I was still in practice in 2009 and played my critical care physician role in treating patients as part of the H1N1 swine flu pandemic. I do not recall issues as much as they pertain to personal protection equipment (I believe supplies were sufficient) but, as a tertiary care center, our institution was inundated with transfer requests for critically ill patients requiring use of a very sophisticated type of ventilator called an oscillator. Our supply was limited as were the respiratory therapists who could run them and so many transfers were denied once all our oscillators were in use. Regarding the oscillators the biggest hurdle I can remember was knowing how many were available at any one time and, fortunately, once the problem was realized, it was quickly solved. I never recall having a conversation with, or hearing discussions about, anyone in my group of 16 critical care physicians regarding rationing the use of an oscillator. The approach was one of “first come, first serve” when an oscillator became available; otherwise patients remained supported by a “standard” ventilator (patients rarely, if ever, went directly to oscillator support) or not accepted in transfer. Fortunately the pandemic subsided and all was (relatively) quiet until the Covid-19 pandemic began its assault on the world.
For a brief time, although it seemed like an eternity to patients and those in the healthcare system, Covid-19 had the potential to overwhelm the system with escalating rates of infection, available healthcare personnel, lack of PPE, and an ever increasing concern regarding the dearth of ventilators and how to ration those that were available. It is to this last point upon which I wish to give my perspective.
Rationing has always been part of healthcare whether we like it or not. For example, drugs or testing (try spending countless time on the phone with insurance companies, Medicare or Medicaid or with “peer to peer” to get something approved for a patient) are often regulated [rationed] by criteria set forth by the “powers that be.” But let me emphasize, there are criteria, no matter how well formulated or stupid, that are utilized. This brings me round to the early discussions regarding potential ventilator rationing if a hospital does not have the the capacity to meet the demand. Once that tsunami of Covid-19 infections hit, physicians and hospital systems worldwide came to the stark realization that there wasn’t enough–not enough PPE, staff, effective treatments, ICU beds, ventilators and…time. Time to think, to take a breath, to make a thoughtful decision knowing its profound consequences on life or death. At that time physicians did their best, decisions made, with the post-mortems of those decisions to follow. Currently the tact being taken is the formation of hospital committees in which rationing criteria are discussed, agreed upon, periodically modified and made available to physicians to help them in their decisions regarding situations where ICU care or ventilator rationing needs to occur. So, what would some of the criteria be?
Age was one of the first criterion to be considered. Why? Based on early data (see graph below) from China it appeared to be a no-brainer; older folks had higher mortalities thus leading to consideration of picking a certain age above which rationing would be considered and/or implemented. Several weeks ago I read a well written thoughtful article by a 70 year old author from the Hastings Center who, in his discussion regarding a particular age cutoff, opined that 70 years would be acceptable. His rationale? Data showed that deaths began to especially spike at age 70, that the older generation had to give the younger ones every opportunity, and he felt that he had lived a good life and would have been willing to forgo ventilator or ICU care if it meant potentially saving someone younger. However, controversy by that time had already arisen about using age as the sole criterion for rationing.
Fortunately, not soon after mortality data by age was published, wiser heads prevailed by asking, “What, other than age, affects mortality associated with Covid-19?” The answer, comorbidities, those chronic conditions or diseases that may be found in any age group resulting in less than optimal health. Listed in the below table are the comorbidities reported early in the pandemic. The developing rule of thumb–the more comorbidities one has, especially, but not exclusively, coupled with increasing age, the more likely of dying from the virus. Later on, morbid obesity and other comorbidities (see bottom of NYC table further on in blog) were added. The coupling of age with comorbidities has lead to subsequent formulation of healthcare guidelines in different settings regarding those situations where physicians and others were faced with the prospect of denying ICU care or ventilator utilization.
Now, with using age coupled with comorbidity, a better perspective of how this combination can provide an evolving overview of the stratification of patient groups as it pertains to dying from the virus. A snapshot of this can be seen in the following chart:
provided by New York City Health as of April 14:
| AGE | Number of Deaths | Share of deaths | With underlying conditions | Without underlying conditions | Unknown if with underlying cond. | Share of deaths of unknown + w/o cond. |
| 0 – 17 years old | 3 | 0.04% | 3 | 0 | 0 | 0% |
| 18 – 44 years old | 309 | 4.5% | 244 | 25 | 40 | 1.0% |
| 45 – 64 years old | 1,581 | 23.1% | 1,343 | 59 | 179 | 3.5% |
| 65 – 74 years old | 1,683 | 24.6% | 1,272 | 26 | 385 | 6.0% |
| 75+ years old | 3,263 | 47.7% | 2,289 | 27 | 947 | 14.2% |
| TOTAL | 6,839 | 100% | 5,151 | 137 | 1,551 | 24.68% |
As I studied the above information what struck me was the number of patients without a comorbidity in the: a) 18-44yr age range who made up 8% of the cohort deaths but only represented 0.4% of total deaths, b) 45-64yr age range who made up 3.7% of the cohort deaths but represented 0.9% of total deaths, c) 65-74yr age range who made up 1.5% of the cohort deaths but represented 0.4% of total deaths and d) 75+ yr olds who made up 0.8% of the cohort deaths but represented 0.4% of total deaths. The obvious conclusion is that few of us get into our older years without experiencing some kind of comorbidity. The second obvious conclusion is that increasing age plus comorbidities increased the likelihood of death from the virus. The less obvious conclusion, however, is that if one gets into their older years without any comorbidities, then the risk of dying from the coronavirus is the same as those without comorbidities who are younger or much younger. This, then, circles back to the argument using age as the sole criterion for rationing; it should not.
Let’s now put the information above to the test. Here are several scenarios I’ve envisioned, but have not specifically read or heard about. You are the critical care or ER physician on duty and are faced with the following two patients, both with Covid, both with respiratory failure, both need ventilator support, BUT…there is only one ventilator. Decide between one or the other or…neither: I) an 18 year old male otherwise healthy or an 84 year old man with COPD and hypertension, II) a 42 year old morbidly obese man with hypertension and diabetes or a 75 year old woman otherwise healthy, III) a 38 year old woman with advanced cancer or a 73 year old woman with diabetes and hypertension, IV) a 68 year old man with COPD and hypertension or a 72 year old woman with diabetes and chronic heart failure, V) a 38 year old man otherwise healthy or a 76 year old man with hypertension, diabetes, and asthma who happens to also be a noted public figure, VI) a 72 year old woman with chronic heart failure, diabetes, and hypertension or a 72 year old man with chronic heart failure, diabetes, and hypertension.
Did you choose wisely or not at all? The one not chosen may not have thought your choice wise at all. Understand that the guidelines put in place by hospitals all anticipate physicians having time to discuss them with a patient and/or family in those critical decision-making situations. If the clinical status of an already hospitalized Covid patient deteriorates to the point of needing more critical care, then there is a relative “luxury” of time to review guidelines with all involved and make decisions no matter how positive or negative they may be. I suspect that if the 70 year old Hasting Center author was hospitalized with Covid there would be a welcome discussion of the guidelines and most likely a decision not choose ventilator support based on his previous opinion. What if there was no time for discussion, for example, two critically ill Covid patients arriving in an ER at the same time? What if the patient and/or family don’t agree with the guidelines and want “everything done”? While not with Covid, I have encountered the latter in previous clinical situations and leads to an incredible amount of stress for all involved.
There are a few final thoughts on a slightly different, but related topic, having to do with elective surgeries or procedures. I can understand the closing of these in light of the real concerns about the virus overwhelming our health care system. There was a need to divert supplies (e.g., PPE, ventilators), nurses, and at least some physicians (e.g. anesthesiologists) until we could have a better idea of how things were going to play out. Screening protocols and testing needed to be put in place. However, in my opinion, the return to elective surgeries or procedures has been too slow. Any surgeries or procedures done at least at a free standing surgery center could have resumed several weeks ago. Unfortunately the next few months will give us a better picture of the likely non-Covid mini-epidemic of missed cancers, delayed non-cancer diagnoses, and delayed corrective therapies leading to prolonged suffering.
If you wish to leave a comment, click on the particular blog title on the sidebar at www.docmentation.com. This will open up that topic again and at the bottom of the narrative there will be a comment section). Earlier blogs: Inaugural, Oscar, “That will be $108”, SODA POP, On the Evolution of the Medical Record, Housecall, The Four Reasons, Medicare and Medicaid, Responsibility, Decisions, Tales from the ER, can be found with “search” or, for some, just scroll down the page.