Who gets a ventilator? New gut-wrenching state guidelines issued on rationing equipment

State officials asked a small number of physicians and bioethicists from hospitals across Massachusetts, including Truog, to develop detailed recommendations for allocating ventilators and intensive care beds, which the group did over the weekend of March 27 to 29.

Many health care leaders had asked the state department of public health to provide guidelines, said spokeswoman Ann Scales.“These are obviously only used in disaster situations – situations we hope — and are working to ensure — do not happen,” she said in an e-mail.

The Massachusetts guidelines appear to be based on those developed by Dr. Douglas White at the University of Pittsburgh, and adopted by Pennsylvania. All patients who would normally qualify for ventilators are assigned a priority score, 1 to 8, based on whether they are likely to survive discharge from the hospital and their likelihood of longer-term survival. The Pittsburgh policy also gives additional preference to medical personnel and younger patients.

Some individual hospitals in Massachusetts have also developed their own ethical guidelines on how to allocate scarce resources.

A number of states hit hard by the pandemic had already released guidance for hospitals and medical providers on rationing care, including Washington state and Pennsylvania, which issued its guidelines on March 22.

How to ration scarce medical resources during an overwhelming health crisis has been discussed within hospitals in many states for years. But the distressing possibility has taken on a special urgency because a specific medical machine — ventilators that help patients breathe — is key to survival for the most critically ill COVID-19 patients. The virus can severely damage the lungs, leaving patients reliant on a ventilator for weeks. A large percentage of people with COVID-19 also require the services of an intensive care unit, where doctors and nurses have specialized training to manage ventilators and nurses usually care for just one or two patients each.

The preference afforded health care workers “has been very controversial in many states,” said Christine Mitchell, executive director of the Center for Bioethics and a nurse who helped develop the Massachusetts guidelines.

New York state, on the other hand, does not give priority to health care workers in its policy, which was released in 2015. And it only considers who is most likely to survive the current illness when allocating ventilators, not how long a person might live after recovering. Governor Andrew Cuomo has repeatedly said he would not allow hospitals to ration care, and recently called for redistributing ventilators to hospitals that need them most.

In Massachusetts and across the country, advocates for people with disabilities are concerned that those with mental or physical limitations will be excluded from life-saving medical care. Eighteen organizations have written Governor Charlie Baker urging him to develop statewide guidelines to prevent discrimination if rationing becomes necessary.

Kathryn Rucker, of the Center for Public Representation in Newton, a public interest law firm, said that the Pittsburgh model contains several important elements — including an appeal process and the use of objective medical evidence to prioritize patients — but that no policy is perfect.

The Pittsburgh protocol still factors in “life-limiting co-morbidities” and their impact on “long term prognosis,” she wrote in an e-mail. “This language increases the likelihood that individuals with disabilities, including those living full and successful lives in the community, could be denied life saving care based on a subjective view of how certain conditions ‘limit’ them.”

Partners HealthCare, which includes Massachusetts General and Brigham and Women’s hospitals, has developed its own framework for how to approach these decisions.

Like the state guidelines, Partners’ policy is closer to Pittsburgh than New York, in that “maximizing lives saved as the sole criteria is a fairly narrow'' benefit without considering a patient’s longer-term prospects, said Dr. Emily Rubin, a critical care medicine physician at Mass. General.

But the Partners framework does not give preference to medical providers. Dr. Eric Goralnick, medical director of emergency preparedness at the Brigham, said the organization would now reevaluate that position, given the state guidance. "That was a piece we struggled with,'' he said.

The state guidelines also made clear that race, disability, socioeconomic status, "perceived social worth,'' immigration status, incarceration status, and other similar factors are "irrelevant and not to be considered by providers making allocation decisions.''

The document also includes a process for determining whether ventilators or critically ill patients can be shifted among hospitals so it’s not necessary to ration care. It also includes guidelines for withdrawing ventilator support from patients who are unlikely to benefit, as well as how to allocate ICU beds in the event of a critical shortage.

Doctors said they hope to never reach the point where such wrenching choices become necessary. Mass. General, for example, is working to increase its ventilator supply from the usual 150 to 300.

“Everything we do is dedicated to try and make sure that we don’t end up in a place where we don’t have enough resources,” said Dr. Paul Biddinger, the hospital’s chief of emergency preparedness. “But we want to be grounded in reality.”

Many medical providers are hesitant to discuss rationing policies, which are referred to as “crisis standards of care.” They are anathema to doctors and nurses, whose goal is to save the individual patients who come before them and who pride themselves on providing the best care — and making available the most advanced technology — to the sickest people.

But the pandemic, which has yet to peak in this country and has already killed more than 12,000 Americans and more than 350 Massachusetts residents, has created a new reality.

“I have a number of friends in New York and New Jersey and what I have heard is they are pushed right up to the brink but have not yet had to refuse ventilation,” said White, the Pittsburgh physician. “It’s likely that in at least some pockets of the US, we will have to ration ventilators. We hope it’s pockets and they are temporally separated, so that resources can be allocated to Boston and then reallocated elsewhere.”

Goralnick said the Brigham conducted a series of webinars over the weekend to educate providers about the Partners’ recommendations around possible rationing of equipment. He said that it is important to have a transparent method for making those types of decisions — before hospitals become overwhelmed.

He believes "it is likely we will have to implement crisis standards of care. The hope is that we don’t have to implement this. But the reality is we should be ready. These are the choices people faced in Italy and they are the choices people are now facing in New York.''

Liz Kowalczyk can be reached at lizbeth.kowalczyk@globe.com.