If we don’t take coronavirus seriously, expect hard choices at Children’s Mercy and beyond
We are at war against COVID-19. The battle requires an unusual strategy. To win, we have to stay home and stay isolated to slow the spread of the virus. If we don’t, we won’t have the resources to care for our wounded and dying. Our doctors and hospitals will have to decide who gets a breathing machine or an intensive care unit bed.
The U.S has about 70,000 ICU beds for adults and another 5,000 for children, and they are already mostly full most of the time. Military hospital ships have a couple hundred more. Our hospitals have roughly 160,000 breathing machines, with a national stockpile of another 12,700.
The goal of all the lockdowns and social distancing policies of the last few weeks has been to decrease the number of patients who will need those ICU beds. We will soon know how well those measures have worked.
In Europe, doctors are making tragic choices. One doctor in Italy wrote that “older patients are not being resuscitated and die alone.” A nurse said, “We are not even counting the dead anymore.” Doctors and nurses here could soon be facing those choices.
This week, two articles in The New England Journal of Medicine propose ethical guidelines for decisions about who gets a ventilator. They make for chilling reading.
In normal times, decisions about life-sustaining treatment are made in careful conversations between doctors and patients. The guiding ethical principle is respect for the patient’s preferences. With pandemic ethics, the guiding principle shifts to one of utilizing scarce resources in ways that will save the most lives. Patient preferences no longer matter. Everyone is treated equally with a goal of maximizing overall survival.
Pandemic ethics are similar to those of triage on a battlefield. A soldier whose injuries are too severe to overcome is allowed to die so that limited resources can be used to treat others with milder injuries.
Coronavirus is turning our hospitals into battlefields. Our health professionals are on the front lines, girding for battle. Elective services and procedures have been canceled. Isolation wards have been created. Clinicians are wearing the body armor of gowns and masks (when they are available). We are hoping for the best and bracing for the worst.
If our efforts to stop the invader have not worked, we will have to make tough choices. Patients who are unlikely to be saved will be allowed to die. Good palliative care can control pain and suffering and make deaths more peaceful.
These decisions will be emotionally painful and ethically troubling. The proposed guidelines suggest that they not be left to doctors at the bedside. Instead, they are to be made by triage committees following strict protocols. Let’s be clear: These committees are not “death panels.” Their goal is to use our scarce ICU resources to save as many lives as possible when not all lives can be saved.
It may still be possible to avoid pandemic ethics. We all need to persist with and intensify our lockdowns and closures to prevent the spread of the virus and decrease the anticipated strain on hospitals.
But we still may need to face the next collective challenges: supporting the difficult work that clinicians will have to do if the resources are not there to provide all the care that patients need. No doctor ever wants to let a patient die from lack of resources. But such decisions may be necessary. To get through this, we need an informed public standing in solidarity with a prepared health care system.
We can do this together. We can only do this together.
John D. Lantos is director of the Bioethics Center at Children’s Mercy Kansas City.
This story was originally published March 25, 2020 at 5:00 AM with the headline "If we don’t take coronavirus seriously, expect hard choices at Children’s Mercy and beyond."