Memphis hospitals finalize life-death plans based on patient survival
Pressure on Memphis hospitals continued to escalate this week, raising the once-inconceivable possibility that hospitals would be forced to sort care based on likelihood of survival.
There were 701 people in hospital with COVID-19 on Wednesday, the most ever. Members of the National Guard were called in to help staff overcrowded hospitals. The continued crush of patients comes as projections from the Memphis County and Shelby County COVID-19 Joint Task Force show 1,040 people could be in hospital by September 1, a level that will likely be higher. beyond what hospitals can handle.
If that tipping point is reached, a small group of doctors and clergy would be tasked with making life and death decisions about individual patients, taking into account their chances of survival while ignoring factors such as their race or their contributions to society.
This is the scenario described in a state document titled “Guidance for the Ethical Allocation of Scarce Resources,” and explained in more detail by Dr. Joe Holley, medical director of the Memphis Fire Department.
Holley was among local doctors, including heads of local emergency services, who recently wrote a letter to local leaders urging a mask warrant or hospitals should start sorting out care. The Shelby County Health Department issued a mask requirement within 24 hours of the letter’s publication.
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As of now, it doesn’t appear that the Memphis metro area has reached such a crossroads, but the possibility remains much closer than it has been since the start of the pandemic.
“I don’t think we’re there yet,” said Holley. The trigger point depends on the hospital staff, which makes it a moving target, he explained.
“I don’t know what the number is today or this week. I’m comfortable saying that whatever the number is this week, it’s probably at the 95th percentile where we’re going to start to really feel it,” he said. Holley said.
Another doctor who signed the letter, Dr Richard Walker, said hospitals in Memphis were not about to need triage of care, but were “closing dangerously”.
“We were already in a situation where we had to work wonders to move people to an appropriate unit,” Walker said, “and these are usually people who need other types of care. [other than COVID-19 care]. “
How hospitals make the decision
If a hospital capacity tipping point is reached, the state of Tennessee has guidelines on how hospitals, emergency rooms and first responders should proceed.
The guidelines note that different hospitals could reach a crisis level at different times and state: “Hospitals still in an emergency phase will not be expected to share their remaining limited resources.”
However, local leaders expect that when and if this point is reached, most hospitals will be on the same page and at the same level of crisis capacity.
Holley said he and local emergency service chiefs would likely alert the Shelby County Health Department and the seven Shelby County mayors that now is the time to sort out care. A discussion would ensue, he said, and then there would be a public announcement.
Holley was part of the statewide panel of experts that revised state guidelines last year. He said that even if Memphis reached crisis point, medical staff would work to limit the number of triage actually performed.
“My feeling is that we wouldn’t be adopting everything in this document immediately. It would kind of be, we would do as little as possible to make it work,” Holley said.
The fire department medical director also explained that the standard of crisis care is not a binary state – it is not an on-off switch. A hospital might run out of ventilators or intensive care space for a patient in the morning, but that could change in the early afternoon, eliminating the need for crisis standards.
“It’s a constantly fluid process,” said Holley.
How rationing of care works patient by patient
Once a decision is made to implement Crisis Care Standards at Memphis area hospitals, the medical staff at each hospital will decide who should receive care.
Holley said decisions about individual patients would be made by two or three doctors, a chaplain or another member of the clergy.
He said this group “would be sort of a panel that could make objective decisions, which were not directly involved in the care of this individual patient.”
The reason physicians who make potential life or death decisions are not involved in the care of this particular patient is to remove as much of the bias from the decision as possible, Holley explained.
“The goal when you get to this point is to try to be very objective in saying that the patient’s chances of survival are less than 5% and so if we don’t have the resources to commit to something like that when we have another patient who needs the same resources, the chances of survival are 40% … “said Holley. “We would try to do the most good for the most people in these situations, but we would also make sure that our, our decision-making, is focused on the most good for the most people, as opposed to all that. is possible for each patient when we know that the chances of survival of that patient [are] extremely low. ”
The paper Holley helped write also emphasizes the need for objectivity.
“Social value and other non-medical factors should not be used in the decision-making process,” the document said. “Decisions about treatment should be based on an individualized assessment of the patient based on the best objective medical evidence available.”
State guidelines also make it clear that resource rationing would apply not just to COVID-19 patients but to everyone.
“It is recognized that during a significant public health event and associated declared state of emergency, patients presenting to acute care hospitals may suffer from conditions unrelated to the emergency event. . These guidelines should apply to ALL patients seeking care in acute care hospitals. during the event, ”the guidelines said.
Walker said that in these scenarios, thousands of diagnoses and the potential outcomes of each create a complex web of decisions physicians must make.
“But there is a scoring system based on the organ systems that are functioning and the vital signs and just the numbers that can produce a probability. And those are often wide ranges,” Walker said.
For COVID-19 patients in particular, their vaccination status is the biggest determinant of their chances of surviving the disease.
“Not being vaccinated is the most dangerous thing right now,” Walker said.
He added that vaccination status alone would not be a determining factor for a patient receiving care.
Behind vaccination status, he said, obesity, diabetes and hypertension also play a big role in a patient’s chances of survival.
And unlike previous surges in the pre-vaccine era of the pandemic, young people and health in general do not offer the same shield against a fatal outcome as before.
“Earlier in the pandemic, it was the 80-year-old man with health problems who [were] at the greatest risk. Now, an overweight 35-year-old man may very well be and is probably more at risk than this 80-year-old man if the eight-year-old is vaccinated and the 35-year-old is not vaccinated. “
Equity becomes an issue
A person’s underlying health issues are already a key factor in whether they will suffer from serious illness or die from COVID-19. These conditions could also determine whether or not they receive life-saving care.
While state guidelines stress that U.S. civil rights laws still apply in a medical emergency, they also note that a person’s underlying conditions can be used to gauge their likelihood of survival. . The guidelines indicate that there are scenarios in which the most aggressive and potentially life-saving care should not be provided to all individuals.
This includes: “Those whose underlying medical conditions make their probability of death so high that it is unreasonable to allocate them intensive care resources in a crisis situation, based on a probability of survival. and individualized assessment rather than outright exclusion. “
In Memphis and across the United States, black people suffer from asthma, diabetes, and obesity at much higher rates than the rest of the population. This is often due to systemic factors such as pollution, lack of access to healthy food and other factors.
Dr Kendra Hotz spoke to The Commercial Appeal in March 2020 about how systemic racism in the United States could emerge in overwhelmed hospitals.
“If health care systems are overwhelmed, one of the tasks of ethics committees is to produce a protocol to help hospitals think about ‘If you have 10 ventilators and 25 people who need them, who gets the fan, ”Hotz said. “The most common type of rule is that the person most likely to survive gets it, but the person most likely to survive is the person with the fewest underlying conditions, which means our triage could reinforce these. disparities. “
Samuel Hardiman covers Memphis city government and politics for The Commercial Appeal. He can be contacted by email at [email protected] or followed on Twitter @samhar