Medical Examiner

When the Doctor Has to Make the Toughest Decision

A hospital room with a bed, screens, and other scattered equipment
A view shows an empty room in the intensive care unit of Lyon-Sud Hospital Center in Pierre-Bénite, France, on Sept. 8. Jeff Pachoud/AFP via Getty Images

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Years ago, the H1N1 outbreak spurred a lot of pandemic planning for the future, mostly because physicians realized they’d dodged a bullet in terms of their hospital functions. And the thing these doctors realized, once they started making these plans, is that there are an awful lot of things to run out of and that need to be temporarily limited in use when we reach crisis mode. Over the past few weeks, you’ve been hearing a lot more about these plans, as hospitals have been inundated to capacity and beyond, and doctors have had to choose who gets priority treatments. The idea that one of these plans being implemented could mean you turn up at a hospital and lose out on care is frightening. I asked New York Times reporter Sheri Fink about that fear, and whether the triggering of care rationing signaled a new stage of the pandemic. Fink says no—because, plan or not, each surge in infections has already been making everyone worse off. On Tuesday’s episode of What Next, I spoke with Fink about what rationing health care during COVID really means. Our conversation has been edited and condensed for clarity.

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Mary Harris: You’ve said many hospitals are in the first stage of their pandemic handbook. And that means they aren’t officially rationing—yet.

Sheri Fink: They’re telling me they’re in this contingency mode where they’re just stretching, stretching, stretching, where it’s incredibly difficult for the providers, where the patients aren’t able to get the kind of care they would like to provide. Another step in freeing up capacity, as many of us know, is that a lot of regular types of care are being canceled—if you can hold off on a surgery, sometimes even a cancer surgery, they’re doing that now. These have been called “elective procedures.” But if you’re the one waiting to have your tumor out, that doesn’t seem very elective. And doctors feel that way as well.

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It seems to be trickling down to people in emergency situations. You realize everyone’s being affected, really.

Exactly right. It hasn’t felt like all these people arrive and you choose between them. It’s this horrific situation where a lot of patients are not getting regular care. You’re being denied the type of care that would be most recommended. That’s what we call a “standard of care,” what would typically be given to you. And there can be more risk with missing out on that care, more chance that you won’t survive. We’ve seen that during surges, even survival from COVID has been lower in stressed hospitals.

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Sometimes it does come down to choosing who gets a dialysis machine or an ECMO machine— when your lungs aren’t working and you need a machine that does the work of the lungs. That is something that’s been rationed for sure.

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And sometimes you’d use that in surgery, for instance. But this is for COVID patients now.

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Exactly. It can be important for both. There are not many hospitals that provide the machines, and the number of hospitals that provide it can only give it to a few patients. So there are definitely cases where there have been choices about which patients get a particular resource. For example, dialysis: Sometimes everybody’s gotten a shortened course of dialysis rather than giving a full course to one person and nothing to another person. It’s a lot of gray areas.

There are shortages in medicine, there are shortages of staff because workers are getting burned out after a long time too. I feel like that’s all affecting just when we lean on these crisis standards of care.

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That is a huge, huge part of it. The extraordinary sacrifice of providers and the stress and their dedication—there are now, many stories about just how difficult this is. In some areas, including in Idaho, I’m hearing a lot that there’s an active antagonism toward the medical community, toward the hospital providers. I had one doctor say to me that “Our hospital is full of patients dying of COVID who don’t believe that this pandemic exists.” There are many layers to this. I can’t stress enough how much these people care, and it’s so, so hard for them to watch so many people die.

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There’s one other level that we haven’t talked about, and that is that some of these crisis-standards-of-care plans envision a situation where somebody has a resource like a ventilator or a critical care bed and doctors expect this patient won’t make it—or that the patient has maybe less of a chance to make it than other patients—and the resources are actually reassigned to somebody else.

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What really adds to the emotional difficulty there is that in a lot of hospitals, during COVID surgeries or while in units that treat patients, the families aren’t being allowed to visit. In a surge, you can imagine that doctors and nurses barely have time to make phone calls. But they’re trying really hard to stay in touch with family members, and it is harder to wrap your mind around the situation in a hospital with your relative or loved one when you can’t actually be there.

In Idaho, “crisis standards of care” have showed up in the form of a high rate of transferring patients, a diminished amount of care, and long waits. There are rules for how to withdraw care without the consent of patients if they fail to improve after a certain period of time. They vary from state to state. Some come with elaborate point systems to help assign relative value to different types of people. Some of those systems incorporate patients’ long-term chances of survival. But using a point system like this is also relatively untested, and these plans often don’t go in front of the public for feedback before they’re put into action. So doctors are understandably wary of putting the exact “crisis standards” into practice.

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I would say that I’ve really been stretching to find a place that is using these plans as written. I will also point out that there’s always been a problem with these plans because there’s not a lot of research that suggests that you will meet your goals by using these scoring systems. The whole purpose of choosing who gets the resource based on a scoring system, the whole goal is to maximize a certain outcome. Then the question becomes, what are you trying to maximize here? Is it the number of lives you save? Is it the number of years of life? Is it a number of healthy years of life? Do you look at whether that person has underlying conditions?

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Who’s judging all of that?

Exactly. That’s the other question: Who gets to make that choice? Who’s on the triage team? Who drew up the plan? Often, as you could imagine, a group of people from a particular socioeconomic and educational background. It has been troubling to look at some of these plans and feel that they didn’t have a lot of input, there wasn’t a huge public awareness of them, and there wasn’t even a lot of awareness among providers that states and hospitals were coming up with these plans. Now that they’re in the public eye, now that they’re being noticed and written about, there’s been pushback. A number of disability rights organizations have filed complaints with the Office of Civil Rights at the Department of Health and Human Services to say that if you implement some of these plans as written, you will discriminate in ways that are unlawful. Some had these aspects that sound very discriminatory, that may have nothing to do with maximizing survival. And there are people who would argue that it should be randomized, that there should be a lottery system, because all of this has a danger of reinforcing structural inequities in our health system.

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The more light that shines on these documents, the more problems with them are found. The other big issue is that these plans are not so easy to implement.

With better planning, a lot of these hospitals wouldn’t even need to consider these standards. The United States has the resources, but they’re just not distributed correctly.

What would that look like if we did do this better? Would it look like physicians relocating from a place like New York and having a more fluid workforce?

Absolutely. There is some coordination going on for getting providers from other places, and there are some very wonderful steps that some hospitals are taking to voluntarily care for patients from other places. But there are places in the world where there’s a much more organized approach to this, where they’re one step ahead and they’re keeping track in real time and they’re actually moving patients ahead of getting into crisis mode. We can do that now with technology. But that’s just not being done for various reasons.

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It requires so much coordination. We have 50 individual states, and often they’re taught to think of themselves as little islands that have their own departments of health and that communicate with their own hospitals.

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But we do this coordination during events like hurricanes, for example. We do it when large numbers of patients have to be moved. There is a better way to coordinate. We don’t have to deprive people of care. There’s a lot more work to do on this

What makes me very disappointed—angry, sometimes—is that we’re more than a year into this pandemic, and we’re still in this situation that’s unconscionable. Why aren’t we doing better? We could be! But now, we’re in what is the fourth surge for many places. Every time a surge has subsided, we’ve kind of felt like, “OK, hopefully it’s going to be all better now. We’re not going to get into this situation again.” There hasn’t been a lot of “What did we learn from it and what can we implement?” I feel that we haven’t learned enough, though we’ve had a chance to improve within the crisis.

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