Once Again, I Ask WHO Is to Get the Limited Ventilators? #coronavirus #COVID19

Are you tired of this pic yet?

Physicians in New York City, Los Angeles, and Seattle may soon need to answer the question, if they haven’t already.

From a Perspective article in the New England Journal of Medicine:

But though approaches vary even within a single hospital, I sensed that age was often given the most weight. I heard one story, for instance, about an 80-year-old who was “perfect physically” until he developed Covid-19–related respiratory failure. He died because mechanical ventilation could not be offered. Though Lombardy’s richly resourced health care system has expanded critical care capacity as much as possible, there simply were not enough ventilators for all patients who needed them. “There is no way to find an exception,” Dr. L. told me. “We have to decide who must die and whom we shall keep alive.”

Contributing to the resource scarcity is the prolonged intubation many of these patients require as they recover from pneumonia — often 15 to 20 days of mechanical ventilation, with several hours spent in the prone position and then, typically, a very slow weaning. In the midst of the outbreak’s peak in northern Italy, as physicians struggled to wean patients off ventilators while others developed severe respiratory decompensation, hospitals had to lower the age cutoff — from 80 to 75 at one hospital, for instance. 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.”

Dr. S. was hardly alone. The agony of these decisions prompted several of the region’s physicians to seek ethical counsel. In response, the Italian College of Anesthesia, Analgesia, Resuscitation, and Intensive Care (SIAARTI) issued recommendations under the direction of Marco Vergano, an anesthesiologist and chair of the SIAARTI’s Ethics Section.2 Vergano, who worked on the recommendations between caring for critically ill patients in the ICU, said that the committee urged “clinical reasonableness” as well as what he called a “soft utilitarian” approach in the face of resource scarcity. Though the guidelines did not suggest that age should be the only factor determining resource allocation, the committee acknowledged that an age limit for ICU admission may ultimately need to be set.

It would be easier to make this life-and-death decision if the experienced Italian physicians would share their ventilator survival rates—i.e., how many and what kind of patients were successfully weaned off the ventilator and walked out of the hospital—and who were the patients in which ventilator care was futile. As far as I know, 97% of ventilator patients in China died.

Source: Facing Covid-19 in Italy — Ethics, Logistics, and Therapeutics on the Epidemic’s Front Line | NEJM

Steve Parker, M.D.

Steve Parker MD, Advanced Mediterranean Diet

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2 responses to “Once Again, I Ask WHO Is to Get the Limited Ventilators? #coronavirus #COVID19

  1. It also behooves the elderly and their families here to have this discussion NOW. I did with my mom (87)–“Mom, if you are on a ventilator, and a mother of three comes in who needs one…?” “Of course she should have it. As a matter of fact , don’t even intubate me. I’ll never be the same,and I am already not exactly great.”

    • That is one brave and wise woman, Lee. Of course you’re right about having the discussion now.

      I can’t wait to get the data from Italian physicians regarding survival rates for COVID-19 patients who were put on ventilators. Those rates are quite likely to depend on age and co-morbidities. If 250 consecutive 80-year-olds were intubated but all perished within 3-4 weeks anyway, that should be a clue as to how to allocate limited resources. Physicians are under no obligation to offer futile care.

      But I can hear the objections already. “But medical care is better in the U.S.!” But we’re learning more every day about effective ventilatory techniques.” “But those patients never had the benefit of hydroxychloroquine/azithromycin.” “But I’ll get sued by the patient’s survivors if I don’t give the patient a shot at that one-in-thousand recovery.” To name a few.