Worst Case: Choosing Who Survives in a Flu Epidemic

James Estrin
The New York Times

 

New York state health officials recently laid out this wrenching scenario
for a small group of medical professionals from New York-Presbyterian
Hospital:

 

A 32-year-old man with cystic fibrosis is rushed to the hospital with
appendicitis in the midst of a worsening pandemic caused by the H1N1 flu
virus, which has mutated into a more deadly form. The man is awaiting a lung
transplant and brought with him the mechanical ventilator that helps him
breathe. New York’s governor has declared a state of emergency and hospitals
are following the state’s pandemic ventilator allocation plan – actual
guidelines drafted in 2007 that are now being revisited. The plan aims to
direct ventilators to those with the best chances of survival in a severe,
1918-like flu pandemic where tens of thousands develop life-threatening
pneumonia.  Because the man’s end-stage lung disease caused by his cystic
fibrosis is among a list of medical conditions associated with high
mortality,

 

the guidelines would bar the man from using a ventilator in a hospital, even
though he is, unlike many with his illness, stable, in good condition, and
not close to death. If the hospital admits him, the guidelines call for the
machine that keeps him alive to be given to someone else.  Would doctors and
nurses follow such rules? Should they?

 

In recent years, officials in a host of states and localities, as well as
the federal Veterans Health Administration, have been quietly addressing one
of medicine’s most troubling questions: Who should get a chance to survive
when the number of severely ill people far exceeds the resources needed to
treat them all? The draft plans vary. In some states, patients with Do Not
Resuscitate orders, the elderly, those requiring dialysis, or those with
severe neurological impairment would be refused ventilators, or admission to
hospitals. Initially, hospitals would apply triage rules to residents of
mental institutions, nursing homes, prisons and facilities for the
handicapped.” If an epidemic worsened, the rules would apply to the general
population. Federal officials say the possibility that America’s already
crowded intensive care units would be overwhelmed in the coming weeks by flu
patients is small but they remain vigilant.

 

The triage plans have attracted little publicity. New York, for example,
released its in 2007, offered a 45-day comment period, and has made no
changes since. The Health Department made 90 pages of
 public this week only after receiving a request under the state’s public
records laws.

 

Mary Buckley-Davis, a respiratory therapist with 30 years experience, wrote
to officials in 2007 that “there will be rioting in the streets” if
hospitals begin disconnecting ventilators. “There won’t be enough public
relations spin or appropriate media coverage in the world” to calm the
family of a patient”terminally weaned” from a ventilator, she said.

 

State and federal officials defend formal rationing as the last in a series
of steps that would be taken to stretch scarce resources and provide the
best outcome for the public. They say it is better to plan for such
decisions than leave them to besieged health workers battling a crisis.

 

“You change your perspective from thinking about the individual patient to
thinking about the community of patients,” said Rear Adm. Ann Knebel of the
Department of Health and Human Services.

 

But some health professionals question whether the draft guidelines are
fair, effective, ethical, and even remotely feasible.

 

Most existing triage plans were designed for handling mass casualties. They
sort injured victims into priority categories based on the urgency of their
medical needs and their potential for survival given available resources.
Much of the controversy over the state plans focuses on two additional
features.

 

These are “exclusion criteria,” which bar certain categories of patients
from standard hospital treatments in a severe health disaster, and “minimum
qualifications for survival,” which limit the resources used for each
patient. Once that limit is reached, patients who are not improving would be
removed from essential treatment in favor of those with better chances.

 

A version of these concepts was outlined in a post-9/11 medical journal
article that suggested ways to handle victims of a large-scale bioterrorist
event. The author, Dr. Frederick Burkle Jr., said he based his ideas in part
on his experiences as a triage officer in Vietnam and the gulf war and on a
cold war-era British plan for coping with a nuclear strike. Dr. Burkle said
that during the gulf war he once instructed surgeons to halt an operation
and work on another patient who was more likely to survive. Surgeons later
returned to the first patient.

 

Dr. Burkle’s ideas were key aspects of
 after SARS to plan for avian flu and other pandemics. This approach and
were modified by groups developing similar guidelines in the United States.

 

There were important distinctions. Dr. Burkle’s original paper did not
anticipate withdrawing care from patients and stressed the need to reassess
the level of supplies “sometimes on a daily or hourly basis” in a fluid
effort to provide the best possible care.

 

Some states’ triage guidelines are rigid, with a single set of criteria
intended to apply throughout the severe phase of a pandemic. That disturbs
Dr. Burkle.

 

“I have said to my wife, I think I developed a monster here,” he said.

 

Recent research highlights the problem of a one-size-fits-all approach to
triage. Many state pandemic plans call for hospitals to remove patients from
ventilators if they are not improving after two to five days. Studies show
that people severely ill with H1N1 flu generally need a week to two weeks on
ventilators to recover.

 

There is also controversy over what values and ethical principles should
guide triage decisions, how to engage the public, and whether withdrawing
life support in the hospital and withholding it at the hospital door are
distinct.

 

Normally, removing viable patients from life support against their or their
families will would be considered murder. The New York-Presbyterian Hospital
employees who participated in the recent exercise said they would not comply
unless given legal protection.

 

They also never figured out what to do with that hypothetical patient who
had his own ventilator, said Dr. Kenneth Prager, a pulmonologist and
ethicist.

 

“The issue of removing patients from ventilators,” he said, “w as so
overwhelming that it precluded discussion of further case scenarios.”

 

, an M.D., is a staff reporter at ProPublica, the independent nonprofit
investigative organization.

 

 

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