Rationing ventilators in a pandemic: How to mitigate the burden of life-or-death decisions?

Physicians in some well-resourced countries are having to make the unprecedented decision of which patients get a mechanical ventilator due to shortages under the coronavirus disease 2019 (COVID-19) pandemic. According to experts from the US, triage committees can help mitigate the enormous burden and buffer treating clinicians from the distress of such life-and-death decisions.

“The COVID-10 pandemic has led to severe shortages of many essential goods and services, from hand sanitizers and N95 masks to intensive care unit [ICU] beds and ventilators,” wrote Dr Robert Truog, Ms Christine Mitchell and Dr George Daley from the Harvard Medical School and Boston Children’s Hospital, Boston, US, in an article published recently in The New England Journal of Medicine. [N Engl J Med 2020, doi: 10.1056/NEJMp2005689]

Several countries, but not the US, have experienced a shortage of ventilators in the current pandemic. However, with experience in Italy suggesting that 10–25 percent of hospitalized COVID-19 patients will require ventilation, in some cases for several weeks, and the US Centers for Disease Control and Prevention (CDC) estimates that 2.4–21 million Americans will need hospitalization during the pandemic, the authors pointed out that there could be 1.4–31 patients requiring ventilation for each ventilator available.

“Unlike decisions regarding other forms of life-sustaining treatment, the decision about initiating or terminating mechanical ventilation is often truly a life-or-death choice,” they wrote.

In the absence of a pandemic, mechanical ventilatory support would be continued in patients who are already on the treatment, even if their chances of survival may be low. According to the authors, withdrawal of ventilatory support at the request of a patient or a surrogate is considered an ethical and legal obligation, and can be done in certain settings when treatment is determined to be futile.

In a pandemic, however, decisions to withdraw ventilatory support cannot be justified in either way to make the resources available to other patients, they noted.

Yet, in Italy, there have been reports of physicians “weeping in the hospital hallways because of the choices they were going to have to make”.

“The angst that clinicians may experience when asked to withdraw ventilators for reasons not related to the welfare of their patients should not be underestimated – it may lead to debilitating and disabling distress for some clinicians,” the authors pointed out.

A triage committee, composed of volunteers who are respected clinicians and leaders among their peers and the medical community, could buffer the treating clinicians from the potential harm of decisions on ventilator withdrawal during the pandemic, they suggested.

With the goal of saving the most lives possible during an unprecedented crisis, the use of a triage committee allows treating clinicians to maintain their traditional roles as fiduciary advocates, and removes the weight of decisions on ventilator withdrawal from any individual clinician, explained the authors.

In addition, such decisions made by the committee would be consistent and unbiased across patient groups, with flexibility to consider factors that may be unique to a given situation. “The committee can also adjust its rationing criteria to achieve the best possible outcomes as the availability of ventilators increases or decreases,” they added.

Triage committee members should also be tasked with communicating decisions on ventilator allocation to patients’ families, the authors suggested, because the treating clinicians’ well-intended representations to comfort family members, if inaccurate, could ultimately undermine public trust and confidence.

“Similarly, the physicians, nurses or respiratory therapists who are caring for the patient should not be required to carry out the process of withdrawing mechanical ventilation. They should be supported by a team who is willing to serve in this role and has skills and expertise in palliative care and emotional support for patients and families,” the authors emphasized.

In New York State, guidelines on ventilator allocation, updated in 2015, target saving as many lives as possible based on a patient’s short-term likelihood of surviving an acute medical episode. Rationing is performed by a triage officer or a triage committee with no clinical responsibilities for the care of the patient. [https://www.health.ny.gov/regulations/task_force/reports_publications/docs/ventilator_guidelines.pdf]

“Although some people may denounce triage committees as ‘death panels’, in fact they would be just the opposite,” the authors pointed out.