A Doctor’s Hardest Call

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S1: It’s hard to remember now, but back before anyone knew what a coronavirus was. We had plans for what to do if one emerged. It wasn’t a complete plan. It wasn’t even one single plan. More like a lot of little plans. State by state. Hospital by hospital. But doctors were imagining a moment like this one.

S2: So a number of years ago, well over a decade ago, there was the H1N1 flu pandemic. If you remember that

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S1: Sheri Fink reports for the New York Times.

S2: It was a flu strain that people were afraid was going to be the next big and bad pandemic, Sheri says.

S1: This H1N1 flu? It’s where a lot of pandemic plans got started. Mostly because physicians realized that they’d dodged a bullet.

S2: They realized that if there were ever a really bad outbreak, particularly of a virus that affects the respiratory system, that even though the US has an enviable health care system, has a lot of resources, it’s very advanced that we could run out more.

S1: And once they started making these plans, doctors realized there were an awful lot of things they could run out of. They even started using a little mnemonic for thinking about all the resources that could be drained. It went like this staff stuff and space.

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S2: These are the three components and that there’s a typical standard by which we get care. And then in a crisis like this, where there are so many more people needing those resources, the staff stuff in the space that the standard of care would not necessarily meet what we’re used to. And so there was this recognition Wow, we better plan for this. What do we do?

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S1: And the answer to that question was these plans. I imagine them sitting around in a dusty three ring binder. But Sheri says they’re probably just a PDF file on some government computer. Whatever the plans look like over the last few weeks, you’ve been hearing a lot about them.

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S3: 10 Idaho hospitals are now operating under crisis standards of care.

S1: What does

S2: that mean? Does this

S1: mean doctors there possibly have to

S2: choose between helping and unvaccinated

S1: patient who severely ill from COVID

S2: and someone else who may be having a heart attack?

S1: What that means in English is that hospital care is now being rationed. The idea that one of these plans could mean you turn up at the hospital and lose out on treatment. It’s frightening. So I asked Sheri about that fear, whether rationing signaled a new stage of the pandemic and she surprised me. She said no, because plan or not surge after surge in COVID infections. It’s already been making everyone worse off.

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S2: I’ve had so many doctors say to me, I know I could be saving more of these patients lives if I could practice in a way that I’m used to. That is a common refrain during COVID surges. And maybe what’s different about this moment is that they’re putting a name to it that some of these states have come forward and some hospitals and said openly to the public, we are triggering these PDF documents that you were imagining these dusty papers on a shelf. But we’re actually letting you, the public, know that we’re in this situation, that our providers are not able to treat you the way they normally would. And I think it’s been happening a lot. But what may be unique is that now they’re having press conferences, now they’re they’re being open about it.

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S1: Today on the show, a closer look at what rationing care really means. I’m Mary Harris. You’re listening to what next? Stick around. Now that a couple of states are finally saying out loud, we’re in a crisis. Sheri has been curious to see how that’s changed things for doctors and patients. She says a lot of hospitals are in the first stage of their pandemic playbook, and that means they aren’t officially rationing yet.

S2: They’re telling me that 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 that 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 cancelled surgeries because often surgeries require you to stay in an ICU for a while, and that can be predicted. So if you can hold off on a surgery, sometimes even a cancer surgery, they’re doing that. Now they’re canceling. It’s been called elective procedures, but if you’re the one waiting to have your tumor out, that doesn’t seem very elective and the doctors feel that way as well.

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S1: Yeah, it seems to be trickling down to people in emergency situations, too, like the director of the Iowa Department of Health talked about his own mother going to a hospital because she’d had a stroke. Just a

S3: few hours after crisis, standards of care was activated statewide,

S1: and in normal times, she would be kept for observation.

S3: But because of crisis standards of care after she was stable, she was discharged later the same day from the E.R.. My family and I took over monitoring her at home.

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S1: You know, it doesn’t feel great when you hear stories like that, you realize really everyone’s being impacted.

S2: Exactly right. I think this was one of the revelations that some of the providers I was speaking with had it hasn’t felt like, you know, all these people arrive and you choose between them. It’s this horrific situation where a lot, a lot, 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 so there’s there can be more risk with that more chance that you won’t survive. And we’ve seen that during surges, even survival from COVID has been lower in stressed hospitals.

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S1: So the doctors felt like they would be standing over a couple of patients where both need a ventilator. But there’s only one and making a decision. But then they realized that because of the crisis, standards of care kick in a little bit. Before that, they’re actually making more wide ranging decisions that impact more people. But people they didn’t think they would be necessarily denying care to.

S2: This is true, and sometimes it does come down to choosing who gets a dialysis machine or an echo machine. That is something that’s been rationed, for sure. Select moments like when your lungs aren’t working and you need a machine that does the work of the lungs kind of like dialysis does the work of the kidneys.

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S1: And sometimes you’d use that in surgery, for instance. But this is for COVID patients now.

S2: Exactly. It can be important for both. And there’s not many hospitals that provide it. The number of hospitals that provide it can only provide it to a few patients. Typically, it takes a lot of again the staff stuff and space, a lot of stuff, a lot of staff care for those patients. And even because it’s a lot of stuff, you need a lot of space for it. 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 the full course to one person and nothing to another person. It’s a lot more gray areas, I guess, than that stark decision between patients. And then there’s just a lot of stretching and not perfect ideal care being given to a lot of people.

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S1: I’m really grateful for that stuff. Stuff, space like three word phrase, because I feel like it really does sum up the problem hospitals are facing here because we’re so often framing this in terms of COVID surges and like COVID patients are flooding the hospitals. And that’s not untrue, but it’s there are other things that are happening, which is there are shortages in things, there are shortages in medicine and there’s shortages in staff because the staff is getting burned out after a long time, too. And I feel like that’s impacting when we flip on these sort of crisis standards of care.

S2: That is a huge, huge part of it. And if there’s anything I can say to anybody or everybody, I want to shout it from the rooftops, the extraordinary sacrifice of providers and the stress and their dedication. There are now many stories about just how difficult this is, especially now. That in some areas, including in Idaho, I’m hearing this a lot, there’s an active antagonism toward the medical community toward the hospital providers. Even people had one doctor say yesterday to me that our hospital is full of patients dying of COVID who don’t believe that this pandemic exists. And there are so many layers of this. There’s issues around payment and nurses being offered lots of money to travel to places where there’s a need for them. But then what does that feel like if you’re working in that place as a nurse and you have a much lower salary? You know, so many people like you said, burning out, and I just can’t stress enough how much these people care and it’s so, so hard for them to watch. So many people die, and 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, for example, expect that they won’t make it or that they have maybe less of a chance to make it than other patients and that the resources actually reassigned to somebody else.

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S1: Well, and you’ve chronicled doctors who get up to that point, like with the chemo, for instance. I know you’ve written about, you know, a patient who is on an echo for a month and it wasn’t looking great and the doctors had to place a phone call.

S2: That’s right. That’s right. They were gently trying to tell the family that the Carmel wasn’t expected to help their loved ones survive, that there was almost no chance at this point that their loved one would ever recover. And the doctor I remember said something like, We’re in a crisis, we’re in a surge. And there’s there are a lot of other patients who who are waiting to get on chemo, and I believe it was the patient’s daughter who just flat out said, So are you telling me that you want to take the machine and give it to somebody else? And the doctor just sort of took a moment, and in a way, that’s kind of what the situation was right before she made the call. She was told she was trying to get this other patient on chemo, and she was told by the chemo team, You have to give one to get one. Essentially, they’d need to free one up in order for a new patient to be put on a curveball. And that’s a situation that I’ve heard over and over again, and it’s not just with Echo, it can be with critical care as well.

S1: I imagine that’s a conversation they never prepare you for in medical school.

S2: And in what really adds to the emotional difficulty of this is that in a lot of hospitals during COVID surges or, you know, units that treat COVID patients or families aren’t being allowed to visit, whereas normally they might be there every day, they might be there for rounds, hearing the doctors and the nurses talk about what the reality is. But now in a surge, you can imagine that the doctors and nurses barely have time to make phone calls, and they’re trying really hard to stay in touch with the 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.

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S1: When we come back, what happens when hospitals have to stop stretching and start deciding who gets treated at all? In Idaho, crisis standards of care have meant a high rate of transferring patients, a diminished amount of care and long waits to see a doctor. But eventually, this is all supposed to look a little different. There are rules for how to withdraw care without the consent of patients if they fail to improve after a certain amount of time. These kinds of rules vary from state to state. Some come with an elaborate point system to help assign relative value to different types of people. Some of these systems incorporate patients long term chances of survival. Aside from being cringeworthy, using a point system like this is also relatively untested, Sheri Fink says. A lot of times these plans haven’t gone in front of the public for feedback, so doctors are understandably wary of putting the exact crisis standards into practice.

S2: I would say that I’ve really been stretching to find a place that is using these plans as written. Hmm. And 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. So the whole purpose of giving points, assessing points to patients and then choosing who gets the resource based on a scoring system, the whole goal is to maximize a certain outcome. And 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, i.e., should age come into it? Is it a number of healthy years of life? Do you look at whether that person has underlying conditions?

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S1: Who’s judging all of that?

S2: Exactly, exactly. Mary. That’s the other question. Who gets to make that choice? Who 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, this has been troubling to look at some of these plans and feel that number one, they didn’t have a lot of input. There wasn’t a huge public awareness of them. There wasn’t even a lot of awareness amongst 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 a push back and a number of especially disability rights organizations have filed complaints with the Office of Civil Rights at HHS that the federal health agency to say that if you implement some of these plans as written, you will discriminate and 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, for example, because all of this has a danger of being very inequitable or reinforcing structural inequities in our health system. Who is it who has poor health at a baseline? If you incorporate that into your scoring system for deciding who gets a ventilator in a pandemic, are you reinforcing inequities? And we already have been equities and outcomes with this pandemic and different groups in this country that are dying at higher rates than others.

S1: So has this pandemic been like a moment where? Because doctors have been forced to make decisions along the way. You feel like the public has started to understand more about what it values and what should be in these kinds of, you know, documents that are trying to guide decision making.

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S2: I just think that the more light that shine on these documents, more problems with them have been found. And the other big issue is that they’re not necessarily so easy to implement. I think that’s another reason that they’re not necessarily being used as written. One of the hospitals where I said, you’re in quite far into contingency care, they’re stretching in every way possible. There’s their distress. Many of the patients are not getting the standard of care that the hospital usually provides. And I said, Are you at least kind of having your triage team start to score people in case you decide you’re going to slip into that other mode called crisis, where you’re literally rationing? And and the individual who’s in a leadership position at this hospital said to me, Well, you know what? We’re not doing that for two reasons. One is that the same people who we’d be asking to spend time on that we need them to care for patients. And if we take them away, there’s more chance that we’ll need direction. So it’s time consuming, they said. And the second thing they said is, we’re afraid that if we officially trigger that, that then people will sort of rather than fight to find somewhere to transfer this patient. They’ll just say, OK, now we’re in this crisis mode. We can just withdraw care and let them die. They don’t want to go there.

S1: Sheri says with better planning, a lot of these hospitals wouldn’t even need to consider these standards. The United States has resources. They’re just not distributed correctly.

S2: My biggest takeaway is we’re not doing enough to use our resources across a system that could provide more and better care to more people, and I’ve seen it over and over again, and it’s just it would be shameful to not give resources to somebody when there is capacity in the health care system, but either because of differently owned entities or a lack of using the available technology that we now do have that could let us know that could let say, a public health official, know where the resources are in real time, where patients could be moved. We’re really not doing that to a great enough extent in this country and that includes in Idaho.

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S1: What would that look like if we did it? Would it look like patients in Idaho? I mean, patients in Idaho are already being transferred to Washington. Does it look like spreading that burden out further? Does it look like physicians relocating from a place like New York, which is doing OK right now? And, you know, sort of having a more fluid workforce? What does it look like to you?

S2: Absolutely surging in providers from other places. There is some coordination going on and some very wonderful steps at some hospitals are voluntarily taking 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. And we can do that now with technology. And that’s just not being done for various reasons. In a lot of places,

S1: it requires so much coordination. I’m not saying it’s not a good goal. I’m just saying we have a system where we have 50 individual states and often they’re taught to think of themselves as little islands and have their own departments of health and communicate with their own, you know, hospitals. And I don’t know that there’s even a system that you could flip on to do the kind of work that you’re imagining.

S2: But we do it in things like hurricanes, for example. We do it where large numbers of patients have to be moved. There are coordination systems and there is a better way to coordinate. We don’t have to deprive people of care. We have capacities in our health system. There’s a lot more work to do on this.

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S1: You seem weirdly optimistic where you recognize how awful of a position the health care workers are in. But you also see how they want to. Do a lot to make sure their patients make it.

S2: I’m not I’m optimistic that maybe we’ll come out of this with some lessons, but what makes me very disappointed, angry sometimes is that what is it, 18, 19 months into this in this country and that we’re still in this situation is just unconscionable. Why aren’t we doing better? We could be. And it’s of course, the number one thing is why are we still having surges this bad when we have these incredible scientific tools, these vaccines, even treatments that can keep people out of an ICU? Why aren’t we doing better as a country? That’s number one. But number two is that this is the fourth surge for many places. So why is a surge still so devastating both to patients and to providers? So I would say I’m not optimistic because every time a surge has subsided and 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. Then there hasn’t been a lot of, OK, well, what did we learn from it and what can we implement just in case? Why are we talking about rationing at this point this far into this? So. No, I’m not optimistic. I feel that we’re not. We haven’t learned enough. We’ve had a chance to improve within the crisis. So what’s to say we’re actually going to learn for next time?

S1: Sheri Fink, thank you so much for joining me. Thank you. Sheri Fink is a correspondent for The New York Times. And that’s the show. One final thing before we head off. Do you have teenagers in your life? My colleague Lizzie O’Leary, the host of our Friday show. What next TBD? She is hoping to hear from teens about their experiences on Instagram for teenagers listening. How does Insta make you feel about yourself? Does what you see in your feed changed the way you feel about your body, your friends or anything else? Let us know. Leave us a voicemail with your parents permission at two zero two eight eight eight two five eight eight. We might use it in our Friday episode. What next is produced by Daniel Hewitt, Alaina Schwartz, Davis Land, Carmel Delshad and Mary Wilson. We’re led by Alison Benedict and Alicia Montgomery. And I’m Mary Harris. Go find me on Twitter. I’m at Mary desk. Thanks for listening. I’ll talk to you tomorrow.