We are doctors. We were trained to heal, to bring relief, and on occasion, to guide patients and families through end-of-life challenges. Unfortunately, with the emergence of the COVID-19 pandemic, places such as Italy have had to suffer from needing to make life-and-death decisions for patients simply due to insufficient resources. In Los Angeles, it seems that we are on-track with preparation for the COVID-19 surge after having learned from those that have been most heavily impacted before us, and we appear to have sufficient resources to administer care to all. However, the process of preparation involved discussions of frameworks for resource utilization that may come as foreign concepts to many. Having knowledge of these frameworks for scarce resource allocation may be beneficial in planning for future emergencies.
COVID-19, also known as both coronavirus disease 2019 and SARS-CoV-2, is a rapidly spreading virus with an estimated 2 to 3 percent mortality rate in the United States. It has grown to become a global pandemic. With almost 2 million cases globally and over one-third of these cases occurring in the United States, the virus has been spreading like wildfire. It is staggering that COVID-19 now results in roughly 1200-2000 deaths per day, now becoming a leading cause of death. The combination of ease of transmission and how highly communicable the disease is, along with a significant rate of mortality, has resulted in not only a national emergency but has also had the power to impact nearly every facet of global affairs and financial markets.
The response to COVID-19 has been social distancing, improved hygiene, and a medical call-to-arms, but what is done in places where this is not enough? Globally, we witnessed the massive spread of the virus throughout various countries in Europe and Asia, and the capacity of COVID-19 to overwhelm and exhaust available medical supplies and personnel became painfully clear. In Italy, a hospital system with 3.2 hospital beds per 1000 people, compared to 2.8 in the United States, became easily overwhelmed by the COVID-19 surge. Even with the cancellation of elective surgeries, postponing non-urgent/emergent interventions, and converting operating rooms to function as intensive care units (ICUs), capacity was reached, and ultimately there were not enough ventilators available to support all those that required this level of intervention to support their breathing to stay alive. A medical provider highlighted in the New England Journal of Medicine article, “Facing Covid-19 in Italy – Ethics, Logistics, and Therapeutics on the Epidemic’s Front Line,” has stated, “we have to decide who must die and whom we shall keep alive.” This is what Italy has faced. We are hopeful that resources are sufficient for the remainder of the outbreak in the United States, though it certainly has brought questions regarding resource utilization to the limelight.
Italy found the demand for resources greater than the supply. If we were to reach a time that our health care system is similarly overwhelmed, then the decision-making needs to switch from the individual to the population with the goal to viably save as many as possible. The goal would be to provide limited resources in a manner that achieves the greatest benefit. Resource considerations account for not only the limited supply but also for the prolonged duration of use of some of these resources, as it is not uncommon for patients to require ventilatory support for well over a week. This decision-making applies not only to ventilators, but other limited critical care resources such as critical care beds, continuous renal replacement therapy (CRRT) for end-stage kidney disease patients, intra-aortic balloon pumps (IABPs) to support blood pressure in severe heart failure or after a major heart attack, and medications.
A solution many hospitals pursued in an anticipatory manner is the development of committees to have providers who are not directly administering treatment to be involved in execution of resource allocation and triage of patients. The benefits of such a committee include minimizing moral distress to the treating provider, avoidance of conflicts of interest, and promoting objectivity in decision-making. It is guided by a framework that assesses individuals based on their prognosis for both short- and long-term survival, consideration of comorbid conditions (e.g., heart failure, end-stage kidney disease, liver disease), probability of survival, as well as the severity of the respiratory illness. These are not novel concepts and have been applied in some areas to the novel coronavirus.
We are grateful to be avoiding the need to use draconian measures for resource allocation. We have been afforded the blessing of lead-time here in Los Angeles and have the chance to learn from other parts of the world, as well as other areas within the United States. We are preparing our personal protective equipment, re-organizing team structures and hospital workflow, taking new precautionary measures, and expanding the skillset of providers to maximize manpower. In case resource utilization reaches capacity, frameworks are in place to guide decisions in the most ethical and morally appropriate manner possible, and such frameworks remain available in future disaster scenarios. While we as health care providers address COVID-19 from the frontlines, there are still many ways the public at large can contribute to the battle against this pandemic that we all face, though the storm seems to slowly be calming.
Alexander Connelly is an internal medicine physician.
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