Catapulted into the frontlines—and the headlines—by the ravages of the current pandemic, U.S. critical care medicine faces imposing challenges. So too, therefore, do patients requiring critical care, right along with their families. The news is awash with dire predictions about ventilator shortages, inadequate personal protective equipment, and staff to care for the most critically ill or injured. Equally alarming are critical medication shortages in locations with adept critical care units such as Madrid, Spain. At the same time, the world looks on with hope that cases will diminish as they have in China and Italy. Meanwhile, clinicians fervently hope that the critical decision-making faced elsewhere will never surface where they may need to provide—or receive—care. We have enacted social distancing, and states have issued lockdown orders for residents. Non-essential businesses have shuttered their doors. Even playground basketball hoops have been removed where I live to help limit gatherings and reduce the rate of viral spread.
Those were the easy decisions. The hard ones? Those that address what happens when more people need care and care resources, than we have available. Those resources include ICU beds and mechanical ventilators. Saving lives drove us into medicine, but resource limitations underscore the harsh reality that we may not have all that we need. In a system perhaps marked by innovation, horizon expansion, and exceptional complex care, US medicine now enters principally uncharted territory. Nonetheless, we must prepare to make those very decisions—who receives potentially life-saving care, and who does not—in advance of needing to make them lest we be inadequate to the task.
Such decisions must hew to ethical principles and not reflect individual bias. A cornerstone of the physician-patient relationship—that there is a relationship—is forged while learning about why your patient came to the hospital, who accompanied them, and is reinforced during their examination. Touching someone and looking into their eyes while explaining their illness, as well as your plan for care, is inherently biasing. It is all the more so, when their condition is one for which you have a therapy. Therefore, the bedside clinician—the one with that prized relationship—must be relieved of the ability to decide how resources are allocated, or rationed, during a crisis.
Rationing is a powerful word. It inspires fear over just how it is to be accomplished, and to whom it will apply. This is a challenge for which we are partly prepared. Disasters, both natural and man-made, war, as well as mass casualty events from firearm injury spurred the development of triage guidelines. Practical training for triage officers and incident command leaders reinforced those principles. Recent preparation for influenza, MERS, and SARS brought rationing to medical professional meetings, politics, media, and the dinner table. But none of those truly prepared us for the scale we now face with the COVID-19 pandemic. Now is not the time, however, to abandon hope.
To that end, medical professional organizations are furiously adapting and refining existing guidelines to inform practitioners, bedside teams, hospitals, and governing bodies how to approach rationing in the most equitable fashion. Indeed, each of those team members have a realistic chance of being subject to the framework they help erect; they could be the next patient. A key aspect is that the current standard of care (first come, first served) must instead change to a different standard—a crisis standard—that relentlessly pursues the greatest good for the greatest number. Common features include assessing resources, identifying triggers to engage the crisis standard, preparing and enacting a triage system, providing alternative care (including palliative care) with equal vigor, supporting families, and establishing healthcare worker support systems.
Everyone must recognize that rendering rationing decisions, and perhaps more importantly, enacting them is exceptionally hard for clinicians. We embrace palliation when there is no hope or cure, or when what is required for cure is not what the patient desires. Palliation relieves pain, curbs anxiety, and mitigates symptoms while supporting death with dignity. The potential time when we could offer therapy, but there are no tools with which to do so, is not for what clinicians are prepared during training. Clinicians who have deployed with the military or a civilian tactical (SWAT) team—like me—may better understand these tenets as part of Tactical Combat Casualty Care. And yet, bearing witness to using them will predictably, and perhaps indelibly, engender moral distress. That distress is in part alleviated by having the rationing decisions occur at a remove from the bedside clinician. But it is unlikely to erase the imprint left on your soul.
By making the process and the participants transparent to the medical community, patients, families and legislators we hope that everyone understands the spirit and the specifics of an ethical approach to rationing. We do this all while fervently, and perhaps desperately, hoping that rationing need never occur.
Lewis J. Kaplan, MD, FACS, FCCP, FCCM, is the President of the Society of Critical Care Medicine (SCCM).
The views expressed in this article are the author's own.
