A few weeks ago, as Gov. John Bel Edwards warned that parts of the state were on track to run out of ventilators amid a coronavirus surge, Dr. Stephen Brierre went looking for a document he hoped he would never have to use.

If coronavirus overwhelmed state hospitals, the governor would likely have implemented “crisis standards of care” — a set of doomsday guidelines that directs hospitals on how to dole out equipment and choose which patients get potentially lifesaving treatments. Brierre helped to write those guidelines in 2009 amid the swine flu outbreak.

Just writing them was painful for Brierre, an LSU Health Sciences pulmonary and critical care specialist. The idea of having to use them seemed to go against his mission to save the sickest of the sick; Brierre often treats patients who are on life support and has been working in coronavirus intensive care units at Baton Rouge General.

“It makes me sick to my stomach to think about it,” Brierre said. “This is the worst. But it is our duty to plan for it, because you can’t step into this situation, if it ever occurred, and say, ‘Oh shit, what now?’

“It’s like having a plan to push the button on a nuclear war,” he added. “You never want to push the button.”

The risk of Louisiana running out of ventilators appears to have passed, thanks to social distancing measures that have slowed the virus’s spread. Brierre said the past month was the closest the state has ever come to enacting the crisis plan but that they were still a long way off from needing it.

Patients in the U.S. typically expect to receive every type of care possible to stay alive, and their health care providers anticipate having every resource at their disposal to keep patients alive. A pandemic like COVID-19 could have changed that, with triage committees and rarely seen plans determining who gets a ventilator, who gets a hospital bed and who gets a full-court press of lifesaving care.

For Louisiana hospitals, it is all laid out in a 70-page document titled “State Hospital Crisis Standard of Care Guidelines in Disasters.”

The document says that the level of care a patient should receive would largely depend on how a patient performed on a test, known as a modified sequential organ failure assessment score, which assigns points based on how a patient’s brain, heart, lungs, kidneys and liver are performing.

Dr. Michael Rolfsen, an internal medicine physician who teaches bioethics at LSU, said that the more failure those organs are showing, the less likely they are to recover. Rolfsen also helped to draft the 2009 guidelines.

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Rolfsen said that using the assessment score “allows us to respect our duty to be good stewards of societal resources without discrimination.” Someone who is elderly, disabled or has another underlying health condition might score lower because their organs are shutting down or their immune system is not up to fighting a vicious virus, he said.

“Their score would reflect that, but without regard to the reason, they were sicker,” Rolfsen said.

The document includes three stages of triage plans: conventional, contingency and crisis. In crisis, when hospitals are operating with too few resources, not every sick person would be a candidate for admission to intensive care units, or even the hospital’s non-ICU areas.

Patients with intermediate to high chances of survival with treatment would be admitted, based on the triage flowcharts. Others patients deemed too sick to benefit as much as others from lifesaving measures would be sent to palliative care and hospice services.

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“Priority should be given to patients for whom treatment would most likely be lifesaving and whose functional outcome would most likely improve,” the standards say. “Such patients should be given priority over those who would likely die even with treatment and those who would likely survive without treatment.”

Physicians who worked on drafting the “crisis of care” document and academics who run the LSU Ethics Institute say they want the public to be aware of what the guidelines say and how they work.

But Brierre said it’s something no doctor ever wants to face.

“Personally, I would deplete everything I had, I would call in every favor I know, I’d call every doctor I know to never activate this plan,” he said. “If that means I’m sending a hospital COO in a van to Arkansas to grab me some ventilators, go get me some ventilators. When I say, I’m going to deplete everything, I’m going to deplete everything, including my own personal health.”

Still, a grim calculus of care rationing had to be put in place in Italy, in an area with an advanced health care system on par with the United States. Overwhelmed with patients, doctors had to make horrific choices about who to save and who to abandon to the virus.

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The awful scenes from Italy were fresh in the minds of American officials, including Edwards and New York Gov. Andrew Cuomo, when they were pleading with the federal government for more ventilators.

“As the governor has said before, it's why flattening the curve is so important — so that we don't have to make the sort of tough decisions that Italy has had to make,” said Aly Neel, a Louisiana Department of Health spokeswoman.

If the state ever reaches a stage of crisis, whether because of coronavirus or some other pandemic or natural disaster, the standards advise health care workers to ignore age, race, gender, disability status and class and to focus only on how sick each patient is and how likely he or she would be to recover.

“Social worth, age and other nonmedical factors should not be used in the decision making process,” the document says.

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Some patient advocates worry that the protections don’t go far enough. Late last month, disability-rights advocates filed a lawsuit in federal court in New Orleans against the state Department of Health.

Attorneys Andrew Bizer and Garret DeReus argued that health care providers need to investigate why a particular patient might have a lower chance of survival. They used a hypothetical example of a hospital deciding to give a ventilator to someone without disabilities who had a 75% chance of survival instead of someone with disabilities with a 50% chance of survival.

In a scenario like that, health care providers “cannot default to providing the ventilator to the individual without a disability,” their lawsuit said. Instead, they argued, providers need to determine why they believe someone with a disability has a lower chance of survival, and if their disability is the reason, then care should be allocated on other grounds.

The attorneys withdrew the lawsuit after the Department of Health issued new guidance saying that such decisions needed to be based on objective medical evidence rather than generalized assumptions.

The guidelines say that if they were implemented, health care workers would have to shift to a utilitarian mindset — to provide the most good for the greatest number of people possible.

Still, the crisis of care standards raise the notion of other considerations that could enter a doctor’s mind during a pandemic — such as how many years a patient has left to live, their celebrity status or their ability to care for others as a health care provider.

Rolfsen said the guidelines recommend ignoring such factors because they could be seen as discriminatory against certain groups.

Cecil Eubanks, who runs LSU’s Ethics Institute, said the guidelines are not exhaustive, but that they lay a crucial foundation for health care workers to consider their options in times of crisis.

“One cannot invent enough rules or satisfy enough conditions for there to be certainty in our ethical choices,” Eubanks said.

Some Louisiana doctors and nurses have faced urgent life-or-death scenarios before, especially in the aftermath of Hurricane Katrina in 2005. The state didn’t have similar guidelines back then, medical evacuations were in short supply and a doctor and two nurses were later arrested on second-degree murder counts for the deaths of patients at Memorial Medical Center after their autopsies showed high doses of pain medications. A grand jury refused to indict them, and the state passed new laws to protect health care workers from prosecution for their actions in disaster medicine protocol.

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Brierre noted that Katrina was a fundamentally different type of medical disaster than a pandemic. Patients in hurricanes can theoretically be transferred to other hospitals, and hospitals affected can receive supplies from other places, he said. But in order for the crisis standards to kick in, every hospital or option for resources throughout the country would have to be depleted, he said.

Implementing the standards — which would affect hospitals, mental health providers, Emergency Medical Services and others — would typically require an executive order from the governor, and hospitals would also have their own committees to help implement them. The standards can’t be implemented until nine requirements have been met. Among them: A hospital has reached the limits of its surge capacity; it has tried to get extra resources from local, state and federal levels; and the governor has declared a state of emergency.

“The whole point of having these documents is to prevent front-line workers from having to make those decisions,” said Dr. Sunita Puri, the palliative care medical director for the University of Southern California’s Keck Hospital.

Puri recently spoke to reporters about how hospitals across the nation are responding to concerns about running out of ventilators and other critical resources. She said it’s important to understand the kinds of outcomes patients might have even if there are enough ventilators — Puri said she tries to have frank conversations about the quality of life that patients envision before they’re in a position of needing life support.

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Brierre also warned against misinterpreting Louisiana’s “crisis of care” standards to mean that hospitals would withhold available ventilators or other resources from sicker patients. He said crisis standards differ from rationing because hospitals would not hold back resources simply to have them on hand at a future date.

“That’s not what we do with ventilators,” he said. “We would use every damn ventilator that we had on every patient. That is my biggest fear: that the population would ever think that we would have a ventilator available and not give it to somebody.”

And even if ventilators were to run out, Brierre and Rolfsen said health care workers would continue to treat patients with whatever resources they had, while also reassessing them every day.

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Eubanks said a new and distinct round of unprecedented ethical considerations are coming into focus now as society gets ready to reopen and leaders must balance the possibility of a resurgence of infections with rebuilding the economy.

“The ethical issues we’re going to face are just incredible,” he said.