Who Lives And Who Dies? Bursting COVID Wards Force Docs To Make Dire Decisions

Dr. Jeffrey Pothof is flipping towards the last page of his pandemic book.

Yeah, there’s a book.

It was prepared in March and lays out a plan for how to accommodate a surge in COVID-19 patients, build out capacity, and eventually ration care. It wasn’t needed then. But Pothof, the chief quality officer for University of Wisconsin Health, needs it now.

The last pages, Pothof said, deal with how the hospital will implement its crisis standard of care: when doctors will be forced to decide who can receive treatment and who cannot.

“We know that the end of it is now a couple of pages away,” Pothof told TPM on Friday. “Nobody here has ever lived through what it’s like when you need medical care and you can’t get it.”

“Even our doctors haven’t — what do you mean, you have to turn someone away with a heart attack?” Pothof asked.

Pothof, whose health system operates throughout Wisconsin, is facing questions that are being echoed around the country, as hospitalizations surge and doctors in overflowing wards struggle to find places to transfer patients.

“Crisis standards of care” is a term of art for the temporary, emergency level of care that can be provided during situations, like disasters, when there simply aren’t enough resources to maintain the normal standards. Invoking the crisis standard gives hospitals and medical providers broad liability protections in a disaster, but the term also describes the protocols for making the kind of gut-wrenching changes that health care systems are forced to make to accommodate surges of patients.

States, cities, and hospital systems began to draft plans for crisis standards of care in March as COVID-19 surged in New York City, Detroit, New Orleans, and other hot spots. The first outbreaks were intense, but relatively contained, giving the rest of the country time to plan.

“They’re needed when demand outstrips supply, when you need to ration care,” Dr. Harald Schmidt, an assistant professor of medical ethics and health policy at the University of Pennsylvania, told TPM.

Crisis standard of care plans vary from jurisdiction to jurisdiction — there’s no national, standardized plan for how to treat a surge of patients with fixed resources. Many states put forward guidelines; some states, including New York, went further. The state did not initially release new crisis standards as the pandemic took hold, but instead passed a law in April immunizing providers from liability during the worst parts of the pandemic.

Some areas, like Utah, use a system that assigns patients a point value depending on the likelihood of treatment being effective. That has, in turn, led to criticism regarding age as a factor; in the event of a tie in points, under the Utah system, the younger patient will receive care.

But few hospitals or states announce when they’ve transitioned to crisis standards of care. Rather, it tends to come out after the fact, like in New York City, where doctors were forced to make life-or-death decisions with few resources at their disposal.

Arizona is the only state to have actually activated its crisis standards of care in an official, statewide way, and is the first state in U.S. history to do so.

“These are life-and-death decisions, but there’s little transparency,” Schmidt said.

But now, with the country breaking COVID-19 hospitalization records daily, the issue has gone from the abstract to the acute as medical systems face a surge in new patients.

In St. Louis, Children’s Hospital has begun to admit adult patients. In Wisconsin’s Fox Valley region, Dr. Paul Casey described to TPM last month how his hospital had been forced to place patients in hallways for treatment.

“We’re tight on beds,” he said.

El Paso, Texas, has spent the last month watching its ICU beds fill up. County Judge Ricardo Samaniego told the Texas Tribune last week that hospital officials were beginning to discuss how they would have to ration care amid a lack of ICU beds and available doctors, even after the state opened field hospitals in the city.

“We don’t have the personnel,” Samaniego told reporters last week. “We’re at a point where we start thinking of rationing health care — who’s going to get what? We’re not there yet, but we’re pretty close to it.”

The increase comes right before the Thanksgiving holiday, which epidemiologists and public health officials expect to further juice case loads around the country.

“If in fact you’re in a situation when you do the things that are increasing the risk — the travel, the congregate settings, not wearing masks — the chances are you will see a surge superimposed upon a surge,” said Dr. Tony Fauci, director of the National Institutes of Health, on Monday.

Wisconsin Governor Tony Evers (D) ordered a field hospital to be built in Madison, the state capital, to relieve the burden on medical providers in the area. But Pothof said that it had so far been less than effective, in part because patients were choosing not to go, assuming that the field hospital would offer a lower standard of care.

“They’ve already been admitted to a hospital, maybe a special pathogen unit,” Pothof, the Wisconsin doctor, told TPM. “It’s not a bad place to go if you’re beating your fight against COVID, but it’s difficult to convince them to go to that.”

Pothof added that his hospital system had been able to add around 20 percent more beds by using operating rooms as intensive care units, converting an under-construction neurology unit into an ICU unit, and converting wings of the hospital into COVID-only ICU spaces.

He added that the situation is chaotic enough that it was becoming harder to tell what care was available at a given moment and what wasn’t. The hospital, he added, was around two to three weeks away, should hospitalizations continue at the same rate, from being unable to treat more patients.

“The reality is that we meet two to three times a day to figure out what options do we have to meet everyone’s needs,” he said, adding that it had gotten to a point where it wasn’t a “binary” between normal and crisis care.

“There’s a whole other level of rationing care, which means I can’t provide your care, we can’t stabilize because the resources aren’t there,” he added. “From a health care perspective, that’s armageddon. That’s losing the fight.”