By Pat Anson, PNN Editor

With face masks, surgical gowns, hospital beds and ventilators in short supply, some U.S. hospitals are preparing to make stark choices about which patients to treat – and who not to treat – during the coronavirus pandemic.

The Henry Ford Health System, which operates dozens of medical centers and emergency rooms in the Detroit metropolitan area, has contingency plans to take critically ill patients off ventilators and out of intensive care if they have little chance of recovery.

“Some patients will be extremely sick and very unlikely to survive their illness even with critical treatment. Treating these patients would take away resources for patients who might survive,” the plan states. “Patients who are treated with a ventilator or ICU care may have these treatments stopped if they do not improve over time.”

Under the Henry Ford policy, patients suffering from terminal cancer, organ failure or severe trauma “are not eligible for ICU or ventilator care” and would be given pain control instead.

When a document from the 50-page plan – a letter addressed to patients informing them about the policy – began circulating outline, it was met with outrage.

“Reading that policy truly removes the usually veiled thoughts about the disabled being less than, not enough, or not fully whole. Being shown that one is not ‘eligible’ to continue living is despicable,” Koa Kai, a pain patient and advocate for the disabled, told PNN.  

“I question the ethics and danger of policies such as this, and outright reject their use. We are seeing humanity stripped down to its most basic elements now. As the hysteria continues, it continues to bring both the best and worst out in humanity.”  

Henry Ford officials were quick to point out their contingency plan was prepared for a worst-case scenario and has not yet been implemented. It was shared with other health care systems in Michigan to help them develop similar plans – which is apparently how it leaked..

“Gathering the collective wisdom from across our industry, we carefully crafted our policy to provide critical guidance to healthcare workers for making difficult patient care decisions during an unprecedented emergency,” Dr. Adnan Munkarah, Henry Ford's executive president and chief clinical officer, said in a statement.

“It is our hope we never have to apply them and we will always do everything we can to care for our patients, utilizing every resource we have to make that happen.”

Michigan reported nearly a thousand new coronavirus cases Saturday, bringing the state’s total to 4,650 cases. At least 111 people have died from the virus in Michigan – with most of the deaths occurring in the Detroit area.

Michigan Gov. Gretchen Whitmer, a Democrat who has been feuding with President Trump, told a radio station Friday that medical supply vendors told her they’ve been told “not to send stuff” to her state. Whitmer complained earlier that the number of masks and gowns sent to Michigan by the federal government was inadequate. The state reportedly hasn’t received a single ventilator.

‘We Are on the Precipice of Rationing’

Ventilators are medical appliances that force air into and out of the lungs – essentially doing the breathing for patients who are unable to breathe on their own. Connecting a sick patient to a ventilator – and taking them off – are life-and-death decisions.

“When patients’ breathing deteriorates to the point that they need a ventilator, there is typically only a limited window during which they can be saved. And when the machine is withdrawn from patients who are fully ventilator-dependent, they will usually die within minutes,” lead author Robert Truog, MD, a medical ethics professor at Harvard Medical School, wrote in an op/ed recently published in The New England Journal of Medicine.

Some hospitals in New York City are so overwhelmed with coronavirus patients they may have to start rationing ventilators and other critical medical supplies. The state has over 52,000 confirmed cases, nearly half of the nation’s total.

“Today was the worst day anyone has ever seen, but tomorrow will be worse. We are on the precipice of rationing. Needless to say, these decisions run counter to everything we stand for and are incredibly painful,” wrote Meredith Case, an internal medicine resident at Columbia/New York-Presbyterian Hospital, in a March 25 Twitter thread

Two days later, the situation had not improved.

“Yesterday brought another onslaught. Endless overheads calling for anesthesia and respiratory therapy for intubations. Friends at other hospitals having the same experiences. We are rising to a challenge that already overwhelms us,” Case tweeted. “Frustrating to realize that different things are in shortage in different places. Some will soon run out of vents, others CRRT machines, others nursing staff, others rooms or physical space.”

‘The Ethical Thing To Do’

As stark as it sounds, rationing scarce medical resources is “the ethical thing to do” during a pandemic, according to an op/ed in The New England Journal of Medicine.  

“Because maximizing benefits is paramount in a pandemic, we believe that removing a patient from a ventilator or an ICU bed to provide it to others in need is also justifiable and that patients should be made aware of this possibility at admission,” wrote lead author Ezekiel Emanuel, MD, a professor at the Perelman School of Medicine, University of Pennsylvania.

“Undoubtedly, withdrawing ventilators or ICU support from patients who arrived earlier to save those with better prognosis will be extremely psychologically traumatic for clinicians — and some clinicians might refuse to do so. However, many guidelines agree that the decision to withdraw a scarce resource to save others is not an act of killing and does not require the patient’s consent.”

Who decides which patients should be taken off ventilators? In many cases, the decision is made by a hospital triage officer or a triage committee composed of providers who have no direct responsibility for the care of a patient.  

“In the weeks ahead, physicians in the United States may be asked to make decisions that they have never before had to face, and for which many of them will not be prepared,” Dr. Truog wrote in his op/ed. “Though some people may denounce triage committees as ‘death panels,’ in fact they would be just the opposite — their goal would be to save the most lives possible in a time of unprecedented crisis.”

‘Ruthless Utilitarianism’

In response to growing concerns about healthcare being rationed during the coronavirus outbreak, the Office for Civil Rights (OCR) at the Department of Health and Human Services issued a bulletin Saturday warning healthcare providers not to discriminate against patients, regardless of age or disability.

“Our civil rights laws protect the equal dignity of every human life from ruthless utilitarianism,” said Roger Severino, OCR Director. “Persons with disabilities, with limited English skills, and older persons should not be put at the end of the line for health care during emergencies.” 

Severino was responding to a complaint from advocates for the disabled in Alabama. Under a state emergency plan, patients with “severe mental retardation, advanced dementia or severe traumatic brain injury” could be considered “poor candidates for ventilator support” during a pandemic. Patients with AIDS or compromised immune systems could also be taken off ventilators.

“Healthcare organizations incorporating this ventilator triage protocol into their disaster plans and attempting in good faith to follow it will be considered to be in compliance with the standard of care necessitated by the prevailing proclaimed respiratory disaster,” the Alabama plan states.