When a hospital is overwhelmed with COVID-19 patients, deciding who gets critical care

New state plan guides doctors, nurses on difficult ethical questions

It is a nearly impossible decision: Who would get life-saving treatment when hospitals are overwhelmed by critically ill patients and running out of equipment or space?

The state released a plan last month to help guide medical providers navigate these ethical questions.

Under the state’s direction, the NC Institute of Medicine, the NC Healthcare Association, and the NC Medical Society developed a hospital triage plan to use in a pandemic. It ranks patients based on how well their vital organs are functioning, as well as determinations of whether they would live long enough to leave the hospital if they got intensive medical care.    

The goal “is to maximize benefit to populations of patients, often expressed as doing the greatest good for the greatest number,” the plan says. “It should be noted that this goal is different from the traditional focus of medical ethics, which is centered on promoting the well-being of individual patients.”  

Dr. Sunita Puri is the ethics committee chair at Keck Hospital of USC and Norris Cancer Center. In a webinar with reporters last year, Puri said contemplating “population-centered ethics” is difficult for medical providers, who take a professional oath to save individual lives whenever possible. 

“It’s a very, very big shift in the thinking physicians and in the expectations the public might have of doctors and nurses during the time of shortages,” Puri said. “I want to acknowledge that’s a big shift and uncomfortable for everyone involved.”  

North Carolina’s plan would go into effect in a pandemic when the governor declares a state of emergency, and the “critical care resources are, or shortly will be, overwhelmed.”   

The state has met the first condition, but not the second, a state Department of Health and Human Services spokeswoman said in an email.   

“The goal is to never need be in a position where hospitals have to make very difficult decisions about when and where to use critical resources,” the DHHS email said. “In a pandemic, however, such a situation remains a possibility.”   

Work on the plan started last year but approval was delayed when disability rights advocates, including Disability Rights North Carolina, and The Arc of North Carolina, filed a complaint with the U.S. Department of Health and Human Services’ civil rights office. They said the plan would put people with disabilities at a disadvantage if life-saving equipment became scarce.   

The advocacy groups said they approve of the revised protocol issued last month. 

Disability Rights North Carolina had objected to estimates of long-term survivability counting against people with disabilities. The protocol now states that estimates of how long patients will live after they’re discharged cannot be considered.  

“This is an enormous improvement over the April published policy,” said Corye Dunn, public policy director at Disability Rights. “The rights of people with disabilities and people with chronic illnesses to receive treatment for COVID will be honored under this policy.” 

Dr. Tara Bastek, a neonatologist who chairs WakeMed’s ethics committee, said an early version of the protocol made clear that everyone was eligible for critical medical care.  

The revision has specific protections for people with disabilities, stating, for example, that people who have personal ventilators wouldn’t have them taken away.   

“I appreciate the efforts the medical organizations have made to tackle a hard topic,” Bastek said.   

The NC Institute of Medicine, the NC Medical Society and the NC Healthcare Association did not return calls or emails. 

North Carolina’s protocol and those in other states rely on priority scores based on the health of a patient’s major organ systems. Patients with lower scores are considered to have the best chances of survival. Triage teams and triage officers would decide who would get critical care — not the treating physicians.   

“The separation of the triage role from the clinical role is intended to enhance objectivity, avoid conflicts of commitments, and minimize moral distress,” the plan says.   

Patients who aren’t sent to intensive care would still receive treatment for their symptoms. They would be told about triage decisions and could appeal on the basis that their health scores were wrong.   

Hospital administrators with Novant Health in Winston-Salem ran a simulation using the state protocol before it was changed. The North Carolina Medical Journal published the results last month. In an email, the lead author, Deborah Love, cautioned that the simulation used only a small number of patients.   

The paper gave a glimpse of some of the concerns medical staff raised about the protocol – whether biases would creep in and whether all doctors’ medical assessments were reliable. 

The triage teams were to make decisions using on the patients’ health scores. They weren’t told the patients’ race or ethnicity, insurance status, sex, or any information the paper called “irrelevant social factors.”  

The paper noted that people who participated in triage teams were uncomfortable not knowing more about patients and relying on scores to make decisions.   

Still, one person said that issues such as occupation, homelessness, substance abuse, payer source and education came up in a discussion between triage teams and an attending physician, the paper said. 

“A nurse commented, “You wonder about those internal biases, because even when the provider spoke, one of the things that kind of made me cringe: ‘This family was reasonable and this family is unreasonable.’ So, I’m like, what does that mean? Does that mean we should look at the unreasonable family and make a different decision?”?  

The triage teams and hospital review committees rely on other doctors’ patient assessments, which conflicted with doctors’ training to make independent judgments, the paper said.   

The journal paper quoted one doctor saying, “At some point in our career, we have followed and we’ve picked up a situation from a colleague that we’re like, ‘I have no idea why these decisions were made and I would never make these decisions.’ So now I’m left with this pile of whatever and now I’ve got to try to make the best of it and restore it into something that I can stand by.”  

Although the state plan says its triage steps for adult patients are recommendations, the DHHS email said hospitals would be expected to follow them.   

The leaders of ethics committees at WakeMed and UNC Hospitals said shortly after the revised protocol was released that they would use it under state orders.  

“It makes sense for all hospitals in the state to follow one protocol, said Dr. Benny Joyner, vice chairman of the ethics committee at UNC Hospitals and chief of pediatric critical care medicine.   

The goal is to make sure hospitals don’t have to use it, Joyner said. “Good stewardship is understanding where we are and having good situational awareness so we don’t ever reach that point.”  

Graphics and data analysis by Yanqi Xu.