Hospitals are now overwhelmed. They have to let some
patients die, so others may live. Most shortages are chronic. For example, more
ventilators can be produced, but they need respiratory therapists and trained nurses
to operate them. The therapists and nurses work in three shifts. Frontline
soldiers in this war, they must remain healthy through the pandemic. Manpower
is a serious limiting factor for ventilator use.
For patients and relatives, denial of access to
intensive care or withdrawal of ventilator support can be traumatic. In the
USA, law and lawyers are more developed than health care. Hospitals implement the
health departments’ triage guidelines to protect themselves from future
lawsuits.
New York Times (31 March) studied the health-care
rationing strategies of ten states. I offer here the highlights from that
article.
State of New York doesn’t admit people who may die despite treatment to
the ICU. Patients with cardiac arrest not responding to defibrillation, or with
brain injury or severe burns are excluded. Patients on ventilators are assessed
every 48 and 120 hours. Ventilator support is continued only in case of
improvement. If a patient’s condition worsens, the ventilator is removed.
Alabama denies ventilator support to AIDS patients, severe
cases of mental retardation and children with severe neurological problems.
Washington can refuse ICU access to severe failures of the heart,
lung, liver or multi-organ. Patients on the ventilator are checked once a day.
If improved, they are moved out of the ICU. If the condition becomes worse, the
ventilator is taken off, and end-of-life care is offered to free up space. This
policy has been criticized, because in many cases the condition becomes worse
before improving. Days or weeks of ventilator support can bring a patient back
to life. (Boris Johnson).
Louisiana denies the ICU to patients with severe dementia.
Sequential Organ Failure Assessment (SOFA) scores patients based on the
functioning of heart, lungs, kidneys, liver, blood and brain. (Here low scores are
better, high scores bad). Maryland
disqualifies people with higher SOFA scores. Pregnant women with a healthy
foetus get a one-point credit in Maryland, two-point credit in Pennsylvania and
one-or-two in Utah depending on how advanced the pregnancy is.
Between “Patient A, age 24, with a SOFA score of 13”,
and “patient B, age 72, with a SOFA of 10 and mild Alzheimer’s”, Maryland will treat the older patient because he has a lower
SOFA. But in Pennsylvania, moderate Alzheimer’s
penalizes him, and the younger patient gets precedence.
Besides Alzheimer’s Pennsylvania is harsh on cancer patients with less than 10 years of
expected survival. Premature infants with low chance of survival qualify for
neither ICU nor ventilator. Pennsylvania offers one credit point to health
workers.
USA’s federal civil rights office has started investigating discrimination based on disabilities, race, age or religion. Measures
such as SOFA are criticized as they discriminate against the black and poor.
Because of low health care access, their health is normally poorer. Currently,
disproportionate numbers of blacks are dying of covid-19 in New York.
*****
In March, a group of ten MD/PhDs from across the world
has published an excellent paper on this subject. I will discuss their
recommendations tomorrow.
Ravi
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