Medical care, under dire circumstances

Sunday, July 26, 2009

When two or more patients need a ventilator, how do we decide who should receive the only one available? With the H1N1 influenza pandemic surging, we can expect this scenario.


The World Health Organization reports that "in past pandemics, influenza viruses have needed more than six months to spread as widely as the new H1N1 virus has spread in less than six weeks." Will vaccines mitigate the flu's impact?

With at least 50 countries ordering vaccines from GlaxoSmithKline and Novartis, hopes are high for first doses by September. But let us not be overconfident. Novartis has reported H1N1 vaccine production slow-downs because of low antigen yields. This means, according to WHO, that vaccine quantities will be insufficient by fall, and countries will receive half their needs.

University College London biochemical engineer Peter Dunnil predicts global vaccine-making capacities will not cover 10 percent of the world population.

If viral strains become more lethal, rising cases of respiratory distress will exacerbate the need for ventilators, already in short supply.

In 2005, the U.S. Department of Health and Human Services estimated the toll from influenza pandemic using two scenarios. The state Health Department applied these to New York's 19 million-plus population with a 35 percent infection rate over a six-week duration. The moderate scenario reveals a 1,256 ventilator shortfall and 18,650 flu-related deaths. In the severe scenario, a 16,929 ventilator shortfall could lead to 153,301 deaths. Should H1N1 become more virulent, not only vaccines but ventilators will need to be rationed.

The Health Department recognized this when it has asked the New York State Task Force on Life & the Law to establish ethical guidelines for distributing ventilators. The task force's planning document, "Allocation of Ventilators in an Influenza Pandemic," tackles these hard-hitting questions (http://www.health.state.ny.us/diseases/communicable/influenza/pandemic/ventilators/).

During a pandemic, when ventilators are in short supply in acute care settings, who gets them first? The report says priority should go to the "patient with pulmonary failure who has the best chance of survival with ventilatory support, based on objective clinical criteria." This means withdrawing ventilators from patients most likely to die regardless of treatment. However, the group rejects applying an incoming patient's prospective benefit as the barometer to gauge an existing ventilator-dependent patient's prognosis.

The group recommends that physicians who are "triage officers" make this decision, not one's primary physician. The report underscores that rationing depends strictly on medical prognosis -- that is, the likelihood of survival and recovery from ventilator treatment -- and not on age or occupation.

This differs from an earlier report by the Ethics Subcommittee of the Advisory Committee to the Director, Centers for Disease Control and Prevention. According to "Ethical Guidelines in Pandemic Influenza" (http://www.cdc.gov/od/science/phethics/panFlu_Ethic_Guidelines.pdf), "individuals who are essential to the provision of health care, public safety and the functioning of key aspects of society should receive priority in the distribution of vaccine, antivirals, and other scarce resources" (my emphasis).

Should occupation matter? Which aims are more ethically tenable: maximal survival or restoring and sustaining public order and function? How do we measure social worth? Who decides?

Dire circumstances signal the need for altered standards of care. To what degree will the community be engaged in guidelines that will directly impact all of us?

The Health Department guidelines are not yet finalized. You can comment by e-mail to PanFlu@health.state.ny.us.

Public response, discussion, and engagement are crucial.

Michael Brannigan is the Pfaff Endowed Chair in Ethics and Moral Values at The College of Saint Rose. His e-mail address is michael.brannigan@strose.edu.