In addition to ventilators, there are four primary care rationing scenarios during the coronavirus pandemic, a bioethicist says.
“It is not just about ventilators. This pandemic, particularly in places such as New York, Detroit, and New Orleans, is forcing triage and rationing at almost every level,” says Christine Cassel, MD, a bioethicist and adjunct professor at UCSF Medical School in San Francisco, and a former president and CEO of the National Quality Forum.
There are four main areas of care rationing during the COVID-19 pandemic, she says.
1. Coronavirus testing
Diagnostic testing has been rationed since the first U.S. COVID-19 patient was identified in January, Cassel says. “Everywhere across the country, you can’t just walk in and get a test. There are certain criteria—in the beginning, you had to have a history of foreign travel and you had to be symptomatic. So, many people who want to get a test cannot get one because there is a shortage.”
With coronavirus tests in short supply, there should be prioritization for who gets tested, she says.
“We need to test high-risk populations. Every nursing home should test every one of their patients. Healthcare workers who are exposed to the virus should be very high priority for testing. People who provide essential services such as pharmacists, grocery store workers, and anyone else whose work exposes them to the public also should be high on the priority list.”
Healthcare workers and essential service workers should also be high priority for testing because they are at risk of infecting other people, Cassel says.
The next level of priority for testing is people who are symptomatic or have been in contact with infected people, she says. “If a family member gets ill, you want to test everybody in that family, not just the infected family member. It is the cluster principle—you want to test everyone who has contacted an infected person.”
2. Healthcare worker shortage
The scarcest resource in the pandemic is often healthcare staff, Cassel says.
“We just do not have enough trained doctors and nurses who have the skills and the training to deal with respiratory failure. Before the pandemic, there would be one or two nurses per patient on a respirator because these patients need constant attention. Now, there could be one nurse per 10 patients. That nurse is trying his or her very best to provide the care that all patients need, but there is only so much attention that you can give to any one patient at any one time.”
Healthcare workers should have a framework that helps them ration their care time, she says. For example, ICU nurses should have guidelines for prioritizing care of ventilated patients.
“The framework should have clinical characteristics to prioritize patients for attention. It is very important that these characteristics be clinical and not social, or racial, or age-based, or disability-based, ” Cassel says.
3. Emergency medicine
During COVID-19 patient surges, emergency rooms can become overwhelmed and staff can face difficult decisions on whom to treat first, Cassel says.
“The emergency room physicians have metrics that they use similar to the clinical scores that critical care doctors and nurses use. Using those metrics, they can often figure out the risk patients face. Ideally, they have the time to think things through and make tough decisions. When there is little time for decision-making, a gut feeling or clinical experience can determine whether a patient needs help immediately or they can afford to wait for care.”
4. Therapies and vaccines
Remdesivir has been shown to have a modest clinical impact on COVID-19, but the hope is that more effective medications and vaccines will be available in the future. In the short term, there will likely be rationing decisions in this area, Cassel says.
“Once we have an effective treatment or a vaccine, those medications are not going to be instantly available to everyone. So, we must anticipate that there may be decisions to be made from a public health perspective.”
There are several guiding principles for making rationing decisions during the COVID-19 pandemic, Cassel says.
“The best way to do it is to be very transparent, rather than having each clinician on the frontlines feeling like they have to make these decisions. There need to be clear guidelines at the state or municipal level that are endorsed by the government because clinicians will often feel legally vulnerable. In our system, where people are very litigious, doctors and nurses can feel vulnerable, and that just adds to the anxiety and the moral distress they are already experiencing.”
Rationing guidelines should be developed as quickly as possible through an inclusive process, she says. “Ideally, the guidelines will have broad public input from all the stakeholders involved. That way, if the guidelines need to be put into effect, they come from the community.”
Attending physicians should not be thrust into making rationing decisions for their patients, Cassel says. “The decision should be made by an independent committee that is not directly involved in the patient’s care. That is ideal because the individual doctor does not have to feel conflicted in that decision.”
Fairness and justice are key concepts in rationing decision-making, she says. Fairness can simply mean first-come, first-served or a lottery to be blind to the characteristics of patients. However, rationing decisions based on fairness alone are usually considered unjust because care may not benefit the people who need it the most.
“In a situation of dire shortage, you may have to provide care to the patient who has the better chance of survival,” she says.
Care has been purposely rationed in the United States for decades, Cassel says. The most conspicuous rationing of care has been on the ability to pay.
“Because we have a market-based system and because we do not have universal health insurance, people who are poor are much less likely to be able to afford high-quality health insurance. They either have no insurance, or they have Medicaid, which pays very little in many states and is not accepted by many physicians or hospitals, or they have very high-deductible insurance plans, which you have to pay thousands of dollars out of pocket before any coverage kicks in. So, very often, poor people make the decision not to seek care.”
Organ transplants have been rationed by law since the passage of the National Organ Transplant Act in 1984. “There are thousands of people on waiting lists all over the country for organ transplants—some of them more desperately ill than others,” she says.
The 1984 law established a national organization—the United Network for Organ Sharing. “They set up broad guidelines for allocation. People get on the lists under certain criteria. Sometimes, those criteria are controversial, sometimes the criteria vary from state to state. There are committees—there are people who make this their work of deciding who should get an organ when one becomes available,” Cassel says.