THE Covid-19 pandemic continues to spread unapologetically, creating acute shortages of essential healthcare resources ranging from simple hand sanitisers and face masks to hospital beds and mechanical ventilators. Presently, exhausted healthcare systems globally are facing the very real prospect of rationing medical goods and services diligently.
It is expected that in the face of a healthcare crisis, such as disasters and pandemics, there will be a shortage of resources which may contribute to worsening patient morbidity and mortality. Such risk multiplies for patients suffering from breathing complaints and possibly requiring ventilators. There is a very narrow window when those lives can be saved. Hence, all other medical shortages aside, the decision to initiate or withdraw mechanical ventilation is truly a matter of life and death which hangs heavy on the decision-makers whether they be family or the treating medical team.
The goal of ventilator rationing in a pandemic is to save the greatest number of lives. Therefore, the decision about which life to save is usually determined by the likelihood of a particular patient’s survival. Today, the withdrawal of ventilatory support often happens in the emergency department or intensive care unit (ICU) upon the request of the patient’s family and is considered to be an ethico-legal obligation. Withdrawing life support without informed consent is rarely justified but typically it only occurs in specific circumstances when further treatment is deemed futile. However, during the present pandemic, it is the acute shortage of medical/clinical resources that is the driving force and guiding principle behind triaging the allocation of ventilators.
The emotional trauma caused to the front-line emergency or in-patient ICU teams in making such decisions as to place patients on ventilators or withdraw them from the equipment, cannot be ignored. However, a more palatable scenario may arise in leaving the decision in the hands of a hospital ventilator rationing committee consisting of relevant experts including those with sound knowledge of medical ethics. Such a process shall serve as a buffer from critical decision-making for other clinicians who may then remain focused on providing the best clinical care possible.
Ventilator use should be discussed as a time-limited therapy.
We believe that ventilators should not be allocated based on considerations that are difficult to morally and ethically justify. Hence, parameters such as gender, caste, religion, wealth, citizenship, social status, profession, connections, and others, either individually or collectively, should not be used for the rationing of ventilators in these difficult times.
The age of the patient presents an interesting conundrum, with many people simply assuming that all children would automatically be able to access a ventilator if and when required. But during pandemic times with limited machines, moral intuition may best support prioritising a patient, irrespective of age, who could optimally recover from treatment and otherwise would stand to lose significant years of life, compared to one with chronic illnesses that would likely result in death within the span of a few years.
There is a strong precedent for using this criterion when allocating scarce medical resources. The treating clinicians on the other hand should be allowed to repeal the ventilator-rationing committee’s triaging decision if they feel it is unjustified or unwarranted. Ventilator use should be discussed with the family as a time-limited therapy and not an unlimited promise in order to set realistic physician-family expectations. The duration for the trial of ventilation should not be too long whilst causing a steady, progressive and inevitable clinical deterioration of the patient nor too brief in order to avoid the rapid withdrawal of ventilators from patients who, if treated for a few more days, could have survived.
However, the aforementioned recommendations on how to allocate scarce critical care resources during a pandemic or disaster contain ethical and problematic provisions that require appropriate definitions and the establishment of policies on a governmental scale for uniformity during application in various hospitals.
In this pandemic, physicians may have to face situations they have never experienced before and may have to take decisions they have never taken before. This is not the time to blame the healthcare system for its inefficiencies. Our hope is that we are able to identify patients that may benefit the greatest from scarce critical care resources, ventilators per se, while continuing to remember our obligations to care for all patients as best as we can under such difficult circumstances.
The writers are emergency physicians at the Aga Khan University Hospital in Karachi.
Published in Dawn, July 12th, 2020