The coronavirus outbreak is forcing the U.S., a nation largely unaccustomed to scarcity, to have tough conversations about how to allocate limited medical resources as hospitals warn its only a matter of time before they're inundated with COVID-19 patients.
Across the country, hospital officials are discussing ethical dilemmas and attempting to draft policies about rationing care when patients needing ventilators and other resources dwarf the supply, several hospital ethicists told Healthcare Dive. In addition to issues of mortality, questions also are being raised about whether medical workers can opt out of treating patients with COVID-19, particularly if they don't have the right personal protective equipment.
"They are having these conversations at the policy level," Kelly Dineen, director of the health law program at Creighton University and a member of COVID-19 Ethics Advisory Committee at the University of Nebraska Medical Center, told Healthcare Dive.
Ethical dilemmas are usually tackled by a hospital's ethics committee, which, in an ideal scenario, encompasses a variety of workers from across the hospital, including clinicians, ethicists and social workers.
No federal mandate exists requiring hospitals to have such committees. However, many do to meet accreditation standards that require facilities to have some sort of mechanism for ethics conflicts and decision making. Many choose to meet that standard by having an ethics committee, though not all do, according to one expert.
Hospitals are at risk of not having the capacity to care for a surge of COVID-19 patients if an outbreak similar to Wuhan or Italy occurs here. New York Gov. Andrew Cuomo has pleaded with the federal government to allow the Army Corps of Engineers to build back-up facilities as the COVID-19 rapidly spreads through areas of the hard-hit state. Similarly, California Gov. Gavin Newsom has requested a Navy hospital ship and two mobile hospitals to address a surge in patients.
Federal officials are urging Americans to do their part by retreating to their homes to socially distance themselves from others in an effort to hamper the disease's reach. CMS also last week urged hospitals to put off non-essential elective surgeries to prepare for an onslaught of cases. Years of culling hospital beds in a shift to outpatient care has the nation's facilities short of meeting expected demand under some prediction models.
The concern about scarce resources is not unfounded. Italy's healthcare system has been pushed to the brink and many see parallels in terms of the trajectory of the spread. Overwhelmed with sick patients, Italy's society of anesthesiology and intensive care published recommendations on how to prioritize patients and not just serve the first in the door.
China, the first country to report cases of the disease, feverishly began building hospitals to meet demand.
And the U.S. has far fewer hospital beds per 1,000 residents than China or Italy.
It's important facilities across the country start having conversations about allocating resources now before clinicians are pushed to their limits, ethicists said.
"Any time you have that kind of pressure and load … it's going to be hard to also be thinking about all of the ethical implications and what that means in a way that might otherwise not be so hard," Dineen said.
The struggle will be effectively communicating those policies throughout a system or hospital, Erica Salter, associate professor and program director of the doctorate program for healthcare ethics at St. Louis University, told Healthcare Dive.
"It's wise to anticipate failures of communication and protect against those," Salter said.
Ultimately, those policies will vary by institution, though ethicists said it's important to be proactive rather than reactive. And hospitals should also be prepared to be held to account for decisions that are made, Dineen said.
Patients and their loved ones will want to know there was a process and that it was fair, not arbitrary.
"There's no reason we can't be prepared with a process, even if we don't necessarily have a better answer," she said.
Still, despite the most well-intentioned plans it will always be the doctor's call, Arthur Caplan, head of the division of medical ethics at NYU School of Medicine, told Healthcare Dive.
"You're going to see variation in what is decided floor to floor, doctor to doctor, hospital to hospital," Caplan said.
Still, some hospitals are hesitant to issue overly broad guidance because of the liabilities that might come later. However, depending on the state, emergency orders issued during a pandemic may help shield providers or systems from liability as standard of care decisions were made during a unique situation.
And, though Americans may struggle to talk about the end of life and mortality, the medical profession is used to tough conversations about scarce resources.
For example, when dialysis machines were first developed, the technology was not widely available for everyone with end-stage kidney failure. A decision had to be made about which patients were granted access to the lifesaving treatment and which ones were not. It's a conversation that continues today for those needing transplants.
"The principles guiding these decisions are not new," Salter said. "We've been dealing with issues of scarce resources for many decades."