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If Critical Supplies Run Out, Here's How Hospitals Will Make Tough Choices


As New York hospitals run low on ventilators amid the coronavirus pandemic, Americans face the fearsome new possibility that doctors may be forced to essentially play God, decide which patients get lifesaving care and which will not. But this kind of rationing doesn't have to be arbitrary. As NPR's Martin Kaste reports, there are people who've worked for years to prepare for this kind of situation.

MARTIN KASTE, BYLINE: In the years after 9/11, the federal government encouraged states to write guidelines for rationing medical care in a disaster. Now those plans are coming out.

RON TELLES: We have reviewed them. That's a scenario which we hope will never happen.

KASTE: Ron Telles is CEO of WhidbeyHealth, a small hospital on an island near Seattle. It's been gradually filling up with COVID-19 patients. But he's optimistic. Ten ventilators just arrived from the federal stock pile, he says. He compares the situation to Apollo 13, one crisis after another but ultimately survivable. But if rationing becomes necessary, he says it has to be a shared decision.

TELLES: It cannot be just WhidbeyHealth. It has to be a region. It has to be a region because it doesn't work for one hospital to do that.

KASTE: And that is how it's supposed to happen. Like many states, Washington has a plan to declare the start of rationing. The formal term is crisis standards of care. At one of the University of Washington's hospitals in Seattle, pulmonary and critical care specialist Randall Curtis says if that declaration were made, he and his colleagues would turn to the state's official rationing guidelines.

RANDALL CURTIS: We would be consulting a grid if we got to that point.

KASTE: Grids, checklists and flow charts would help them decide how to allocate certain kinds of treatment to certain kinds of patients. Curtis says the hospital's ethics committee has already been meeting to review the rules on how they would guide what he calls difficult decisions.

CURTIS: So that we're using the ventilators to produce, you know, the maximal benefit for the largest number of people.

KASTE: But what does maximal benefit mean? University of Maryland Health law professor Diane Hoffmann has closely followed the development of these state policies over the years as well as the ethical values that inform them.

DIANE HOFFMANN: Usually, there's pretty much agreement on short-term survival. Would the person survive the virus and be able to leave the hospital?

KASTE: But when it comes to long-term survival, Hoffman says there's less agreement. If resources get scarce enough, secondary considerations may become more important.

HOFFMANN: Are we going to look at issues like dementia, other disabilities? And are we going to look at quality of life?

KASTE: As COVID-19 advances, these questions are gaining new urgency. The Journal of the American Medical Association published a viewpoint article calling for ventilators to be allocated with an eye to, quote, "the number of years of life saved." The American College of Physicians, on the other hand, put out a statement pushing back on that idea. Dr. Robert McLean is the ACP's president.

ROBERT MCLEAN: If we're using life years as a concept, it is inherently biased against the elderly or the disabled, who may not live as long after they would potentially recover.

KASTE: These are thorny ethical problems even in the best of times, more so now in the midst of a mounting national crisis, which is why the committees of doctors, ethicists and lawyers spent so much time in recent years writing these state rationing policies. They were hoping to give hospitals some clarity in the midst of chaos. Vicki Sakata is an emergency room doctor in Tacoma who was instrumental in putting together Washington state's policy.

VICKI SAKATA: My goal is, you know, to give our providers something in hand to know how to do it. It's terrifying, obviously, for a lot of people, but we need to have information. And we need to have a process. And that's what I work to do.

KASTE: And then she adds, as did every doctor in this story, that rationing is the last thing she wants to do and that they're doing everything they can to avoid it. Martin Kaste, NPR News, Seattle. Transcript provided by NPR, Copyright NPR.

Martin Kaste is a correspondent on NPR's National Desk. He covers law enforcement and privacy. He has been focused on police and use of force since before the 2014 protests in Ferguson, and that coverage led to the creation of NPR's Criminal Justice Collaborative.

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