Who Gets the Ventilator? Age Shouldn't Be the Deciding Factor

In recent days, states across the U.S. have shattered their previous COVID-19 infection and hospitalization numbers. Startling data reveals that more than half of the country is experiencing a significant increase in COVID-19 patients, with numerous cities approaching full capacity in their hospitals’ ICUs. In some areas, the positivity rate for tests is in the double-digits. (The positivity rate is the number of positive test results divided by the number of total tests administered, yielding a percentage of COVID-19 positive diagnoses.)

For example:

In Arizona, they are reporting their highest level of hospitalizations since the pandemic began in March with 85 percent of hospital beds full and 91 percent of ICU beds full. As of Friday, there were only 156 unused ICU beds in the entire state.
ICUs in Los Angeles County, the most populous county in the nation, and adjacent Riverside County are expected to run out of beds this month.
Three of southwest Florida’s nine acute care hospitals had no available ICU beds as of mid-week last week and their COVID-19 hospitalizations have doubled in recent weeks.
In Texas, Austin currently has the highest positivity rate in the country for COVID-19 tests with 22.2 percent of tests coming back positive for the virus. Texas’ three largest metropolitan areas — Houston, Dallas, and San Antonio — were also in the nation’s top five highest positivity rates for COVID-19 tests.

With so many hospitals reaching capacity across the country, critical provisions like personal protective equipment (PPE), hand sanitizer, and cleaning supplies are in short supply as well. And this list of shortages may soon include equipment like life-saving mechanical ventilators.

Acute care hospitals in the United States have about 62,000 full-function ventilators and about 98,000 basic ventilators. The Strategic National Stockpile has an additional 8,900. But as the nation eclipses 2.7 million COVID cases and 130,000 deaths, some difficult ethical questions may arise in the hardest-hit areas.

A life-or-death supply and demand issue

According to Centers for Disease Control and Prevention estimates, somewhere between 2.4 and 21 million Americans will require hospitalization during this pandemic — obviously a huge range. Based on global pandemic data collected thus far, the CDC expects that somewhere between 10 and 25 percent of those hospitalized with COVID-19 will require mechanical ventilation, and some of these patients will need to be on a ventilator for several weeks.

Using these figures, the number of COVID-19 patients who will require ventilation might be between 1.4 and 31 patients per ventilator — a jaw-dropping estimate.

Now, these numbers don’t predict when and where ICU influxes will occur in the U.S. — hopefully these hospitalizations and intubations will be spread out enough to ensure everyone who needs a ventilator gets one. Some hospitals have even devised ways to split one ventilator between two patients, though this is not optimal since the settings on a ventilator should be tailored to the individual patient’s needs.

But what do doctors do if they run out of ventilators? What life-or-death choices will they be forced to make…and how?

The bioethics of resource allocation

When a patient is unable to breathe, reaching the point that they require a ventilator, there is usually a very narrow window for intubating them in order to save their life. For people in that state of deterioration, if mechanical ventilation is stopped, the person will usually die within just a few minutes.

As of last week, Arizona has unfortunately had to enact their “crisis standards of care.” These standards take into account factors like the patient’s acuity (how sick they are), other pre-existing health conditions (like cancer or dementia), and age in order to calculate how many “life years” the person might expect to have remaining if they are treated and survive this virus.

Life years gained is a measure of “the of years of life that a person lives as a result of receiving a treatment,” per the European Patients’ Academy.

But the bigger ethical question arises when people start talking about taking one patient off of a ventilator in order to give that ventilator to another patient who might have more life years gained as a result — sacrificing one life in order to potentially save another.

To counter this type of Sophie’s choice scenario, where there is no good option, bioethicists at University of Pittsburgh Medical Center (UPMC) developed a set of standards that includes an eight-point scoring system, which helps determine the patient’s odds of leaving the hospital alive.

The UPMC protocols delegate the final assessment of a patient’s score and decisions on resource allocation to a triage committee of non-frontline physicians at that hospital. This process is intended to prevent the ethical conflicts that could arise if the bedside physician were asked to make these truly life-and-death decisions for their own patient.

The value of a life

The coronavirus has been particularly deadly for seniors and minorities in this country. A majority of the deaths have been among those age 70 and over. While many of these people had underlying health conditions, the question remains: How many life years would they have had remaining if they had not become infected with COVID-19?

Another issue is the rising number of younger adults who are becoming infected and seriously ill with COVID-19, requiring hospitalization. For example, in Florida, the state with the highest per capita population of seniors, they also have a steadily declining median age for confirmed COVID-19 cases — currently 37 years old and dropping. These younger patients further jeopardize infected seniors’ ability to access the healthcare services and equipment they need as resources become strained and rationing is required.

If it gets to the point where ICU doctors are having to essentially make choices about which person to sacrifice so another can live, we will have reached an agonizing new depth in this pandemic crisis. We should never have to calculate the value of a person’s life based on their age or a pre-existing condition.

As a nation, we must innovate —and quickly — in order to address the ventilator shortages that might arise from a sudden influx of COVID-19 patients. How many “life years” would an otherwise healthy 80-year-old have were it not for this virus? If a doctor must calculate who gets a ventilator — a 50-year-old or the 80-year-old — who do they choose? In the wealthiest nation in the world, have we come to the point where sacrificing our older citizens is somehow an acceptable solution to deal with equipment shortages? What must the leadership of our states and our country do in order to stem this preventable healthcare crisis?