In the coming weeks, difficult decisions about who will live and who will die in Alabama may hinge on a little-discussed document outlining the state’s suggested “criteria for mechanical ventilator triage” during pandemics like the current COVID-19 outbreak.

According to the state document, any of a wide range of underlying health conditions – such as metastasized cancer, AIDS, “severe mental retardation,” advanced dementia and “severe burns” – could disqualify patients from being put on potentially lifesaving ventilators if a pandemic grows dire enough. And some people already on ventilators could be removed from them to make space for people impacted by the pandemic, according to the guidance.

Over the past two weeks, doctors in Italy have called on the world to take the disease more seriously, sharing horror stories about having to choose which people to put on ventilators. They have had to make those dire decisions based on patients’ age, underlying health problems and other considerations.

Under the triage criteria, which the Alabama Department of Public Health initially drafted in 2009, many patients could be denied access to ventilators and instead relegated to in-patient or home palliative care.

In April 2010, the State Committee of Public Health approved a revised version of the protocol detailing the exact processes hospitals and health care facilities should follow when making such decisions during a deadly flu outbreak or other major pandemic.

“ADPH suggests that hospitals utilize this criteria as a template for local and regional disaster management plans,” according to a 2009 ADPH study on the ethics of disaster response that analyzed the draft version of the protocol.

Dubbed “Criteria for Mechanical Ventilator Triage Following Proclamation of Mass-Casualty Respiratory Emergency,” the document is based on a three-tier triage criteria model designed by two Minnesota emergency doctors in 2008, according to the 2009 study.

The Alabama plan, which is still posted on the ADPH’s website, was developed as part of a years-long effort to prepare for potential pandemics and institute protocols for such events.

The department did not respond to an inquiry about the document. But spokesman Arrol Sheehan said in an email last week that the ADPH “is basing its actions and response to COVID 19 on upon (sic) previously developed Pandemic Plans. ADPH is continuing to adapt pandemic planning based upon the disease patterns of COVID 19.”

And a notice on the department’s dedicated pandemic influenza website states that “[g]uidance and tools developed for pandemic influenza planning and preparedness can serve as appropriate resources for health departments in the event the current COVID-19 outbreak triggers a pandemic.”

Ventilators needed

The Alabama document states that it “outlines a ventilator triage protocol intended for use only during a mass casualty event, proclaimed as a public health emergency by the Governor,” and names pandemics and influenza epidemics as key examples of such an emergency. On March 13, Gov. Kay Ivey declared coronavirus a state public health emergency.

In countries where COVID-19 patients have already filled ICUs and exhausted stockpiles of medical equipment, one critical limiting factor has been how many ventilator machines have been available for patients facing respiratory failure.

According to the Alabama Hospital Association, there are currently 1,344 ventilators statewide, about 546 of which are in use on an average day. That leaves about 800 available ventilators to handle the anticipated surge in coronavirus patients.

Experts say that might not be enough. If precautions like social distancing are not properly followed, Don Williamson, president and CEO of the Alabama Hospital Association, said last week that Alabama “will have a huge spike of disease over a potentially short period of time and our healthcare system will be overwhelmed … We won’t have enough doctors, beds, ventilators, PPE and it will be absolutely catastrophic.”

Early on in the 18-page protocol is the assertion that as a “measure of last resort,” after all other possible remedies have been exhausted, “[a]ll efforts should then be directed to provide aggressive treatment to those with the greatest chance of survival even if that requires removal of supportive care from others.”

The document includes a flow chart for implementation of the protocol, including how to determine which patients to deny the use of a ventilator and instead offer “supportive or palliative care either in-patient or home.” The plan also provides guidance about which patients to remove from ventilators to make room for other patients once “all available resources such as ventilators and staff are exhausted.”

A ventilator triage flow chart, from the Alabama Department of Public Health's "Criteria for Mechanical Ventilator Triage Following Proclamation of Mass-Casualty Respiratory Emergency" protocol.

'Last resort'

During a mass-casualty respiratory emergency, the Alabama protocol says that hospitals should “not offer mechanical ventilator support for patients” if they suffer from or undergo any of a long list of medical issues and events, such as cardiac arrest, severe trauma, dementia, metastatic malignancy, severe burns and end stage organ failure.

Another subset of patients that could be denied the use of a ventilator is people “with severe functional impairment produced by static or progressive neurological disorders … For example, persons with severe mental retardation, advanced dementia or severe traumatic brain injury may be poor candidates for ventilator support.”

AIDS is listed as a diagnosis that could result in a person not being put on a ventilator, though the document states that “presence of +HIV status without AIDS is not an automatic exclusion.”

In the event of a severe health crisis in which no ventilators are available and all other options have been exhausted, the document states that health care facilities should “[r]eassess ALL ventilator patients [after] 48 and 120 hours” to determine whether they still meet the criteria to be on a ventilator.

The protocol notes that it does not “preclude ventilation by hand provided the appropriate resources are available.”

The document makes clear that the ventilator triage protocol should only be used as a “last resort” in the face of a health crisis “characterized by frequent, widespread cases of respiratory failure occurring in sufficient volume to quickly exhaust available mechanical ventilator resources. One example might include, not exclusively, a virulently aggressive form of pandemic influenza.”

If conditions become grave enough, “availability of ventilator care and Intensive Care Unit (ICU) care may become extremely limited in any locale,” the document explains.

“Some mass casualty disasters, such as a pandemic event, may necessitate that commonly accepted standards of medical care be altered to provide the maximum number of patients their best chance of survival.”