Stretched to the breaking point by a deluge of COVID-19 patients, four public hospitals in Los Angeles County are preparing to take the extraordinary step of rationing care, with a team of “screening officers” set to decide which patients can benefit from continued treatment that are beyond salvation and should die.
The county’s top health officials have yet to declare a shift to a crisis level of care, which would trigger the rationing system, but the leader of public hospitals acknowledged in a letter reviewed by The Times this week that “there will probably come a point when we simply don’t have enough staff or essential supplies to care for all of our patients the way we normally would. “
The crisis designation would enable newly appointed triage officers – usually critical and emergency care physicians – to decide which patients in municipal hospitals would have access to resources such as ventilators, respiratory therapists and critical care nurses when they become too scarce to care. be provided to each patient.
Hospitals outside the county system will have to decide for themselves whether to invoke similar emergency measures, although state officials told them last week that they should have screening plans in place.
Within many crowded hospitals in Southern California, an undeclared form of rationing already appears to be taking place. Ambulances with patients with COVID were diverted from overburdened medical centers. Severely ill patients sometimes wait days to get intensive care beds.
At a private hospital in Lynwood this week, doctors were in a hallway, arguing out loud whether to give one of the few remaining ventilators to an elderly woman. The doctor who describes the scene said the hospital did not have a formal plan to resolve these disputes.
To confront life and death screening choices, the California Department of Public Health and some hospital systems recommend relying on clinical scoring systems that assess the functions of patients’ organs, generating numerical scores designed to indicate the chances of survival for patients. an individual.
County health leaders found the most common scoring system too rigid and inaccurate to be used as the sole criterion for making screening decisions.
Changing the care of terminally ill patients
They instructed screening officers to use a broader “principled approach” that seeks to shift care from patients deemed terminal to patients deemed to have the best chance of survival.
“Our goal as a health care system will be to save as many lives as possible,” said Dr. Christina Ghaly, who oversees county public hospitals, in a letter to employees this week. “This means failing to provide the best care for each individual patient and moving on to providing the best care for our entire patient population. It also means, possibly, reallocating resources from a patient who is not benefiting to a patient who would benefit ”.
Doctors, clergy and ethics experts have debated for generations how to allocate scarce resources equitably in times of crisis.
“Now we are about to enter unknown territory, as we may have to actually make these decisions,” said Dr. Arun Patel, a doctor and lawyer who oversees the LA county screening program. “Nobody in the United States has had to implement guidelines like this, on this scale, or for as long as necessary.”
Doctors and ethics experts in Los Angeles and across the United States have failed to agree on a single methodology to prioritize patients, or even agree on the appropriate factors in determining who should receive medical care.
Should age be a factor?
Should the patient’s age be a factor? Some ethics experts say that age should rarely, if ever, be a reason to suspend, say, a ventilator or an intensive care bed. Other medical experts say age should be considered, as long as it is not the only reason for providing or denying care.
LA County has warned the 29 doctors who have been put on “hold” to act as triage officers to be aware of possible prejudices or “preconceived notions of quality of life for individuals”, such as the elderly and the physically challenged, according to a memo sent to county health officials in November.
However, in the same memo, the county recognizes that screening decisions can focus not only on saving as many lives as possible, but also on “prioritizing patients who are likely to survive the longest after treatment.”
A doctor at a large Los Angeles hospital acknowledged that he would likely tend to provide care to a 40-year-old over the age of 80, even if they both had an equal chance of surviving COVID-19, because the younger patient would probably have the highest expectation of life.
But Patel also painted a scenario in which a younger patient would not be the obvious choice for the preferred treatment. He noted that Dr. Anthony Fauci, head of the coronavirus response in the United States, is 80 years old, but he is also a runner in good physical shape, able to work 18 hours a day.
“If he was competing for resources with a 60-year-old man, who was very ill, with advanced heart disease and diabetes, I will not make that decision based on a single factor like age,” said Patel.
The county screening document acknowledged that it did not provide a concise set of instructions for screening officers covering “all possible circumstances that may arise in the context of an overwhelming increase in demand”.
County policy is clearer about what it does not allow: discrimination against individuals based on their identity. The guidelines note that it is unethical and illegal to deny care to individuals based on their religion, race, ethnicity, sex, gender identity, sexual orientation, immigration or disability status.
Screening officers should focus instead on each individual’s chance of surviving COVID-19 or other illnesses.
Several doctors who helped build the guidelines said that they emphasize an imperative that should guide medical care even in normal times, but sometimes it does not do that – only provide “beneficial care”.
This means providing treatment only to patients who have a reasonable chance of recovery. The doctrine rejects taking extraordinary measures just to prolong the life of a patient whose death is certain and imminent, often to placate disturbed family members.
A ‘fearful time’
In a memo this week, one of the county’s top health care physicians reminded his colleagues that they should be sure to apply the standard of beneficial treatment immediately – even before an official crisis was declared – so that scarce facilities and personnel do not be wasted on those who have no reasonable chance of improving.
Dr. Nikhil Barot, pulmonary care physician at Olive View-UCLA Medical Center, said he is facing a “terrible time” as he prepares to take on his role as one of the county’s screening officers.
Special training in palliative care and medical ethics makes him feel prepared for the job, but he said he has some anxiety about performing the delicate balancing act that is likely to come.
“We want to give everyone the benefit of the doubt and say, ‘Listen, this is someone who is improving or has a chance to improve, we will continue to do everything we can to bring him back to where he was,'” Barot said .
At the same time, he said he believed that, historically, the United States has often provided excessive treatment to patients.
“I absolutely think that we offer a lot of care that prolongs people’s suffering and keeps them alive when we know that the expected result is death,” he said.
One of the tools invented by the medical community to try to clarify inherently obscure ethical issues is the Sequential Assessment of Organ Failures, or SOFA. The score is based on the condition of six major organ systems: lungs, circulatory, heart, kidney, liver and neurological. Higher scores mean less chance of survival.
SOFA scores gained preference because “they exempt the individual doctor from having to sort everything out on their own,” said Dr. Larry Churchill, professor emeritus of medical ethics at Vanderbilt University in Tennessee. “I think it takes a lot of anxiety out of the decision, but not all, certainly. It relieves the person of having to say, ‘God, I have to figure this out on my own and I’m concerned about my prejudices.’ “
But in LA County, the authorities did not emphasize the use of scores, in part because of a “table” exercise in which an intern applied SOFA to 10 COVID-19 patients and found that nine had the same score. County officials told screening doctors in Los Angeles that SOFA scores are “not the focus” of the rationing plan, although they can be used if they provide clarity.
Rationed care is not inevitable
The shift to care rationing, while likely, is not inevitable, Ghaly and others said. A slight leveling off in the number of new coronavirus infections gave some hope that the emergency rules would not be invoked. And county officials hoped that other guidelines, like ending elective surgery and ending “futile care”, would unlock the ability to treat more patients.
If triage officers are activated, their goal is to allow frontline doctors to continue to focus on the needs of their individual patients, just as they would before the pandemic.
“It is good for the patient and the attending physician to understand that both are focused on patient care and recovery,” said Patel. “The screening officer may be concerned with the broader scenario.”
In LA County, it is recommended that the attending physician inform patients and their families of decisions to remove the ventilator, a nurse, or other care.
Ghaly told county health professionals in his letter to prepare for “difficult conversations between treating physicians, patients and family members about the progression of a critical illness, about the effectiveness of treatment, about letting go”.
Patients or family members who wish to appeal a decision will be referred to the screening officer first. If they are still not satisfied, their concerns will be referred to the chief executive of the hospital or someone designated by the executive.
Health care professionals who have seen many Americans break the rules of social detachment and wearing masks realize that rationing rules, equally inclined to promote the greater public good, will not fall easily with some people.
“We are in a culture that today leans towards individual rights and autonomy,” said Barot. “And these rules say that the health of the population is more important than the health of the individual. There will be an obvious reaction to that kind of statement … no matter how much it makes sense. “