COVID-19: who gets an ICU bed and who decides?
The prospect that Australian doctors will have to decide who gets access to an ICU bed and life-saving ventilators should the number of Coronavirus Disease 2019 (COVID-19) cases exceed resources raises the question of how these decisions should be made, and by whom.
Should these decisions be based on consensus medical opinion or a ‘survival of the fittest’ approach? Can research provide clear real-time evidence to inform these difficult moral decisions? And who gets the final say?
This is not an academic question.
Italy to limit ICU access based on age
In Italy the number of COVID-19 cases exploded from three to 27,000 patients in just three weeks.
Faced by this tsunami, particularly among older people, doctors in Italy have issued medical guidelines advising that access to intensive care units should have an age limit.
At the same time, a leading Australian intensive care expert is urging the federal government to fund a study that could inform these decisions by revealing which patients would most benefit from intensive medical care.
The new guidelines distributed by the Italian College of Anaesthesia, Analgesia, Resuscitation and Intensive Care are based on a rationale that says older people are a relative waste of scarce medical resources in the context of the coronavirus pandemic: they are less likely than younger people to survive — even in an intensive care setting — and besides, they’ve lived more of their life than younger people.
“Informed by the principle of maximizing benefits for the largest number,” the guidelines written by doctors say that “the allocation criteria need to guarantee that those patients with the highest chance of therapeutic success will retain access to intensive care,” and that “it may become necessary to establish an age limit for access to intensive care.”
Of course, decisions about who gets access to life-saving healthcare are made every day by doctors, hospital administrators and insurance companies but the biases and reasoning behind these decisions are usually hidden from view.
Now they are being put under the spotlight like never before. And as the number of coronavirus cases starts to overwhelm medical services, citizens should have an opportunity to examine and question the values and assumptions informing these practices.
Who will get access to ICUs in Australia?
Australian intensive care expert Professor John Fraser is leading a study with specialists from 100 hospitals around the world that will help clinicians predict and plan the allocation of limited ICU beds, mechanical ventilators and extracorporeal membrane oxygenation, a procedure that could improve survival among COVID-19 patients.
He says it will provide decision-support to doctors and nurses, providing information on how to best treat patients.
It will do this by analysing data from thousands of cases and crunching hundreds of variables that could affect survival, including age, sex, symptoms, severity of infection, treatments, side effects, and length of stay in hospital.
By examining these variables in real time, researchers will be able to quickly see what treatments work best in which patients.
This is the essence of evidence-based medicine and the government will be under pressure to fund the $1 million being sought — which is small change given the caseload that’s predicted to swamp health services.
But what if the study reveals that younger people treated with ventilators in ICUs have better health outcomes than older people?
Explainer video — how a ventilator works
Should doctors ration scarce healthcare care based on this evidence alone?
Moral philosopher at the University of Notre Dame in Fremantle Philip Matthews says it’s ethical for doctors to restrict access to critical equipment like respirators to young and healthy people.
“I’m not sure what number you would choose, but I think there ought to be a number like 60,” he told ABC news.
“I’m 60 … I shouldn’t get a ventilator at any stage if someone younger needs it. For instance, if I was in competition for a mechanical ventilator with one of my children, it would be absurd to give it to me.”
Coronavirus cases in Australia by age group
Nearly one-fifth of all 368 coronavirus cases reported in Australia were recorded on Monday 16 March 2020. [i] People in their 30s account for the greatest number of cases. Three times as many people in their 30s have been diagnosed with the virus compared to people in their 70s.
The Western Australian President of the Australian Medical Association, Dr Andrew Miller, has scotched the idea that people aged over 60 should be restricted from ventilators.
“I don’t agree with that at all,” he said, while admitting that having to ration access to ICUs is a “position you never want to put your healthcare staff in.”
In a blog this week, Dr Miller, who is a specialist anaesthetist in private practice, said “compassion and respect for patients and avoiding futile treatment should come first in all healthcare decisions.”
He said some of the factors that doctors and hospital managers will be take into account when they decide whether a patient with COVID-19 should get access to ICU include:
- age — over 80 will look very closely at usual quality of life
- high care residents over 80 probably will not be transferred to hospital
- any significant other disease such as dementia or advanced life limiting cancer — for these patients their regular carers will be encouraged to establish clear goals of care
- what ICU capacity is available.
As mentioned, these factors are commonplace criteria for deciding who gets access to intensive care resources, although they have rarely been so conspicuous or open to debate as they will be as the pandemic worsens.
Preferencing patients with the highest probability of survival
The argument that patients with the highest probability of survival should get preferential access to ICU beds and ventilators is based on a utilitarian logic that seeks the greatest good for the greatest number of people.
Utilitarianism ideas originated with the 19th century philosophers Jeremy Bentham and John Stuart Mill. They argued that the most moral acts are those that maximize pleasure and minimize pain.
This logic is easy to understand and apply and has an intuitive appeal, suggesting a kind of fairness about it. It also removes potential biases and emotions from decisions that have life and death consequences.
However, one of the oldest criticism of utilitarianism is that it ignores our ‘special obligations’, meaning that it doesn’t take account of human or qualitative factors. For example, given a choice between saving two random people or one’s mother from mortal danger, most people would choose to save their mothers.
Preferencing patients based on medical consensus
Medical consensus statements are another tool for informing doctors and health administrators who face difficult healthcare decisions. They rely on the knowledge and opinions of medical experts in a particular field and they are commonplace in western medicine.
Medical consensus statements are produced by a panel of experts who have synthesized the latest available research and provide a ‘snapshot in time’ of the state of knowledge in a particular area of medicine.
However, they are not medical guidelines, meaning that doctors and health administrators are not meant to rely on consensus statements alone in their decision-making. Furthermore, medical consensus statements are not perfect. They are only as good as the research underpinning them — and they rely on an assumption that the appointed experts have the latest and best research data at their fingertips.
Preferencing patients based on gold standard research
Using evidence based medicine is the gold standard of modern healthcare. It means that doctors should base their decisions on objective information arising from the best available evidence, namely randomised control trials. However, these trials often take years to produce results and cost millions of dollars. The rapid onset and spread of coronavirus across the globe means they are off the table as a means for informing medical decision-makers and governments.
More to the point, how to best diagnose and treat COVID-19 cases isn’t the issue that’s most vexing our medicos and leaders as the spread of coronavirus threatens to swamp our hospitals or fuel civic unrest. They need ways to gather the best available real-time evidence about the treatment and survival of all patients being treated in ICUs around the world as a platform for sifting that information while having a dialogue with citizens everywhere.
The study proposed by Australian intensive care expert Professor John Fraser is probably the best and most rapid way of generating research-based information to help clinicians predict and plan the allocation of limited ICU beds, mechanical ventilators and procedures like extracorporeal membrane oxygenation.
Engagement and dialogue
On March 14 the Australian government began a national campaign to inform Australians about the coronavirus (COVID-19). It targets the general public and aims to “reduce risks to individuals and families by helping them to make informed decisions and act on health recommendations.”
It is a traditional one-way, top-down, we-know-best communication campaign. It presently covers issues such as good hygiene practices, how to stay informed and traveller advice.
Some news agencies have reported that the campaign’s primary target is groups at risk of contracting the virus, including older Australians and people with chronic health conditions. Thus far the campaign materials do not include information aimed at specific age groups or people with chronic health conditions.
There are certainly no campaign materials flagging plans about how or when decisions will be made about who will get access to ICU beds and ventilators if the number of COVID-19 cases exceed available resources.
On March 16 the WHO released a document to help governments and other authorities engage and communicate with communities about a range of issues arising from the coronavirus pandemic. Government leaders and health agencies are well advised to read it and act on it.
The document, titled ‘WHO Risk Communication and Community Engagement (RCCE) Action Plan Guidance COVID-19 Preparedness and Response’ contains a wealth of information and advice about how best to engage in a two-way dialogue with communities, the public, and other stakeholders about decisions such as rationing access to health and medical resources.
“People have the right,” it says, “to be informed about and understand the health risks that they and their loved ones face. They also have the right to actively participate in the response process. Dialogue must be established with affected populations from the beginning. Make sure that this happens through diverse channels, at all levels and throughout the response.”
Everyone is at risk of falling victim to COVID-19 in our interconnected world. We have seen nothing like it in our lifetimes. But our capacity to rapidly engage and communicate on many platforms about a range of issues arising from the pandemic means we have an unprecedented opportunity to make democratic, consensual, evidence based decisions that affect the young and the old, the healthy and the less healthy. These decisions belong to everyone, not just a select few.
Dan Gaffney MPH is a teacher and author. His new book and podcast series, ‘Journey Home — Essays on Living and Dying’ was published in November 2019.
Further reading
Special Report: ‘All is well’. In Italy, triage and lies for virus patients
Make us ventilators to fight coronavirus, UK asks Ford and Rolls Royce
Dutch end-of-life debate flares as coronavirus tests healthcare limits
[i] Data sources: these data come from case reports from state and federal health authorities supplemented by ABC reporting. Data were collated by the ABC to form a national database of all confirmed COVID-19 cases. The data record every case from the first, on January 25, until midnight on Monday 16 March.
