Copyright © 2020 Albuquerque Journal
SANTA FE – Doctors and health care leaders in New Mexico are preparing a grim plan they hope is never carried out – standards for deciding which patients get ventilators if there aren’t enough to go around.
They are crafting the recommendations as New Mexico braces for a surge in coronavirus patients that could overwhelm hospitals throughout the state.
“This is completely new,” said Dr. Jonathan Bolton, director of the Institute for Ethics at the University of New Mexico Health Sciences Center. “You won’t meet anybody who has lived through a pandemic like this.”
Projections released by the state Department of Health suggest the state will face shortages of hospital beds, intensive care beds and ventilators at the peak of the outbreak, which could come later this month or in May.
Bolton is part of a four-person committee working on a protocol to help hospitals navigate the possibility of encountering more patients than they can care for.
Their proposed Crisis Standards of Care will go to the state’s medical advisory team, which will, in turn, make a recommendation to Gov. Michelle Lujan Grisham’s administration.
The governor could issue an order making the standards mandatory or leave it to hospitals to decide.
The goal, in any case, is to relieve the burden on front-line health-care providers – to ensure they aren’t asked to determine whose life is most valuable if, say, only one ventilator is available for multiple patients.
“We’re getting ready for a crisis,” Human Services Secretary David Scrase, a medical doctor, said in an interview. “We don’t want individual doctors and nurses being in a situation where they’re having to make tough ethical decisions without a sturdy and detailed framework.”
Likelihood of survival
The recommended standards, still under development, are expected to focus on one factor above all others – likelihood of survival.
In some ways, the proposal is notable for what it doesn’t include. Doctors and nurses wouldn’t consider patients’ age, whether they have children who depend on them, their occupation or ability to pay.
Instead, the group focused on a patient’s prognosis – their likelihood to survive the treatment. If a tie-breaker is necessary, it would be handled through a lottery of sorts.
Robert Schwartz, a UNM regent, law professor and co-author of a textbook on health law, said the committee members struggled with what criteria to include.
Age discrimination is illegal, so that was out. But Schwartz said the committee considered alternatives that would take into account the patient’s stage of life. Had they had a chance to raise a family or pursue a career?
They also examined whether parents with children should be given priority. But what if a patient couldn’t have children or decided against it for ethical or personal reasons?
Schwartz and Bolton said the committee is leaning against taking such factors into account.
“We couldn’t convince ourselves that there was a just way of selecting among people,” Bolton said.
Schwartz put it this way: “It’s almost impossible to find a principle that can’t be abused.”
Furthermore, they said, health care workers need quick, simple criteria that can be applied to a large number of patients. Prognosis seemed like a neutral standard.
But even that, Schwartz said, is fraught with ethical questions. A person with a strong likelihood of survival, for example, might be in that position because they could afford health care throughout their life while another patient couldn’t.
“There is no perfect answer,” Schwartz said.
But they tried to craft a fair system, Bolton said, “to maximize the number of people who can survive, who can recover from their illness.”
Ventilator shortage seen
New Mexico health officials are employing a statistical model to help them prepare for the worst.
A projection Scrase released Thursday forecasts that New Mexico will have less than half the ventilators and one-third of the Intensive Care Unit beds that hospitals may need at the peak of the virus outbreak.
That’s a shortage of 732 ventilators – a machine that helps a sedated patient breathe – and a shortage of 1,232 ICU beds. The state is also projected to need another 687 general beds.
The forecast, of course, could change. New Mexico hospitals are working to boost their capacity.
Lovelace Health System, for example, is converting anesthesia machines into ventilators, and Lujan Grisham requested an Army field hospital.
The Lujan Grisham administration also ordered the closure of schools and nonessential businesses and instructed people to stay home – an attempt to slow the spread of the disease and ease the burden on hospitals.
“We wanted everything ready,” Scrase said, “so that when we get to the point where we no longer have enough ventilators, ICU beds or hospital beds, we have a plan. (But) we’re doing everything we possibly can to keep from getting to that point.”
Advance directives help
Patients can help, Bolton said, by filling out advance directives.
No attorney or witness is necessary. People can just find the form online, print it and fill it out.
Presbyterian and other health systems also offer the forms through patients’ online accounts.
The form has questions about end-of-life options. There’s also space to write other instructions.
“Some people,” Bolton said, “are deciding they would like to be altruistic and state that if there is a situation where there are too many people, that they themselves would give up” their ventilator to help someone else.
Ethics team to recommend
The ethics committee working on the Crisis Standards of Care includes Bolton, Schwartz, a representative from Presbyterian Healthcare Services and a health consultant.
“It’s a circumstance that none of us ever imagined we’d have to deal with,” Bolton said.
Their recommendation will go next to the state’s medical advisory team. Dr. Michael Richards, vice chancellor for clinical affairs of the UNM Health System, is the team’s operational leader.
The team also includes representatives from Presbyterian, the Department of Health and other state agencies.
After the medical advisory team considers the crisis standards, they would go to Health Secretary Kathy Kunkel, Human Services Secretary Scrase and top staff under Lujan Grisham.