- We have a real equipment problem
the way we needed missiles in world wars,
we need ventilators.
- New York State is preparing its guidance for doctors
and hospitals on how to make some difficult decisions
about patient care that they may soon face.
New York's governor, Andrew Cuomo, says the state
has about 5,000 ventilators but needs 30,000.
Ventilators are machines that aid breathing.
Many critically ill coronavirus patients,
like those with pneumonia, need the assistance to survive.
So, if and when hospitals run out of ventilators,
how would they decide which patients take priority?
- Doctors want guidance.
Samuel Gorovitz is a philosophy professor
and longtime member of the New York State
Task Force on Life and the Law.
In 2015, a group of experts on behalf of New York State
created guidelines for allocating ventilators
should there be a shortage of them in a flu pandemic.
Gorovitz says he's seen a draft
of the guidance the state is developing
for ventilator allocation during a coronavirus crisis.
He says the draft he saw may be different
from the final version.
New York's Department of Health says that,
"While the department has sought input
"from a variety of medical and ethics experts,
"there is no expectation of a formal report."
- The guidance that is being developed
and I believe soon will be promulgated within New York State
will indicate that there will have to be ...
committees, triage committees, that will be required
to contain representation of ethical perspectives.
- [Jason] Triage committees were a key part
of the 2015 guidelines, tasked,
among other things, with determining
a patient's level of access to a ventilator.
- There will be committees that will be involved
in making the tragic triaging decisions ...
in situations in which somebody who needs a ventilator
will be denied access, or perhaps somebody on a ventilator,
for whom the prospects are essentially hopeless,
will have to be removed to make room for somebody else
for whom the prospects are very much better.
- So this committee would be in power
to take a ventilator away from someone who's alive
who probably won't live, but he's still alive,
take them off life support
so they can give it to someone else?
- That's what is going to happen.
- [Jason] The 2015 guidelines say there may be scenarios
in which the triage committee must remove a ventilator
from a patient whose health is not improving.
- The idea would be the critical care team would say,
"Here's the decision we believe we have to make,
"and here's the reason why,
"and we're running that by a triage review team for vetting.
"And are we leaving out anything, are we missing anything?
"Is there any consideration
"that you would call to our attention?"
And the team might say, "Yeah, you're failing to take
"into account thus and such," or, "You've misses that."
Or the committee might say,
"That seems like a heartbreaking but justified choice."
And the critical care doc at that point
would be empowered to proceed.
- [Jason] Gorovitz says he expects that family members
of the patient whose ventilator is set to be removed
would be informed beforehand.
- You, the family member, might at that point say,
"I will not accept this."
You would then be told, if it's as I expect,
"You have a right of appeal."
But this all will play out on a scale of minute, not hours.
- [Jason] In the 2015 guidelines,
appeals are limited to so-called technical injustices,
like for example a withdrawal decision being made
without considering all triage criteria.
- If it's a hospital system, they might be able
to have a committee that would look over several hospitals.
- [Jason] Dr. Tia Powell helped leading the working group
that wrote the original guidance document in 2007.
- In working on guidelines like this,
I never ever thought we would get there.
And now, it definitely is a realistic possibility.
- [Jason] Dr. Powell says that, within the past week,
she too has read a draft of the guidance
New York State is preparing.
- These crisis standards of care,
which are radically different than what we do normally,
would temporarily make it possible to say,
"We're so sorry, we tried to pull you through,
"it didn't work, and now we're going
"to remove that ventilator, and it would go
"to some other person in line.
"An effort to save you is done, and we have people waiting,
"so we're not gonna continue treating you
"with the ventilator."
- Wow.
And then, who makes that call?
- So, that would be the triage committee
will evaluate people at 48-hour intervals.
- Gorovitz says hospitals could, as a last resort,
use a randomization process,
such as a lottery to decide distribution.
There are some circumstances,
I know you all thought of this,
when discretion doesn't really play that much of a role;
the best you can do is a lottery.
- Yes, and, in fact, the guidelines do allow for lottery.
You have to be clear and explicit and operationally rigorous
about how the lottery is to be done.
The outcome will be horrible
for whoever doesn't win the lottery.
- New York's Department of Health declined to comment
on any particular policies it may be considering.
All of this is just so wildly unpleasant
to even contemplate and discuss.
- It is exactly that.
It is searingly difficult even to have to think about it.