Rationing Care in COVID: Whose life is worth saving?

Hospitals in California are contemplating the next grim step in this pandemic. With entire healthcare systems maxed out, crisis plans must be made to ration care.

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Rationing Care in COVID: Whose life is worth saving?

Overwhelmed hospitals in California are rapidly inching towards the abyss of rationing care. 

  • On Jan. 4, 2021, an LA Times headline read “Ambulance crews told not to transport patients who have little chance of survival”. 
  • The same article included a directive from the L.A. County Emergency Medical Services Agency to withhold oxygen from patients with 02 sats of 90% or higher.
  • Two days later, the L.A. Times reported that Methodist Hospital in Arcadia, CA notified the California Department of Public Health that it would implement crisis care guidelines.
  • “If a patient becomes extremely ill and very unlikely to survive their illness (even with life-saving treatment), then certain resources currently limited in availability, such as ICU care or a ventilator, may be allocated to another patient who is more likely to survive,” read the county hospital's message.

Bodies are being stored in hastily ordered refrigerated trucks and morgues are turning away families. Patients are being cared for in hallways and tents.

We’re all exhaustingly familiar with surge/contingency state by now, but the next tier, crisis care, takes us to the far and extreme end of the spectrum. Moving to a crisis standard of care is not optional, it is forced  (IOM 2009). It’s when all other options have been exhausted. 

Crisis Standards of Care

Crisis Standards of Care typically apply to the battlefield. It conjures up movie scenes of doctors and nurses stepping over the bodies of those likely to die to treat only those less likely to die. Once unthinkable in healthcare, the hows and whys of it are now being planned. 

Warning

We were warned to prepare for this scenario decades ago.

“Therefore, the United States must continue to plan for a catastrophic public health event that will cause grave injury, disease, or death to potentially thousands or tens or hundreds of thousands in a city, region, or entire nation.” (IOM, 2009 pg 17). These words, written in 2009, sound almost prophetic when read today.

Hospitals and states are required to formulate Crisis Standards of Care Guidelines to activate during a catastrophe. Once a facility, a county, or even an entire state declares they are operating under Crisis Standards of Care, rationing is in effect. It should be formally announced that the facility is operating under Crisis Standards of Care due to specific circumstances to protect nurses and for public transparency.

According to the Institute of Medicine (IOM), Crisis Standards of Care are guidelines developed beforehand to help decision-makers allocate limited resources in a disaster. They provide a framework for decision-making when a hospital or system is so overwhelmed that it cannot provide the best care. 

Decision-makers under extreme stress need guidelines when information and situations are rapidly changing or otherwise, a first-come, first-serve prevails. Without guidelines, front-line workers have to make life and death and supply decisions at point of need. Chaos ensues.

Doctors could argue about which patients gets a ventilator, or dialysis, or ECMO. Nurses would have to decide who gets what medications and treatments first or not at all. Nursing assistants could compete to get blood pressure machines or oxygen tanks.

Crisis Standards of Care aka Rationing 

It will be called resource allocation by hospitals, and it means rationing. 

Who Gets Care?

Under Crisis Standards of Care, choices will be made to save the most lives, even if those choices are not in the best interests of individual patients.

A triage officer is appointed and a team convened, ensuring no one person has to play God. The team could include doctors, nurses, spiritual care providers, and ethicists. Committee members will not include the patient’s nurse or doctor. 

There are different ways to make such highly sensitive, ethical decisions. What are some criteria being considered?

  • Should age be a determinant? Preference given to a young person who has a full life ahead over a 70 yr old? But some 70 and even 80 yr olds still contribute a great deal, for example, Dr. Fauci, who is 80 yrs old, fit, and works 18 hr days.
  • What about people with disabilities? Some people with disabilities are afraid they won’t make the cut to the front of the line. Should someone with a higher baseline functional status be given preference over someone in a wheelchair, or someone with schizophrenia? 
  • Should likelihood of survival be the main decider? There are patients who have been on ventilators more than 30 days, more than 40 days. Currently if you are on a ventilator, the ventilator is yours until you improve or die. Under Crisis Standards of Care, it could be re-assigned after a period of time or if there’s no improvement.
  • Should those with chronic conditions and co-morbidities be given a lower priority? But won’t that discriminate against people of color, who have chronic conditions due to socioeconomic status and lack of access to healthcare?

These are tough questions. Should patients during admission be asked if they would forgo being placed on a ventilator if there is a shortage?

California guidelines state that a  person's age, race, sex, disability status, religion and ability to pay legally cannot be an explicit factor in making the decisions and proposes sequential organ failure assessment (SOFA) scoring.

 SOFA Scoring

Some hospitals are already measuring SOFA scores.

Scores measure oxygen levels, jaundice, kidney function and responsiveness. All things being equal, if 2 patients qualify for an ICU bed, it can go to the younger patient. Some patients who have been in ICU a very long time and are not improving based on condition scores may get removed or moved to a non-ICU bed.
 

Is your hospital moving toward crisis mode? What are you seeing and what are your thoughts?

Best wishes,

Nurse Beth

Author, "First-Year Nurse" the ultimate insider's guide to helping new nurses succeed while avoiding first-year pitfalls.

References

Berlinger, N., & WM, P. T. Ethical framework for health care institutions & guidelines for institutional ethics services responding to the coronavirus pandemic: Managing uncertainty, safeguarding communities, guiding practice. (2020, March 16). https://www.thehastingscenter.org/ethicalframeworkcovid19/ Retrieved 2021,Jan. 4.

Committee on Crisis Standards of Care: A Toolkit for Indicators and Triggers; Board on Health Sciences Policy; Institute of Medicine; Hanfling D, Hick JL, Stroud C, editors. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington (DC): National Academies Press (US); 2013 Sep 27. 3, Toolkit Part 1: Introduction. Available from: https://www.ncbi.nlm.nih.gov/books/NBK202382/ Accessed 2021 Jan 4.

IOM. Crisis standards of care: A systems framework for catastrophic disaster response. Washington, DC: The National Academies Press; 2012. http://www.nap.edu/catalog.php?record_id=13351. Accessed 2021 Jan 4.

Hanfling, D., Hick, J. L., & Stroud, C. (2013). Toolkit Part 2: Public Health. In Crisis Standards of Care: A Toolkit for Indicators and Triggers. National Academies Press (US).

IOM (Institute of Medicine). Guidance for establishing crisis standards of care for use in disaster situations: A letter report. Washington, DC: The National Academies Press; 2009. http://www.nap.edu/catalog.php?record_id=12749.

Wigglesworth, A., Rong-Gong, L., Karlamangla, S, Money, L.(2021, Jan 4). Ambulance crews told not to transport patients who have little chance of survival. LA Times. Retrieved 2021, Jan 4

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Nurse Beth

About Nurse Beth, MSN

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Hi! Nice to meet you! I especially love helping new nurses. I am currently a nurse writer with a background in Staff Development, Telemetry and ICU.

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Specializes in New Critical care NP, Critical care, Med-surg, LTC.

I am grateful that while my hospital's resources are definitely a bit stretched right now, we are nowhere near making some of these agonizing decisions or working under conditions faced by other healthcare workers and systems. Doctors and nurses being in the position of making life and death decisions is not something that anyone has envisioned when going into the medical profession. Certainly we make recommendations to families all the time on aspects of care like code status, and we may recommend that families withdraw lifesaving measures in some cases, but that's based upon the clinical picture and prognosis for patients that we have had the chance to care for, not a split second decision based on arbitrary criteria like age, disability or other aspects.

This a heartbreaking situation, I hope that the crisis passes without this becoming a frequently encountered situation. For the medical professionals that will certainly will have moral dilemmas and long lasting feelings of guilt and maybe failure, I hope they can get through this situation as well as possible. And for the families, this will bring unimaginable loss and anger in what certainly feels like a failure of the medical system, from people that take an oath to do what is best. 

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I remember at the beginning of the mask wearing that it was suggested that people who refused to wear a mask, follow social distancing standards, and generally isolate should understand they don’t have the right to care.  No way to know who they are by the time they are in the ED. 

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I need to stop watching post apocalyptic TV shows and movies, especially the ones about pandemics.  They are losing their entertainment value when this is becoming the reality.

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Specializes in Tele, ICU, Staff Development.
1 hour ago, JBMmom said:

Certainly we make recommendations to families all the time on aspects of care like code status, and we may recommend that families withdraw lifesaving measures in some cases, but that's based upon the clinical picture and prognosis for patients that we have had the chance to care for, not a split second decision based on arbitrary criteria like age, disability or other aspects.

This a heartbreaking situation, I hope that the crisis passes without this becoming a frequently encountered situation. st. 

Exactly

33 minutes ago, caliotter3 said:

I need to stop watching post apocalyptic TV shows and movies, especially the ones about pandemics.  They are losing their entertainment value when this is becoming the reality.

It is surreal

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California aught to be it's own country.  I've been a nurse for 40 years and have never seen rationing of care.  When I worked at a large teaching hospital in VT, years ago, we always would get patients from Canada, because under socialized medicine health care is rationed.  Now to hear California is doing it. People do not realize when they wish for a government that takes care of their every need, free this and free that,  this is what happens. Some body has to pay for it,  and now that somebody is a patient.  It's only going to get worse.  Glad on on the downhill slide.

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So you think California has the same healthcare system as Canada? What?

 

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My hospital is nowhere near that point, as far as I know. My patients are getting less attention than they would normally get, though.

I'll be blunt and say, some of the people being treated would probably be better off allowed to die naturally. Some of the pictures I've seen in the news are hard to look at ...advanced age, contracted limbs with necrotic wounds, feeding tubes, etc. Yet, they're in ERs around the state and country being "saved".

I would actually feel comfortable deciding who should get aggressive care and who should not (assuming I had a complete picture to work with). I don't think it's something that can be decided with a check list, though.

 

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Specializes in EMS, ED, Trauma, CEN, CPEN, TCRN.

These are the realities of mass casualty incidents - albeit this one seems never-ending. Having to make tough choices is hard on the soul. Every nurse, medic, or physician who has faced a mass casualty incident in a combat zone has had a taste of this, and I can tell you it's awful. Every day I think (worry) about the trauma that healthcare providers are experiencing and the toll it is taking. 

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My hospital in the Central Valley has been at this point already for several weeks. I have seen Doctors talk to patients with poor prognosis ( but still hanging in on vapotherm around 90%) and pushing DNR's hard. Our success rate of getting covid patients off the vent is close to 0%. Even if someone is a full code, if they score poorly on an algorithm ( not sure exactly what it entails), the patient will not get a vent because they will take up that valuable resource for a long period of time and without success.  From my experience over the past 9 months on a tele floor, once someone is maxed on vapotherm or on bipap, they are basically a dead man and its only a matter of time. Once they are made comfort, we hike up the morphine drip quick and whisk away the vapos and bipaps to the next patient needing it. It's dark and sad. However from what I have seen, the rationing of care has felt appropriate because it is rationed away from those less likely to survive anyways. 

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Specializes in New Critical care NP, Critical care, Med-surg, LTC.
3 hours ago, CaliRN2019 said:

Our success rate of getting covid patients off the vent is close to 0%.

We were doing okay back in March-June, about 50% were coming off the vent. We haven't had an extubated patient leave the hospital except through the morgue in the past few months. It's been rough. So many facetime good-byes for families, and with COVID patients no one can come to the hospital to see them. 

 

3 hours ago, Pixie.RN said:

Every day I think (worry) about the trauma that healthcare providers are experiencing and the toll it is taking. 

I also worry about families and the long-term effects of their loss. Some drop off a loved one walking and talking into the ER and all of a sudden they're getting a call from critical care that the patient might not make it, sometimes over the course of 12 hours for those that have rapidly increasing oxygen requirements. They can't see that we're providing care as best as we can. I've set up too many facetime meetings and watched families have a last conversation with their loved one. Especially for those families where another family member gave it to the patient, their sense of guilt and loss is heartbreaking. Worse is when an emergent intubation had to be done and their facetime is with a person sedated on a ventilator who will never interact with them again. 

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Specializes in Clinical Research, Outpt Women's Health.

Sour Lemon spoke a very hard truth. I know nobody wants to touch that reality, but it does not make it disappear.

 

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