'Who lives and who dies': In worst-case coronavirus scenario, ethics guide choices on who gets care

It’s a scenario few health-care leaders want to contemplate much less discuss: What if the ranks of desperately ill patients overwhelm the nation’s ability to care for them?

With respiratory illness caused by the novel coronavirus rapidly spreading, nowhere is that potential more evident than the nation’s limited supply of mechanical breathing machines called ventilators.

Desperate scenes are playing out in Italy, where a spike in COVID-19 cases have overwhelmed the medical system and doctors have reported shortages of staff and equipment. More than 4,800 people have died there, surpassing China in total deaths.

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Because the worst cases of COVID-19 rob a person of their ability to breathe, patients die unless they get life-sustaining oxygen from machines. But there are fewer than 100,000 ventilators in the United States and millions of patients struggling to breathe might need such care.

Other machines can deliver oxygen to help those with mild or moderate forms of the disease, but the most critically ill patients need powerful airway pressure that only ventilators can deliver.

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Federal and state officials are urging people to follow measures to prevent the spread of the respiratory virus that causes the disease. Both California and New York have adopted strict limits on travel and commerce and urged people to stay home and eliminate nonessential travel.

These measures aim to slow the pace of new infections and ease demands on hospitals without the intensive care unit beds, protective gear or ventilators to handle an unprecedented surge of patients.

In a worst-case scenario of ventilator shortages, physicians may have to decide “who lives and who dies,” said Dr. Ezekiel Emanuel, an oncologist and chairman of the University of Pennsylvania’s department of medical ethics and health policy.

“It’s horrible,” Emanuel said. “It’s the worst thing you can have to do.”

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Respiratory therapists, who take care of patients who struggle to breathe, are aware of the pressures that comes from a swift, sudden need for ventilators

“This is something that we have thought about most of our careers,” said Carl Hinkson, director of Providence Regional Medical Center’s pulmonary service line.

Providence, in Snohomish County just north of Seattle, treated the nation’s first known patient with COVID-19, a 35-year-old man who became ill in January after returning from Wuhan, China. The hospital brought the man to health through a combination of oxygen and medications.

At the time, Hinkson and his team of respiratory therapists realized they were soldiers in a war against a virus that might last months. The Seattle metro area has seen some of the most U.S. fatalities from COVID-19 so far, a cluster of 35 deaths at Life Care Center in Kirkland, adding to Washington's state's 94 deaths as of Sunday.

Patients like the Snohomish County man recover after getting care at well-equipped hospitals such as Providence and Harborview Medical Center in Seattle. The key is to manage the flow of patients so the hospital and its staff aren't overwhelmed.

Providence has a roster of 44 ventilators, and the staff is “using a good portion of that capacity right now,” Hinkson said.

Still, Hinkson is optimistic his hospital can handle a surge of COVID-19 patients. His staff has worked long hours, but the hospital contracted with a private company that provides traveling respiratory therapists on a temporary basis. It allowed Hinkson to give time off to one therapist who worked 20 of the last 24 days.

Hinkson is aware of the hard decisions doctors in Italy are making about how to prioritize treatment of desperately ill patients.

"We’ve done a good job of planning and trying to be prepared so that we will avoid those problems," Hinkson said. "Planning and social distancing should help us not having to make those decisions."

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'First come, first served doesn't hold true'

Government public health experts have planned for a scenario in which there are too many patients and too few ventilators.

In a July 2011 report completed by a U.S. Centers for Disease Control and Prevention ethics subcommittee, planners said the “principle of sickest first” for critical care might no longer apply during a severe pandemic because it “may lead to resources being used by patients who ultimately are too sick to survive.”

When there's a severe shortage of life-saving medical resources “priority is given to those who are most likely to recover,” the report said.

Medics in war, for example, might first treat wounded soldiers more likely to return to health. Or emergency workers managing a cholera outbreak in a refugee camp will first give limited IV fluids to moderately dehydrated people because they are more likely to recover than sicker patients.

When these decisions have to be made, however, “health care workers should be the top priority,” Emanuel said, because they “save other people and put themselves purposely in harm’s way to save others.”

The goal is to “save the most lives and the most life years,” he said. “First come, first served doesn’t hold true. It’s not because you’re not a worthy person.”

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The Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care published guidelines for doctors on how to manage the crisis currently gripping the nation. If faced with a scarcity of resources, doctors are told to consider prioritizing treatment for healthy individuals under the age of 80.

Stefano Fagiuoli, a doctor at a hospital in Bergamo, asked for the public's help in a Facebook video posted Thursday. He said his hospital needs doctors, nurses, ventilators and protective gear.

A USA TODAY analysis of cases found that two weeks after cases began to spread in U.S. communities, America's trajectory is similar to Italy's over the same period. U.S. public health officials hope to avoid a similar skyrocketing of cases through aggressive measures encouraging social distancing and discouraging large gatherings.

"There's going to be a very rough road in the weeks and months ahead of us," Francis Collins, director of the National Institutes of Health told USA TODAY. Italy is "trying to manage the situation and make awful decisions about who gets a ventilator and who doesn't. God help us if this happens more broadly across the world and we certainly hope that it doesn't happen here."

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'Nobody is going to have an unlimited claim on a limited resource'

Nancy Berlinger is a research scholar at the Hastings Center in Garrison, New York, and put together an ethics guide for health care organizations treating coronavirus patients.

Berlinger said medical workers and family members often must make difficult choices during non-emergency times involving end-of-life care, such as whether a dying person should be put on a ventilator to temporarily extend life.

But a pandemic involving an infectious disease brings many other factors into play, she said. With COVID-19, hospitals don't yet have a vaccine or proven medications to halt the disease, so they must support people with breathing machines to give their immune systems time to recover and fight the virus.

Because hospitals might face a crush of patients with the same breathing problems at the same time, beds and ventilators may not be available to care for everyone. Hospitals might need to decide which patients are more likely to recover. Or a patient's time on a ventilator could be limited to allow treatment for others.

"First come, first served is not the best way to make decisions about access to care," Berlinger said. "That would give priority to the people who are diagnosed first. So we have to think that nobody is going to have an unlimited claim on a limited resource."

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Some states already have adopted guidelines for the medical community to consider during a pandemic.

In 2015, the New York State Task Force on Life and the Law updated its voluntary guidelines on how to triage patients in the event of an influenza pandemic. Dr. Howard Zucker, New York State Commissioner of Health, warned there may be an inadequate number of ventilators.

“New York State may have enough ventilators to meet the needs of patients in a moderately severe pandemic," Zucker said in the report. "In a severe public health emergency on the scale of the 1918 pandemic, however, these ventilators would not be sufficient to meet the demand.”

Officials from the state Department of Health, the Governor's Office and other agencies are working on an emergency update of the guidelines for use during the COVID-19 pandemic, said Samuel Gorovitz, a task force member and former dean of arts and sciences at Syracuse University.

The group debated how to handle New York hospitals with more ventilators than others, as well as hospitals with more patients who need ventilators than others, he said.

“One walks a very fine line in making these decisions,” Gorovitz said. “One of the concerns is how to walk through this nightmare and not induce panic or despair and yet do the things that serve the greatest needs.”

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There are several projections on how many patients might flood U.S. hospitals. In a report on a moderate flu pandemic, the U.S. projected 200,000 Americans would need the most extreme level of care: a bed in a hospital intensive care unit. If the pandemic worsens to levels of the 1918 Spanish flu pandemic, 2.9 million would need ICU care, according to a CDC report.

The CDC's worst-case-scenario envisions up to 210 million Americans infected by December. An estimated 21 million people would need hospital care and 200,000 to 1.7 million could die by the end of the year.

Vice President Mike Pence said federal officials have worked to shore up the nation's supply of ventilators.

"We’re encouraged to learn that we’ve literally identified tens of thousands of ventilators," Pence said Thursday. "And we remain increasingly confident that we will have the ventilators that we need as the coronavirus makes its way across America."

Contributing: USA TODAY reporters Jayne O'Donnell, Kevin McCoy and Kim Hjelmgaard