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Facing Covid-19 in Italy - Ethics, Logistics,
and Therapeutics on the Epidemic's Front Line
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https://www.nejm.org/doi/full/10.1056/NEJMp2005492?query=featured_home
"We have to decide who must die and whom we shall keep alive."
Whatever fears these caregivers may harbor about their own health, what they seemed to find far more unbearable was watching people die because resource constraints limited the availability of ventilatory support. So aversive was this rationing that they hesitated to describe how these decisions were being made. Dr. S. offered a hypothetical scenario involving two patients with respiratory failure, one 65 and the other 85 with coexisting conditions. With only one ventilator, you intubate the 65-year-old. Dr. D. told me his hospital was also considering, in addition to the number of comorbidities, the severity of respiratory failure and probability of surviving prolonged intubation, aiming to dedicate its limited resources to those who both stand to benefit most and have the highest chance of surviving.
No matter the ethical framework, should such resource scarcity occur, there are many scenarios that will still feel morally untenable, particularly in the face of heightened prognostic uncertainty. Would you remove a ventilator from one patient who was having a rocky course, for instance, to give it to another in the throes of an initial decompensation? Would you preferentially intubate a healthy 55-year-old over a young mother with breast cancer whose prognosis is unknown? In an effort to address such quandaries, Biddison and colleagues also offered three process-related principles that seemed as imperative as the ethical ones.
Contributing to the resource scarcity is the prolonged intubation many of these patients require as they recover from pneumonia - often 15 to 20 days of mechanical ventilation, with several hours spent in the prone position and then, typically, a very slow weaning. In the midst of the outbreak's peak in northern Italy, as physicians struggled to wean patients off ventilators while others developed severe respiratory decompensation, hospitals had to lower the age cutoff - from 80 to 75 at one hospital, for instance. Though the physicians I spoke with were clearly not responsible for the crisis in capacity, all seemed exquisitely uncomfortable when asked to describe how these rationing decisions were being made. My questions were met with silence - or the exhortation to focus solely on the need for prevention and social distancing. When I pressed Dr. S., for instance, about whether age-based cutoffs were being used to allocate ventilators, he eventually admitted how ashamed he was to talk about it. "This is not a nice thing to say," he told me. "You will just scare a lot of people."
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