Reallocating ventilators in the Covid-19 pandemic
Andrew Peterson and colleagues, Emily Largent and Jason Karlawish, publish an analysis in the British Medical Journal on the ethics of reallocating ventilators in the Covid-19 pandemic.
Below is the press release from UPenn:
The COVID-19 pandemic has left many healthcare providers scrambling for resources to treat cases over the last several months. And public health officials fear a resurgence in cases. Doctors and healthcare professionals may be forced into difficult decisions: Whom do you save?
In a recent paper published in the BMJ, authors Andrew Peterson, Penn Memory Center Clark Scholar Emily Largen, and PMC Co-Director Jason Karlawish analyzed the ethics of allocating scarce medical resources in the COVID-19 pandemic while addressing potential harms to at-risk populations.
"The potential for [allocation decisions] to disproportionately affect vulnerable populations—including older adults, people from minority communities, or people with disabilities—is a particular concern," the authors wrote.
Ventilators have been the topic of fraught discussions. How many are needed? Where can hospitals acquire them? And who should receive one if there are not enough for every patient, specifically in the hardest hit nations? While ventilator shortfalls have been temporarily avoided, a potential spike in cases would put even more patients in a dangerous position.
Decisions on treatment are focused on saving the most lives and, in principle, try to avoid assumptions about quality of life. In practice, the authors argue, biases against at-risk populations may disadvantage them from receiving scarce resources.
"When we make rationing decisions, it's the case that even the people who don't get the resource have a legitimate claim to it…Sometimes though, people let inappropriate factors weigh into their calculations, and that can disadvantage some groups," Dr. Largent said.
Dr. Peterson observed that people with disabilities, people from minority communities, and older adults appear to be the first abandoned during a "ruthless utilitarian" approach to resource allocation. The injustice in this, he added, is that emerging data suggest that these populations are the most likely to die from COVID-19 largely due to longstanding structural inequalities in health care.
To combat this indirect bias, the authors suggest several methods, including weighting triage scores based on health disparity indices and including patient advocates from disadvantaged communities in the triage process.
While lockdown restrictions are easing in the U.S, the authors recognize these interventions need time and patient-doctor contact that can be difficult to work around in a pandemic. Still, they argued the health and wellbeing of patients cannot be compromised.
"Doctors need to look at the patient in front of them—as an individual—and decide what care is appropriate or not," said Dr. Largent.
Ultimately, the authors think health care professionals can take this time to reflect and improve on policies put in place early in the pandemic. The scientific community has had a chance to learn more about the virus, the effectiveness of lifesaving treatments like ventilators, and how individualized and compassionate care can still be delivered in the midst of physical distancing guidelines.
"Public scrutiny of recommendations for the withdrawal and reallocation of scarce lifesaving resources is also vital. Vigorous debate can enhance transparency and trust in triage policies and ensure that the most vulnerable among us are treated fairly," the authors wrote.