Los Angeles County’s four public hospitals are preparing themselves to take the extraordinary step of taking care of the rationing, with a team of “triage officers” deciding which patients can benefit from continued treatment. who can be beyond salvation and must be allowed to die.
The province’s top health officials have not yet declared a move to a crisis level of care, which would cause the rationing system, but the leader of the public hospitals acknowledged in a letter reviewed by The Times this week that ‘there probably’ a point will come when we simply do not have enough staff or critical supplies to care for all our patients as we normally would. ”
Indicating the crisis would enable the newly appointed probation officers – usually doctors in critical care and emergencies – to decide which patients at provincial hospitals would have access to resources such as ventilators, respiratory therapists and nurses in critical care if they became too scarce to be provided to them. each patient.
Hospitals outside the state system will have to decide for themselves whether to call for similar emergency measures, although government officials told them last week that they should prepare triage plans.
Within many overcrowded Southern California hospitals, there already appears to be some form of black rationing. Ambulances with COVID patients were diverted from medical centers with too much tax. Critically ill patients sometimes wait days to get intensive care beds.
In one private hospital in Lynwood this week, doctors stood in a hallway arguing loudly over whether to give one of the few remaining ventilators to an elderly woman. The doctor describing the scene said the hospital has no formal plan to resolve such disputes.
To confront the life-and-death menu, the California Department of Public Health and some hospital systems recommend evaluating on clinical scoring systems that evaluate patients’ organ functions, which generate numerical counts to indicate an individual’s chances of survival.
Provincial health leaders call the general scoring system too rigid and inaccurate to be used as the sole criterion for making triage decisions.
Shifting the care of patients with deadly diseases
They instructed triage officials to use a broader ‘principle-based approach’ that seeks to shift care away from patients who are considered terminal, to patients who have the best chance of survival.
“Our goal as a health care system is to save as many lives as possible,” Dr Christina Ghaly, who oversees the country’s public hospitals, said in a letter to staff this week. ‘This means moving from the best care for each patient to the best care for our entire patient population. It also means that you could potentially allocate resources from a patient who does not benefit to a patient who would benefit from it. “
Doctors, clergy, and ethicists have debated for generations how to allocate scarce resources fairly in a time of crisis.
“Now we are about to enter unknown territory, as we may have to make those decisions,” said Dr. Arun Patel, the doctor and attorney who oversees the triage program for LA County, said. “No one in the United States has had to apply such guidelines on this scale or for the duration we need.”
Doctors and ethicists in Los Angeles and across the U.S. could not agree on a single method of prioritizing patients, or even agree on the appropriate factors in determining who should receive medical care.
Should age be a factor?
Should the age of a patient be a factor? Some ethicists believe that age should rarely, if ever, be a reason for withholding, for example, a ventilator or an intensive care bed. Other medical experts say that age should be considered, provided it is not the only reason to give or deny care.
LA County has warned the 29 doctors on ‘readiness’ to act as office bearers to pay attention to possible bias or ‘preconceived notions about the quality of life for individuals’ such as the elderly and disabled, according to a memo sent to provincial health workers in November.
In the same memorandum, the province acknowledges that decisions about triage can not only focus on saving most lives, but also on “giving priority to patients who are likely to survive the longest after treatment.”
One doctor at a large Los Angeles hospital has admitted that he would probably be more likely to care for a 40-year-old parent than an 80-year-old, even if both were equally likely to survive COVID-19, because the younger patient was presumed to have the longer life expectancy.
But Patel also outlined a scenario in which a younger patient would not be the obvious choice for preferential treatment. He noted that dr. Anthony Fauci, the head of the American coronavirus response, is 80, but also a body that is fit and able to work 18-hour days.
“If he were to compete for resources with a 60-year-old, who was very weak, with advanced heart disease and diabetes, I would not make the decision based on a single factor such as age,” Patel said.
The provincial triage document acknowledged that it did not contain a concise set of instructions for triage officers that would cover ‘every possible circumstance that would arise in the context of an overwhelming increase in demand’.
The province’s policy is the clearest on what it does not allow: discrimination of individuals on the basis of their identity. The guidelines note that it is unethical and illegal to deny care to individuals on the basis of their religion, race, ethnicity, gender, gender identity, sexual orientation, immigration status or disability.
The triangular officers are supposed to rather concentrate on the chance of each individual surviving COVID-19 or other ailments.
Several doctors who helped draft the guidelines said they stressed the need for medical care to be conducted properly, even in normal times, but sometimes not – to provide only ‘beneficial care’.
This means that only treatment should be provided to patients with a reasonable chance of recovery. The doctrine rejects the taking of extraordinary measures only to prolong the life of a patient whose death is certain and imminent, often to reassure troubled family members.
A ‘scary time’
In a memorandum this week, one of the best doctors in the province’s healthcare system reminded his colleagues that they must be sure that they will apply the beneficial care standard immediately – even before declaring an official crisis – so that scarce facilities and staff are not wasted on those. who has no reasonable chance of getting better.
Dr Nikhil Barot, a pulmonologist at Olive View-UCLA Medical Center, said he was facing a “frightening time” to prepare to take on his role as one of the province’s subjects.
Special training in palliative care and medical ethics makes him feel prepared for the job, but he said he is concerned about carrying out the delicate balance that is likely to come.
“We want to give everyone the benefit of the doubt and say, ‘Listen, this is someone who’s getting better or has a chance to get better.’ was, ‘”Barot said.
At the same time, he said he believes the U.S. has historically provided patients with excessive treatment.
“I absolutely believe that we offer a lot of care that prolongs the suffering of people and keeps them alive when we know that the expected outcome is death,” he said.
One of the tools devised by the medical community to try to clear up inherently troubled ethical issues is the sequential organ failure, or SOFA. The score is based on the condition of six major organ systems: lungs, blood circulation, heart, kidney, liver and neurological. Higher scores mean less chance of survival.
SOFA scores have been favored because they ‘relieve the individual practitioner of having to sort them out on their own’, said Dr. Larry Churchill, an emeritus professor of medical ethics at Vanderbilt University in Tennessee, said. ‘I think it takes a lot of the anxiety out of the decision, but certainly not everything. It relieves one to have to say ‘Okay, I have to figure it all out on my own and I’m worried about my prejudices. ”
But in LA County, officials stressed the use of the scores, in part because of a “tabletop” exercise in which an internal SOFA applied to 10 COVID-19 patients and found that nine had the same score. Provincial officials told the Los Angeles Triage Doctors that SOFA scores are “not the focus” of the rationing plan, although it could be used if it provides clarity.
Care rations are not inevitable
The shift to rationing care is probably not inevitable, Ghaly and others said. A slight leveling in the number of new coronavirus infections has given hope that the emergency rules will not be invoked. And provincial officials hoped other prescriptions, such as ending elective surgery and ending ‘futile care’, would boost the ability to treat more patients.
Activating the triage officers is meant to allow front-line physicians to focus on the needs of their individual patients, just as they did before the pandemic.
“It is good for the patient and for the attending physician to understand that they are both focused on the care and recovery of the patient,” Patel said. “The triage officer may be worried about the bigger picture.”
In LA County, it is recommended that the attending physician then inform patients and their families about decisions to withdraw a ventilator, nurse, or other care.
Ghaly said in her letter to health workers in the province to prepare themselves for ‘difficult conversations between treating physicians, patients and families about the progression of a critical illness, about the effectiveness of treatment, about releasing’.
Patients or families wishing to appeal against a decision are first referred to the probation officer. If they are still not satisfied, they will be referred to the CEO of the hospital or to someone who appoints the manager.
Healthcare workers who already see many Americans carrying the rules on social distance and mask wear realize that rationing rules, which are also tilted to promote the greater public benefit, are not easy for some people.
“We are in a culture that today leans towards individual rights and autonomy,” Barot said. “And according to these rules, the health of the population is more important than individual health. There will be a clear setback to that kind of statement … no matter how much sense it makes. ‘