ST. PAUL — Minnesota health care professionals may face difficult decisions in coming weeks in how they parcel out limited medical resources in the face of surging numbers of patients infected with the coronavirus.
In an attempt to limit the number of patients with severe infections, Gov. Tim Walz gave a “stay at home” order last week. The hope is to reduce the number of patients needing intensive care units and help breathing with ventilators. Minnesota had 235 ICU beds available as of Wednesday, March 25, according to Walz.
New York is just now beginning to grapple with how to treat huge numbers of infected patients without enough equipment. In countries such as Italy and China it’s meant hard rationing decisions such as prioritizing the young and those with the highest chance of survival.
‘Really, really hard in our culture’
These options are “really, really hard in our culture,” said Joel Wu, a clinical ethicist for M Health Fairview. Wu also is an adjunct professor at the University of Minnesota’s Center for Bioethics who teaches classes on how the law, medicine and ethics intersect.
Rationing limited resources in the face of a global pandemic, where countries and even states are vying for the same supplies is not something health care workers or patients are used to dealing with.
“It’s hard both for patients and their families and members of the community and members of the health care team, because they are very much used to doing their best as much as possible and with all available resources (and) to affirm the interests and the values of their individual patients,” Wu said.
Wu said teams should be in place before these decisions might have to be made. One group should weigh community needs and the health care system level and be independent from the bed-side care providers, who are free to advocate for patients.
A key element — none of these ethical dilemmas can be addressed without protecting the health of nurses and doctors performing the care.
“It first has to do with the sustainability and the maintenance of the health care enterprise,” Wu said. “It’s essentially to say (a priority should be) skilled key workers in all the sectors of the community but particularly front-line medicine and public health. If they aren’t able to work, then it exacerbates the problem and things get worse across the community.”
Wu said attempts at fairness toward patients must be incorporated “and that we are doing it in a way that preserves the public’s trust and has the best outcomes for the most people.”
It’s important that medical professionals are “not stuck in this dual-role position where they have to talk about what is best for the community and what is best for their patient’s interest,” he said.
In a 2006 article in the AMA’s Journal of Ethics titled “Allocating Scarce Resources in a Pandemic: Ethical and Public Policy Dimensions,” Martin Strosberg wrote that a 1918-like flu pandemic would force local communities to rely on limited resources and make decisions balancing an individual’s rights against to the community’s public health needs.
“Put most starkly, the question is should an ICU patient who could potentially be saved but still requires the investment of time and resources — namely staff and ventilator — be discharged to make way for a patient who could be treated more efficiently, that is, with fewer human and other resources? Or are there other criteria that could be useful in setting priorities?” wrote Strosberg, a professor in health care management at Clarkson University.
However those criteria are set, he noted work at the time by a pandemic flu working group at the University of Toronto Joint Centre for Bioethics that suggested “a priority-setting process should be reasonable, open and transparent, inclusive, accountable, and responsive.”
Shortage of resources
In his statements last week, Minnesota’s governor didn’t address what might happen if the amount of severely ill patients in the state exceeds its ability to provide proper care. He briefly mentioned Italy, where hospitals in the heavily hit northern region have had to choose which patients receive care.
A March 16 report for the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care outlined a response to an imbalance between needs and resources. The report said in the “context of a serve shortage of health care resources, we must aim at guaranteeing intensive treatments to patients with greater chances of therapeutic success.”
That means favoring “greatest life expectancy” that takes into account the patient’s age and presence of pre-existing conditions. This could mean providing COVID-19 care in an ICU to a 50-year-old man with no pre-existing conditions instead of a 75-year-old man with lung disease.
‘Too sick to survive’
The U.S. Centers for Disease Control and Prevention ethics subcommittee in 2011 echoed those ideas.
“During a severe influenza pandemic that (sickest-first principle) creates a critical shortage of ventilators,” the CDC report said. “This strategy may lead to resources being used by patients who ultimately are too sick to survive.”
The report says that when there is a severe shortage of medical resources, a priority of care is given to those most likely to recover from the interventions.
The Minnesota Department of Health advises to extend supplies and conserve resources during times of crisis. And, that’s what Walz is trying to achieve with suspending all elective surgeries and treatments and in the “stay at home” order to prolong the rate of infection.
Its aim is to give time to increase the amount of supplies in ventilators, personal protective equipment for health care providers and additional temporary hospital beds.
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