Tough Choices

Diane is a very good friend of ours.  She happens to have Multiple Sclerosis and has been wheel chair bound and dependent on care givers for almost twenty years now.  She has a quick wit, a beautiful smile and a determined will.  Not content to spend the rest of her days in a nursing home, she now resides in her own apartment with some help.  I am amazed by her positive attitude and perseverance.  She is one of my heroes.

She recently forwarded me a document reminding physicians that rationing resources away from those with disabilities is a crime as outlined in the Americans with Disability Act.  It was a good reminder for me given the current pandemic.  It is illegal to deny care to anyone due to disability. Corona virus may preferentially kill those who are more debilitated to start with but we as humanity must never do that.  These are lessons learned from the Nazi regime during World War II.  Recently I listened to a podcast discussing the possibilities of rationing care in the face of resource shortage.  At face value, it seemed to fly in the face of protecting the vulnerable.  The underlying premise was to bring care to the most number of people possible.  That too is an honorable goal but how and who makes the decision in regards to who receives care and who doesn’t when there are not enough resources for all? These are tough choices.

In truth, we ration care right now.  Accessing our amazing health system is difficult for those who are uninsured or underinsured.  Costs are high.  Yes, there is a safety net for the very poor but there are millions of people who are above that level economically but still cannot afford to cover their families.  Our system never has been fair. If there are only so many resources, in this case ventilators.  How do you decide who gets the ventilator and who doesn’t?  That is not a decision that I ever want to make.  New York and Italy have had to make these decisions. They have been gut wrenching for those in the front lines. Here are some of the things we should be doing now to make sure we never get to that point.

The first order of business is to do everything in our power to make sure we have access to every ventilator possible.  The BJC system has a central repository of medical equipment and supples to distribute among the various hospitals according to need.  They have taken them from operating rooms that are not currently being used due to the cessation of elective surgeries.  There are ventilators that had been used at home for patients who have expired.  Novel ways of trying to maintain two patients on one ventilator have been devised. Some of our factories have now been repurposed to make more ventilators as well.

The second order of business is to make sure that mechanical ventilation is used appropriately.  The mindset for COVID-19 has shifted from the earlier days of the pandemic.  Because the virus is so infectious and causes a precipitous drop on oxygenation, it was felt that early intubation was ideal.  That practice has been questioned as those on ventilators seem to do worse.  This is hard to truly ascertain as the sickest patients are the ones put on ventilators, so it is expected that they do worse, but what is being seen seems to be out of proportion to what is expected. If someone is in a stable environment where rapid intubation can be done if needed, such as in the ICU, the approach now is to wait as long as possible.  It has been found that often times using alternate oxygen flow devices and prompting the frequent movement of the awake patient the need for ventilation is less.

Lastly, it is imperative that patients and their doctors communicate clearly what their wishes would be for ventilation if their health deteriorated to the point that would be considered.  I have talked to several patients with emphysema, some of whom are on oxygen at home, and then asked them what exactly they would want us to do if they were in this position.  Such patients have a less than 5% chance of meaningful recovery.  If it were due to COVID-19 that number is likely even smaller.  I also explain that being comfortable in your last days and being on the ventilator are not compatible statements.  It is a very uncomfortable process, usually requiring high levels of sedation and sometimes even paralytic agents to be able to keep the lungs going.  Most patients indicate that they do not want such treatment.  I mark their chart indicating their wishes not to be resuscitated so that others can clearly see. This eliminates the unnecessary use of such resources.

Going back to Diane, what of those with disabilities?  The guidelines are clear, they are not to be discriminated against.  Guidelines in New York and in Switzerland indicate that in the face of scarce resources the guiding principle is to determine who has the higher likelihood of survival regardless of the underlying diagnosis or age of the patient.  If a patient is expected to only live 5 more years of life, a healthier patient would take precedence over them.  These are hard choices to make.

The great news is that here in St. Louis, you all have been flattening the curve.  Just last night I was shown a graph of the predicted number of cases in the hospital here in our area.  There was a line for a “bad case scenario” and another for the best case scenario.  We are currently slightly under the best case line.  I am so grateful to a community who have taken social distancing seriously.  You are helping the rest of us so that we will never have to choose between two patients as to who will live and who will die.  Keep up the fight. Stay safe, stay strong!