ wildly? Is the major difference in whether they incorporate longterm life expectancy or don't or do they not have guidelines and they just make it up one ethics committee decision at a time or one ICU attending in the middle of the night at a time?

Doug: Well, let me start there. There are a couple of things that I think are really important to unpack. One is the age thing, another is the exclusion criteria and approach to doing this. Maybe let's come back to the exclusion criteria and approach. I would just point out that the New York guidelines, and many other States actually do explicitly include something that has to do with age in their guidelines.

Doug: Now New York just said less than 17 versus greater than 17, but that is acknowledging something about the young being the worst off. States Michigan do list age as an important potential criteria and potentially as a tie breaker. And then I would also just point out that, Lee Hardy Bettison, one of my colleagues at Hopkins over the last 10 years has done amazing work doing extensive community engagement throughout Maryland, both in inner city Baltimore and rural Maryland around these allocation criteria.

Doug: And bringing people together actually for day long deliberative to democratic conversations. And what's come out of those multiple engagements with over 300 people is that, there is something important about age. People both are nervous about it because they don't want it to convey less moral worth of older people, but they also think that there's something important there. And so the way that Lee and her group modified the 2009 framework is, rather than the these three principles being equally weighted that instead quality...

Doug: Sorry. Saving the most lives and saving the most life years would be the two most important. And if there is a tie, then life cycle considerations could come into play as a tie breaker.

Alex: It seems in several of these States, the life cycle, the life stages, the fair innings, the age criteria are almost a tie breaker or secondary consideration after you account for short term survivability. Correct?

James: A question that I have, it is comforting to think that there are some principles we can look to, but I feel like operationalizing that is a little more challenging. As you mentioned at the outset of the podcast, we normally think about a very patient centered approach and as we shift to a public health centered approach, I'm not sure we can actually do that. For example, we spend a lot of time typically talking about a patient's goals of care and acceptable quality of life and how do we layer that into a scoring system for resource allocation?

Doug: Well, to two comments. First, the framework that we proposed in 2009 and that Hardy Bettison and colleagues endorse is one that is operationally very feasible with in the vast majority of ICUs. It only requires the use of existing labs, chart review and knowing basic demographic information about the patient. Second, I think you're absolutely right that careful goals of care conversations remain critically important.

Doug: Both because there are... as is often the case, when a critically ill patient and their family are confronted with a very poor prognosis, they often choose to transition to a more comfort focus plan of care rather than ongoing intensive treatment with diminishing returns. And it might also be that some people say, “If my chances are getting worse and worse, give this resource to someone else.” Another is that sometimes in some people that strong ethic of solidarity that I think is also important to understand.

Alex: Yeah. But I do sense that there will be pushback around from critical care docs. I'm hearing a little bit from James around, but can't we just have some hard and fast guidelines that we can cling to like over 85, for example? Because they're easier to interpret. I guess the counter argument will be, “That's intellectual laziness. Physicians can do more. We can account for the complexity of our patients and that there shouldn't be one size fits all guidelines.”

Alex: And yet there is that push and pull in our society around many different things. Cancer screening being one example, where some argue for just let's make a one line, and others argue for individualizing based on the prognosis of the patient in front of us.

Doug: Yeah, I would just say that I think it's important to draw a distinction between the presence of guidelines and the guidelines containing exclusion criteria. Like saying, “If you're 85, you're not getting the ICU.” You can have guidelines that are still very feasible that don't exclude big swaths of the population. And I would just point out, the reason to be very careful about exclusion criteria is number one, the social pushback might be quite big.

Doug: If you're in some way, even if unintentionally conveying that the 85 year old life is not worth saving. And to think about the 85 year old who accidentally got a little bit too much benzo or morphine on the floor and is otherwise totally healthy and with just maybe a brief intubation and some narcan is going to go back to being their happy, healthy 85 year old self. That's why I think these very blunt exclusion criteria are quite risky.

Eric: Yeah. The 86 year old who was playing golf a week ago before social isolation. But otherwise healthy versus the 65 year old with widely metastatic disease who just had a massive CVA and a prognosis of a couple of weeks, that's the issue with these blunt cutoffs.

Doug: Exactly. And you know guys, I know that we're short on time, can I say one more thing. One thing we haven't talked about yet but it's critical is that, we've talked to all about who's going to get access to the resource. We haven't talked at all about, are we going to withdraw people from ventilators who aren't improving? And the general answer is, yes.

Eric: Because we don't it's a first come first serve, right. Whoever gets it first, you got it. And when I look at the chest guidelines from 2007, they actually said, this is about both decisions of intubation and extubation. Right?

Doug: Right.

Eric: If you enter that exclusion criteria and if somebody else needs the vent, you're off it, is that right?

Alex: New York state guidelines have explicit time periods. I think the first was 48 hours and I forget when the next was.

Doug: Yeah,120 hours.

Alex: Yes, exactly. So you don't re-evaluate until that time point and then you re-evaluate and you make a decision then.

Doug: Yeah. And the gist of it is that, you're looking to see is the patient on the right trajectory, and have they developed something that would make the... or have they developed something that would make their prognosis really, really grim. A huge intracerebral hemorrhage in a patient who was just admitted with sole acute respiratory failure might actually really change their prognosis.

Doug: Or evidence that maybe they'd been on the vent for four days, but they're actually getting a lot better. That patient should be treated differently than the patient who's been on the vent for four days and it's actually getting worse every day.

Eric: One more thing James, I think this is one of the reasons everybody hates moral philosophy professors is, they say-

Alex: Everybody doesn't hate moral philosophy professors... [laughter].

Eric: They say withholding and withdrawing treatment is ethically the same. That's generally in the U.S. how we think about this, but it's sure doesn't feel that way.

Doug: Yeah, correct.

James: I just wanted to bring up one other point. Doug, you and others have talked about the importance of transparency and fairness and these kinds of rules. But I'm concerned that as a profession, we have not done a good job in communicating these kinds of strategies and plans to the public. What are your thoughts on what can we do now to try to improve that?

Doug: Well, now is hard because we can't bring people together in big groups for social community engagement about this. I would point to the work that's been done in Maryland and the work that's been done in Kings County, Washington as evidence that robust public engagement can actually yield important insights about community values that can inform the decisions.

Doug: The other part of this is, I think if we are getting close to a point where demand outstrips supply of ventilators, it's going to be really important that there be messaging from the state and federal government that we're in a different space and we're talking about a public health emergency where business as usual is not going to happen. That in the moment of a crisis, that's I think probably about the best you can do.

Alex: The society of moral philosophy professors is desperately trying to get in touch with Eric [crosstalk 00:47:22] statements.

Eric: Yes. Those who don't watch the Good Place, I'm just referring to the Good Place. Doug, any last thoughts that you have?

Doug: Oh, I think I'd bring us back to where we started, which is, first, I hope everyone stays safe. And second, I think we have a huge obligation to really be the ones leading the effort of social distancing and talking to our friends and parents and loved ones about how important these public health measures are. So we can avoid all of this.

Eric: If we are let's say 10 days to 2 weeks behind Italy, anything that we should be doing right now from a local level within our hospitals around this issue of resource allocation?

Doug: I think number one, as most hospitals already are really working on increasing surge capacity. And number two, there does need to be some percent effort allocated to this question of, “What's going to be our approach if demand outstrips supply?” And to get something written down on paper. And Alex and Eric, maybe you can put up examples of this on the show notes of the 2009 paper, the New York guidelines, there are guidelines on chest. That would all be helpful if people need a starting point.

Alex: Great. Terrific. James, any last thoughts from you?

James: I just wanted to say thank you to Doug White. The work that he does really helps so many intensive as think through these really challenging problems and to be able to look back at the publications that he's put together over the years. It's a really helpful resource now.

Eric: Yeah. Big thank you, Doug.

Doug: Thanks. Thank you guys.

Eric: Thank you to both of you. We're going to end with a little bit more of the song, Alex.

Alex: [singing]

Eric: A little mixed messages there around social isolation [laughter].

Doug: Bravo.

Eric: Everybody, Doug, very bug thank you. James, big thank you for joining us today. All of our listeners, please stay healthy, do your best with social distancing and especially for those older adults that you're having in your neighborhood. Please check in on them and make sure that they have enough resources as well.

Alex: Thank you to Archstone Foundation. Thanks everybody.

Eric: Goodbye everybody.

Alex: Bye.



Comments

Joanne Lynn said…
Thanks for mentioning my encouragement for advance care planning - but - no one actually dealt with it in the podcast. Everyone responsible for a nursing home now needs to have 90% or more of the residents with advance care plans for severe Covid-19 - it is not just the progression of the person's dementia or Parkinson's or whatever - this is a clear and imminent threat and it can escalate from initial symptoms to respiratory distress over a few hours. We need to know whether the person wants (or through a surrogate, would want) to stay in the home and be treated as a hospice patient, and we need to be prepared to treat air hunger as symptom relief. There still will be overwhelmed hospitals, but perhaps many fewer if older adults are given the opportunity to state their preferences in this particular situation. This is hard to do, I know - but it is now essential. What do others think?
Jaqs Irvine said…
Have you been able to find data showing outcomes once in ICU for ages and comorbidities? I'm and Emergency Specialist and Medical Director in Australia and am concerned that current data is skewed by deciison being made in resource scarce settings.
Rachel Carson (Nephrology) said…
Super podcast - thank you for framing these questions as I read through my Health Authority's Pandemic and Emergency Resource allocation plans. As a nephrologist, I worry about my dialysis patients being one "exclusion criteria" group if the situation deteriorates to the level of Northern Italy.

Joanne, there are some COVID-specific resources that have been adapted for COVID19 pandemic discussions in British Columbia (Canada) based on Ariadne Labs' Serious Illness Conversation guide. Feel free to message me (@momneph) or Cari Borenko (@CBorenko) on twitter for copies. Vital Talk has also done a COVID-ready communication primer (@jatulsky).
We've also done a "Right Equipment, Right Information" poster for our hospitals on Vancouver Island emphasizing the importance of ACP information during this pandemic. Happy to share.