States, Hospitals Grapple With Medical Rationing

Over the weekend, the U.S. Department of Health and Human Services issued a reminder that people with disabilities have the same worth as everybody else.

That the agency felt compelled to issue such a directive reflects the anguishing choices that American medicine has begun to confront: When medical personnel, equipment and supplies are limited, who gets lifesaving care and who doesn’t?

The HHS bulletin appeared to respond to a complaint filed with the federal agency last week by Washington state groups that serve people with disabilities. The groups argued that a draft of an emergency health plan, proposed by Washington state health officials and hospitals, gave lower priority to those with disabilities.

State and local health departments across the country have developed detailed emergency health plans in recent years, often in response to major natural disasters, such as Hurricane Katrina, or outbreaks of diseases, such as the avian and swine flus. Many of these plans, such as those in Minnesota and New York, included guidelines for rationing care in the event of shortages of medical supplies or personnel.

Federal health agencies have not issued guidelines on how to make such decisions. For example, states say they don’t understand the criteria the federal government has been using in allocating limited medical resources from the U.S. stockpile.

At least some of the state plans include the sort of language that prompted the protest in Washington state. The emergency health plan Alabama drafted in 2010, for example, states that “persons with severe mental retardation, advanced dementia or severe traumatic brain injury may be poor candidates for ventilator support.” It’s unclear if that provision is part of the state’s current emergency plan.

On the front lines, medical providers are desperately trying to avoid choosing among patients. New York-Presbyterian Hospital, at the epicenter of the outbreak, began experimenting with sharing ventilators between two patients rather than one.

According to media reports, some U.S. hospitals already are considering issuing do-not-resuscitate orders for infected patients, regardless of the wishes of the patients. Among the hospitals identified as considering that option is Chicago’s Northwestern Memorial Hospital.

“We have not made any policy changes to patient care,” said Christopher King, a spokesman for the hospital. “What we have been doing, and similar to health systems around the country dealing with COVID-19, is conducting internal discussions and scenario planning on how to care for patients with COVID-19.”

A Change in Decision-Making

To be sure, some medical professionals have long experience making such choices — those who have operated in war zones or provided care in the wake of natural disasters, for example. And doctors and hospitals often have to choose who will get healthy organs for transplants when precious few are available.

In the last decade or so, some states have expanded these conversations.

For example, in 2006 New York health officials created emergency protocols in response to an avian flu outbreak in Asia. Their guidelines addressed an issue rattling health systems now: how to ethically allocate ventilators when the supply doesn’t meet the demand.

“The clinical guidelines propose both withholding and withdrawing ventilators from patients with the highest probability of mortality to benefit patients with the highest likelihood of survival,” the New York guidelines state.

In Louisiana after Hurricane Katrina, lawmakers passed measures to indemnify health professionals when they were forced to determine which patients received life-sustaining treatments. The state also convened medical experts to draft plans to determine how those decisions should be made.

Most other states also began creating emergency health plans, especially after the H1N1 outbreak in 2009. Because of the sensitivity of the subject, many of those conversations occurred without public input, which drew some criticism for a lack of transparency.

Others are just now getting to it. New Jersey, for example, has created a bioethics committee that will meet this week to talk about how to parcel out ventilators and other lifesaving care.