By Dan Gordon. In the face of a pandemic that threatens to overwhelm hospitals across the country, UCLA wrestles with troubling questions about how to deliver the most appropriate care in a potential environment of limited resources.
As the pandemic of novel coronavirus took hold across the globe, hospitals throughout the United States were confronted with the frightening reality that they could be overwhelmed as never before. News and personal accounts from China and Italy pointed to dire conditions that soon might cross the oceans and land on America’s shores — more critically ill COVID-19 patients needing treatment than there were intensive care beds and shortages of lifesaving equipment such as ventilators. For the doctors, nurses and other health care professionals who would be manning the frontlines to confront the anticipated onslaught of cases, there were the added anxiety and fear that they might be placing themselves and their loved ones at risk in the line of duty, particularly amid reports of shortages of personal protective equipment (PPE).
These and other concerns have compelled health care leaders at UCLA and across the country to plan for contingencies they hoped never to experience and to wrestle with ethical questions that have no easy answers.
At the first indication that a surge in COVID-19 cases might be unavoidable, mobile tents went up outside the Ronald Reagan UCLA Medical Center and UCLA Health - Santa Monica Medical Center emergency departments, a visible sign that UCLA Health, like all major health systems in the U.S., was taking steps to expand its capacity. Elective surgical procedures were postponed, extra equipment was stockpiled, PPE was fortified and frontline emergency and critical-care staff was bolstered in anticipation of the influx of patients.
“The goal is to have the resources to handle all of the cases that come in. Unlike a natural disaster such as an earthquake, with a contagion like this, you have lead time that allows the system to plan to take on many more patients during a surge,” says Neil S. Wenger, MD ’84 (RES ’87, ’90, FEL ’89), MPH, professor of medicine and chair of the Ronald Reagan UCLA Medical Center Ethics Committee. “But, of course, systems also have to plan for the possibility that even after increasing their capacity as much as possible, their supply of beds, equipment, doctors and nurses is exceeded.”
In a situation in which every ICU bed in the city is full, “hospitals would face the conundrum of how we fairly, rationally and consistently make decisions on the allocation of limited resources,” adds Clarence H. Braddock III, MD, MPH, professor of medicine and vice dean for education at the David Geffen School of Medicine at UCLA. “That’s a huge challenge.”
Scenarios such as what occurred early on in other parts of the world raise perilous questions. Hospitals under normal circumstances take heroic measures to save the lives of all critical-care patients, but in a surge, with resources stretched beyond their limit, they might have to adopt a triage mode, prioritizing which patients will receive the attenuated supply of interventions based on factors such as the severity of their condition and likelihood of recovery.
For UCLA Health, an institution within whose vision statement are embedded the words “to heal human kind … by alleviating suffering and delivering acts of kindness,” having to make such choices is nearly unthinkable. “It is our mission as medical providers to preserve or prolong life, so in a normal situation, the next available ICU bed or ventilator goes to the person who is sickest,” says Dr. Braddock, who before coming to UCLA served as chair of the ethics committee at Stanford University School of Medicine and director of the Bioethics Education Project at the University of Washington. “In a triage situation, such as in wartime, the next available resource might go to the person who is most likely to recover.”
These are the troubling issues with which physicians across the country have been grappling and debating with each other over online and social networking channels and in journal and newspaper opinion articles since this pandemic erupted.
THOUGH IT IS A SCENARIO NO HEALTH SYSTEM EVER WISHES TO CONFRONT, preparing for the possibility that not every patient will have access to lifesaving treatment, or that the demands on health care personnel will require them to prioritize which cases receive their attention, necessitates the adoption of a different mindset for everyone involved — health care workers, patients and families — as well as clear guidelines for how these heart-wrenching decisions would be made.
The University of California (UC) responded early in the pandemic to convene an 18-member working group of bioethicists and critical-care specialists from across the UC’s six medical campuses to develop systemwide guidelines — based on ethical principles that include a duty to promote health and avoid harm, respect for persons and justice — for the allocation of critical resources if a surge exceeds available capacity. “In a severe crisis, these principles may be in tension, either with each other or with themselves,” states the report, which was released in April (as were guidelines by the California Department of Public Health) and will continue to undergo review, public input and revision over the next several months.
“In such situations, medical institutions must shift from their traditional focus on individual patients to a focus on populations, the common good and the protection of civil society. As the National Academy of Medicine wrote: ‘Ultimately, this shift represents not a rejection of ethical principles but their embodiment.’”
The tension that the report acknowledges is evident in the language of those on the frontline who must grapple with this issue. “As Americans, we are not used to being in a situation where we might have a scarcity of resources to the extent we potentially could experience in an event such as this,” says Rochelle A. Dicker, MD, UCLA professor of surgery and anesthesia, vice chair for surgical critical care and chair of the UC working group.
(Dr. Wenger and Russell G. Buhr, MD [FEL ’17], PhD ’19, UCLA assistant professor of pulmonary and critical care medicine and chair of UCLA’s Crisis Standards of Care-Disaster & Pandemic Response Team, also were members of the working group.) While there are significant health-care disparities and inequities in the United States, “we, by-and-large, live in a land of plenty, so the thought that we may have to make choices about how we deliver the most appropriate care in an environment in which we may not have sufficient resources is incredibly sobering,” Dr. Dicker says.
Before wading into the details of the guidelines, the panel worked to erect an ethical scaffold around which to build its discussions. “This was a group of incredibly ethical, moral and thoughtful individuals,” Dr. Dicker says of her colleagues on the panel. Once that framework was established, “the rest of our conversations, which certainly were intense, flowed from our alignment on the ethical principles.” At the core of those ethical principles was “saving the most lives — which is what we do under normal circumstances — within the context of a duty to prepare and a duty to conserve scarce resources,” Dr. Dicker says. Addressing such issues was an intense experience, but, ultimately, she says, “I’ve never had more pride in being a part of the University of California than I have in this moment.”
THERE IS, IN NORMAL TIMES, ONE NOTABLE EXCEPTION IN WHICH SCARCE RESOURCES DICTATE that mechanisms be developed to determine how lifesaving treatment is allocated: organ transplantation. Because there is a limited supply of donor organs available for transplantation, a federal system has been developed, overseen by the United Network for Organ Sharing, to prioritize patients for transplants based on factors that include waiting time, medical condition and prognosis. It is a system that is administered at the regional level rather than by individual hospitals. “Because UCLA has been doing solid-organ transplants for decades, the ethical concepts related to maximizing benefits under conditions of limited resources — how to do so rationally, justly and equitably — are routinely discussed by many people here,” says Thomas B. Strouse, MD (RES ’91), medical director of the Stewart and Lynda Resnick Neuropsychiatric Hospital at UCLA and the inaugural holder of the Maddie Katz Chair in Palliative Care Research and Education.
Those issues are relevant in the current situation. Since the pandemic began, medical ethicists around the world have been struggling to address such questions as: If a hospital is inundated by COVID-19 cases, how does that impact patients with other conditions? In a system that seeks to maximize the benefits accrued from the allocation of limited resources, does a younger person take priority over an older person, given their longer life expectancy? Should a patient’s underlying health conditions be weighed, and if so, how?
The calculus of determining who would be the best candidate to receive life-saving care in a situation that necessitates medical triage might seem obvious — an individual with good long-term prognosis who needs a ventilator to survive as opposed to a patient with a terminal illness who has only days to weeks to live and has become sick with the coronavirus, for instance — “but in the vast majority of cases, it isn’t so simple,” Dr. Wenger says. “We need objective measures. People are working to build models that produce an estimate of survival, but there are many variables, and much work is necessary to avoid bias.”
Dr. Wenger notes that some of the issues raised in a crisis like this point to similar concerns that arise in hospitals nearly every day, such as when is it appropriate to withdraw lifesaving measures? “In a way, this is something of a teachable moment. What is happening now makes it clearer that it is important to think about the future and one’s priorities,” Dr. Wenger says. “This is what advance care planning is all about: communication about one’s values and goals and how those translate into preferences in the setting of potential danger.” Dr. Wenger says that primary care physicians now are being asked to emphasize these kinds of conversations with their patients. “This is an important issue for everyone to consider,” he says.
IN ANTICIPATION OF THESE CHALLENGES, federal agencies, states and professional organizations have developed general recommendations for approaches to allocating scarce resources during a pandemic, and hospitals and health systems like the UC have brought together medical ethicists and other clinical leaders to determine how they will put them into practice. Dr. Wenger explains that having well-established guidelines is critical, so that treatment decisions are made rationally and equitably, rather than in an ad hoc manner. Transparency, consistency and accountability are all essential in the implementation of such guidelines. In an op-ed in the Los Angeles Times that he co-authored with Martin Shapiro, MD, professor of medicine at Weill Cornell Medical College in New York City and formerly chief of the Division of General Internal Medicine and Health Services Research at UCLA, Dr. Wenger noted: “The American public needs to be educated on the rules for medical decision-making so that it’s clear why some patients receive [lifesaving] treatment while others do not.”
Failing to use objective measures to allocate scarce resources risks tilting the scales toward those with wealth and influence. “We know that in our country, there are inequities in who gets the best care,” Dr. Wenger says. “At a societal level, we must ensure that in a crisis in which resources are strained, those inequities do not get magnified.”
A group providing oversight in the implementation of guidelines is important, Dr. Braddock adds, both to ensure that the policies are being fairly adhered to and so that frontline clinicians working under extreme pressure aren’t tasked with making these difficult judgments on their own. “You probably don’t want individual clinicians having to make these decisions, but instead, recognizing circumstances at the bedside and then referring to a deliberative body that can review a series of situations across the hospital,” he says. “That also allows the individual physician to remain solely focused on responsible advocacy for the best interests of the patient.”
One principle on which there is broad agreement concerning resource allocation is to make the health of frontline clinicians, along with other emergency workers, a high priority, given that their services are essential to the efficacy of the pandemic response. This is a triage strategy known as multiplicity. “Part of the rationale is that health care workers need to know that if they are putting themselves in danger, they will receive treatment, if necessary,” Dr. Wenger says. “Their ability to continue functioning is critical to addressing the needs of patients in a pandemic.”
Beyond that, ethicists have pointed to the need to draw on utilitarian principles aimed at maximizing benefits to the largest number of people and prioritizing patients — whether they are COVID-19 patients or individuals with other medical conditions — most likely to benefit from care and those with the best chance for the longest remaining life. This diverges from the usual approach, in which care is delivered on a first-come, first-served basis. In a worst-case scenario, “this means that ventilators and ICU beds should be denied to or withdrawn from patients for whom the benefits are minimal at best and those resources given to patients who are more likely to survive,” Dr. Wenger wrote in his Times op-ed. He acknowledges that these are “gut-wrenching” choices for everyone involved, and they “must be carried out with compassion, support and palliation.”
Dr. Wenger points out that a different calculus is likely to present itself when an effective treatment or vaccine for COVID-19 becomes available. In the case of a vaccine, for example, maximum benefit would likely be achieved by prioritizing not only frontline health care workers, but also groups at the most risk of experiencing poor outcomes if they contracted the disease, including older patients and individuals with chronic conditions that leave them vulnerable.
ALTHOUGH THE MAGNITUDE OF THE COVID-19 PANDEMIC MAY BE UNPRECEDENTED IN MODERN TIMES, the prospect of a surge of critically ill patients requiring triage decisions related to allocation of staff time and resources is something for which every emergency clinician has prepared, notes Medell K. Briggs-Malonson, MD (RES ’09, FEL ’12), MPH, a UCLA Health emergency physician, who serves as both director of quality for the Department of Emergency Medicine and the medical director of clinical effectiveness for UCLA Health. “We are trained in responding to mass-casualty incidents, where you have a wide variety of patients ranging from the walking-well to those who are so close to death that there is little we can do to help them, and everything in between,” Dr. Briggs-Malonson says.
The emergency department (ED) is the frontline in the battle against COVID-19, as it is for other highly infectious diseases, adds Gregory Hendey, MD (RES ’93), chair of the UCLA Department of Emergency Medicine. “We have to stay ahead of the curve because the ED is the point of the spear, the first place a patient would go.”
Although general triage guidelines have been formulated from experiences with incidents such as natural disasters and mass shootings, Dr. Briggs-Malonson explains that each hospital and its emergency department must develop its own system based on the resources and personnel it has — and that each situation is fluid. “Within the first 24-to-48 hours, you might make certain decisions that then have to change, as your volume of patients continues to increase and your resources decline,” she notes. “At that point, it becomes more important to ensure that energies are directed toward patients most likely to benefit from aggressive measures.”
The difference when the emergency response involves a pandemic infectious-disease outbreak is the potential risk from being exposed to patients — requiring measures to ensure the safety of the doctors, nurses and other staff. “Although we’re highly skilled and comfortable with these mass surges of patients and the need to triage, we have to be very thoughtful about how we minimize the risk to our health care workers, because if they become infected, it has an impact on our ability to care for the community,” Dr. Briggs-Malonson says.
Emergency physicians responding to COVID-19 cases must consider not only how to protect the safety of their patients, but also how to protect their own safety and that of their clinical team. “In a sense, it’s like being on a battlefield, in which you’re trying to provide optimal care while minimizing the number of people who have to wade into the conflict,” Dr. Briggs-Malonson says. “That is not something we would have to think about in the traditional practice of emergency medicine.”
She notes that beyond wrestling with the difficult ethical questions raised by the COVID-19 pandemic, health systems have a responsibility to address the secondary trauma of frontline staff who are working long hours in these battlefield-like conditions, caring for critically ill patients while confronting their own fears about potentially placing themselves and their families at risk. Providing support and looking after the psychological wellness of the health care team is vital, Dr. Briggs-Malonson explains, both to ensure that clinicians are at their best when they see patients and as a moral obligation to those who are putting themselves on the line.
“As emergency personnel, our job is to save lives, but we go home every day with a heavy heart,” she says. “There are people walking the halls of emergency rooms and ICUs who know it is their responsibility to be there, but they see health care workers across the country getting sick, and they worry about themselves and their families. It’s important that they have a safe space and a supportive environment in which they can talk about their feelings and that they can take wellness breaks when they need them.”
Dr. Strouse agrees, and he has worked with other UCLA Health leaders to ensure that staff have access to a wide array of mental health support services. “These are difficult personal decisions each clinician is making, especially when we hear about hospitals that have had shortages of PPE,” says Dr. Strouse, who has taught and written extensively on ethical issues in end-of-life care. “For most of us, though, this is part of our core identity — taking care of sick people even if it means making sacrifices, including putting ourselves in jeopardy.” “Every health profession has a tradition in which there is a responsibility to care for patients even if it entails some risk,” Dr. Braddock says. “COVID-19 challenges our understanding of how much risk we should be expected to take, but most people are recognizing that obligation and meeting the challenge.” Dr. Braddock says he knows of cases in which frontline health care workers with families at home have undertaken extra precautions, such as quarantining themselves to one room within their homes.
“Clinicians do not have an ethical duty to put themselves at very serious risk of harm,” Dr. Wenger says. “But we do have a duty to treat patients within the constructs of the best available protection. The question is where that line is. Here, and across the country, we have seen our health care providers stepping up.”
Dan Gordon is a freelance writer in Los Angeles and a frequent contributor to U Magazine.