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Preparing for a Pandemic, State Health Departments Struggle With Rationing Decisions
New York state health officials recently laid out this wrenching scenario for a small group of medical professionals from New York-Presbyterian Hospital:
Spanish Flu Ward, 1918 A 32-year-old man with cystic fibrosis is rushed to the hospital with appendicitis in the midst of a worsening pandemic caused by the H1N1 flu virus, which has mutated into a more deadly form. The man is awaiting a lung transplant and brought with him the mechanical ventilator that helps him breathe.
Because the man's end-stage lung disease caused by his cystic fibrosis is among a list of medical conditions associated with high mortality, the guidelines would bar the man from using a ventilator in a hospital, even though he is, unlike many with his illness, stable, in good condition, and not close to death. If the hospital admits him, the guidelines call for the machine that keeps him alive to be given to someone else.
Would doctors and nurses follow such rules? Should they?
In recent years, officials in a host of states and localities, as well as the federal Veterans Health Administration, have been quietly addressing one of medicine's most troubling questions: Who should get a chance to survive when the number of severely ill people far exceeds the resources needed to treat them all?
The draft plans vary. In some states, patients with Do Not Resuscitate orders, the elderly, those requiring dialysis, or those with severe neurological impairment would be refused ventilators, or admission to hospitals. Utah divides epidemics into phases [1]. Initially, hospitals would apply triage rules to residents of mental institutions, nursing homes, prisons and facilities for the "handicapped." If an epidemic worsened, the rules would apply to the general population.
Federal officials say the possibility that America's already crowded intensive care units would be overwhelmed in the coming weeks by flu patients is small but they remain vigilant.
The triage plans have attracted little publicity. New York, for example, released its draft guidelines [2] in 2007, offered a 45-day comment period, and has made no changes since. The Health Department made 90 pages of public comments [3] public this week only after receiving a request under the state's public records laws.
Mary Buckley-Davis, a respiratory therapist with 30 years experience, wrote to officials in 2007 that "there will be rioting in the streets" if hospitals begin disconnecting ventilators. "There won't be enough public relations spin or appropriate media coverage in the world" to calm the family of a patient "terminally weaned" from a ventilator, she said.
State and federal officials defend formal rationing as the last in a series of steps that would be taken to stretch scarce resources and provide the best outcome for the public. They say it is better to plan for such decisions than leave them to besieged health workers battling a crisis.
"You change your perspective from thinking about the individual patient to thinking about the community of patients," said Rear Adm. Ann Knebel of the Department of Health and Human Services.
But some health professionals question whether the draft guidelines are fair, effective, ethical, and even remotely feasible.
Most existing triage plans were designed for handling mass casualties. They sort injured victims into priority categories based on the urgency of their medical needs and their potential for survival given available resources. Much of the controversy over the state plans focuses on two additional features.
These are "exclusion criteria," which bar certain categories of patients from standard hospital treatments in a severe health disaster, and "minimum qualifications for survival," which limit the resources used for each patient. Once that limit is reached, patients who are not improving would be removed from essential treatment in favor of those with better chances.
A version of these concepts was outlined in a post-9/11 medical journal article that suggested ways to handle victims of a large-scale bioterrorist event. The author, Dr. Frederick Burkle Jr., said he based his ideas in part on his experiences as a triage officer in Vietnam and the gulf war and on a cold war-era British plan for coping with a nuclear strike. Dr. Burkle said that during the gulf war he once instructed surgeons to halt an operation and work on another patient who was more likely to survive. Surgeons later returned to the first patient.
Dr. Burkle's ideas were key aspects of guidelines Ontario authorities drew [4] up after SARS to plan for avian flu and other pandemics. This approach and one by a team of Minnesota doctors [5] were modified by groups developing similar guidelines in the United States.
There were important distinctions. Dr. Burkle's original paper did not anticipate withdrawing care from patients and stressed the need to reassess the level of supplies "sometimes on a daily or hourly basis" in a fluid effort to provide the best possible care.
Some states' triage guidelines are rigid, with a single set of criteria intended to apply throughout the severe phase of a pandemic. That disturbs Dr. Burkle. "I have said to my wife, I think I developed a monster here," he said.
Recent research highlights the problem of a one-size-fits-all approach to triage. Many state pandemic plans call for hospitals to remove patients from ventilators if they are not improving after two to five days. Studies show that people severely ill with H1N1 flu generally need a week to two weeks on ventilators to recover.
There is also controversy over what values and ethical principles should guide triage decisions, how to engage the public, and whether withdrawing life support in the hospital and withholding it at the hospital door are distinct.
Normally, removing viable patients from life support against their or their families' will would be considered murder. The New York-Presbyterian Hospital employees who participated in the recent exercise said they would not comply unless given legal protection.
They also never figured out what to do with that hypothetical patient who had his own ventilator, said Dr. Kenneth Prager, a pulmonologist and ethicist. "The issue of removing patients from ventilators," he said, "was so overwhelming that it precluded discussion of further case scenarios."
15 Comments so far
Show AllNow we have "Disaster Science".
If if if. Fear mongering hits a new low. A "wrenching scenario" about dilemmas around a non-existent man with end-stage cystic fibrosis. This reminds me of the Discovery Channel coverage of the earth. They have frightening simulations of what would happen if a large meteor hit the earth. Never mind the chances are infinitesimal. Meanwhile, there is very little or no education on the ACTUAL rapidly developing and grave carbon situation, what it means, and what can be done.
So here we have an article laden with scare words about how some virus MAY develop into a virulent form and threaten prosperous white people. So it's time to go into hysterical mode about all kinds of hypothetical agendas.
Meanwhile, deaths from poverty and lack of medical care are not a matter of if if if. More and more people are falling off the cliff from well-being to destitution. Providing universal medical care is a calm and rational step toward preventing rapid spread of disease. Making sure everyone who wanted a job or dwelling could get a job or dwelling would help both physical and emotional health and reduce community deaths driven by various forms of despair. Diverting money from weaponry to public health would be very effective.
Right now New York City is debating whether to mandate paid sick leave from work as a way to limit the spread of flu. Well Duh. Welcome to the civilized world in which the issue of paid sick leave was settled long ago. For low wage hourly workers, taking unpaid time off from work results in an immediate food crisis. Hunger is a quiet personal health issue that has little effect on the well-dressed, so it is an issue easy to ignore. But if flu laden poor and hungry go into the subway and workplace, well it could affect number one. So it is now being discussed.
The ever-present health concerns that affect poor people, the lack of medical care, do not apply to the extremely prosperous. The solutions lack a lurid drama currently favored by media. So we get the liberal version of death panels in the news, in which the "authorities" are faced with "wrenching scenarios" about whether to disconnect a fictional character with a fictional disease from a fictional life support system
Joe
Joe--You are so right about everything. This article, and the entire gov't response, is mostly fear-mongering. The WHO even changed the definition of a pandemic to fit the situation. The CDC refuses to recognize that good vitamin d status may be protective--of course, we don't know for sure but we don't know the effects of a vaccine that is not tested either. What we do know is that 5,000 IU daily of vitamin d for 3 at least months won't hurt you unless you have kidney disease or other strange diseases related to calcium metabolism. You can also have your serum levels checked to assure 50-80 ng/ml. The exemption from liability fuels the dangers of the vaccine and reduces testing further. They won't be held liable "if they didn't know" about a side effect. What better way to discourage testing?
For a discussion of a CBS News report that actually put this in perspective, see: www.articles.mercola.com/sites/225850.aspx or www.articles.mercola.com/sites/articles/archives/2009/10/24 The article is entitled "CBS Reveals that Swine Flu Cases Seriously Overestimated". The article is below the video. Being on dial-up I haven't seen the video.
That all said, it is hitting and killing young people, most of whom have "serious underlying conditions".
Regarding possible protection with good vitamin d status, see www.vitamindcouncil.org under "Noteworthy News", link to Sept 2009 letter. Can also get a home witamin d test for $65 through this site.
I agree that good nutritional status is one of the best protections against ordinary infectious disease for most people. Vitamin D is only one factor of many.
People can get enough vitamin D by spending about 10 minutes a day in the summer sun without sunscreen or excessive clothing. The concern about skin cancer, once again ramped up to the level of hysteria by sunscreen companies and reductionist medical doctors, has led to some people not getting ANY sun on the skin. We evolved in the sun. Of course because we live longer and because the rays of the sun are now more potent, some caution is advisable. Another choice is Vitamin D enriched dairy products for people like northerners in winter, agoraphobic city dwellers, computer game addicts and burka wearers.
Honestly, I would not pay $65 for a vitamin D test. It seems expensive, unnecessary and rather scattershot, considering all the factors that lead to health.
Joe
Joe--I love the adjective "reductionist" when referring to M.D.s
Of course D is only one factor but it is a critical one, especially for those who take drugs that destroy it (anti-seizure meds for example)--exactly those with a "serious underlying condition". D operates as a hormone and affects gene expressions related to the immune system. Obviously without protein, zn etc the immune system can fail but the amount of D needed is never in an MVI the way zinc is. My point is that they won't advise people about this, which is harmless, but are quick to say take the shot which we do not know is harmless.
You'll never get enough with fortified dairy products. The Canadian Health Service recommends 1000 or 2000 IU/day to prevent cancer. And that's low according to the long time researchers. Auto-immune diseases including MS, Alzheimer's, heart disease and on and on are implicated in deficiencies. The darker the skin, the greater the risk but research at UCLA showed 16-22 yr old Caucasions to be deficient. The only reason to test is because everyone is different and optimal blood levels, rather than specific amount, provide the best protection. Toxicity can also occur if too much supplement is taken. If it's from sunlight there's an automatic biological shut-off when enough has been made.
Hope you'll check out vitamindcouncil.org
Food sources are minimal--mainly fatty fish. Tanning booths must have UVB rays to be useful.
$65 is actually a cheap test. Most labs cost over $200 and you need a doctor's order, i.e., another charge.
Some grass-fed milk would work too :-)
Apparently some journalists find better reporting in hypothetical "crisis" than real ones.
Hmmm. What is real?
Wow, am I really asking this question?
This whole world is gone down the rabbit hole.
We're only one pandemic declaration away from Death Camps. Heckuva job!
Did the five people that have responded to this article even read it? Are you aware of what happened in the Katrina crisis? Blah, blah, blah about "hypothetical crisis". Katrina was a hypothetical crisis until it happened. The medical professionals who found themselves without any guidelines in the sweltering, flooded, powerless hospital in New Orleans did the very best they could, including deciding who should die. They worked night and day under horrific conditions, assumed that help was on the way when it was not, and then only to find that they were seen as monsters by the press and faced lawsuits by the dead one's reletives. That is what this article is about. It is not about Vit D and C. Or sick leave. Or WHO calling it a pandemic, or not. Or death from poverty. Etc. It is about removing real live people from life support because you have made the decision that another person is more important than they are. Are you ready to do that without even discussion, let alone legal protection?
The flooding of New Orleans was a preventable tragedy brought on by years of neglect of the infrastructure while we nattered on and on about Arab threats and spent national wealth on adventures and bases abroad. The medical emergency that followed was the result of total failure by local, state and national forces to plan or respond in any meaningful way, partly because they were corrupt and stupid and partially because our National Guard was tied up chasing phantoms in Iraq and Afghanistan. There was never a need to get to the point where medical personnel were left in such an untenable position. A reasonably thought out pre-hurricane evacuation, few timely helicopter lifts, intelligent deployment of boats could have largely prevented the problems that developed over the course of many days. I am among those who feel that much of this misery was caused by malign neglect and was then exploited to get rid of public housing, schools, etc. for the benefit of the local real estate and tourist industry.
Right now we have a similar situation in which real structural problems are neglected while theoretical problems are elevated to nightmare status. We could help ward off the epidemic by giving sick people time off work. We could address the persistent understaffing of hospitals, which even under normal circumstances causes death and misery every day. We could make sure every person under 60 has access to prompt medical care and vaccine where appropriate. Once you allow situations to devolve to the point described in the article, or in the horrible situations faced by the nurses and doctors of New Orleans, it is too late for rational decisions.
They are anticipating a crisis, but not doing many of the obvious things to prevent it.
Joe
Joe, I'm in agreement with most of what you say, certainly everything that you say about Katrina. I am also in agreement with much of what others have pointed out: This flu has been hyped by Big Pharma to make a killing off flu shots and medications, and they are certainly doing that. Thousands die from lack of health care, poor nutrition, medication side effects from meds often not even needed in the first place, industrial pollution, and the list goes on and on, and yet people have been worked into a frenzy over a flu just slightly more dangerous than the regular seasonal flu, which is not very dangerous at all.
But again, these are not the issues that this article is about. If anyone thinks that we won't eventually be hit by a flu pandemic every bit as serious as the 1918 flu pandemic, they are delusional. It is not a matter of "if", it is a matter of "when", and hospital workers may find themselves with conditions similar to the conditions following the New Orleans flooding. When I read of what went on in the flooded hospital in New Orleans, my heart really went out to the hospital staff. Of course they said afterwards that they did not just let some DNR's die and even help them over the edge--what else *could* they say? Maybe some people bought their story, but every last person that I spoke with who has worked in a hospital knew darn well that they were not telling the truth. And they all supported their actions, as well.
But after the Katrina horrors, what would hospital workers decide to do if they suddenly found themselves with thousands of very sick patients and possibly even power and food shortages to boot? Is it fair to expect them to make decisions about who should live and who should die knowing what happened to the staff in New Orleans? Would you be willing to go to jail for taking someone off life support so that another more promising patient could be put on?
Swine flu, as it is right now, is overrated.
However, like in 1918, if there's a mutation into something that starts killing more than 15% of the infected, we will have a major problem. (The H5N1 bird flu comes to mind; a combination between this contagious H1N1 swine flu and deadly, not very contagious, H5N1 bird flu would likely create a pandemic with fatalities at upwards of 50%.) Rules are definitely needed to ensure all patients are treated properly (and if wards are being overrun, that we maximize the number of survivors), though obviously, for any set of regulations, doctors should have flexibility to assess exceptions.
If the swine flu vaccine was dangerous, there would probably be medical problems showing up right about now.
Oh, by the way,
http://infowars.net/articles/october2009/231009Vaccinations.htm
www.fourwinds10.com/siterun_data/health/disease/news.php?q=1256238868
Because there's no one to sue them this time, Big Pharma has been increasing the irritating aluminum phosphate levels in their vaccines over last time (when all those side effects appeared at the lower dosage). It's all about maximizing profits. If wrongful death lawsuits aren't allowed, the cost of murder drops to zero and then corporations adjust their products to "maximum effectiveness".
"The vaccine against swine flu differs from ordinary flu by most so-called adjuvants are higher. It is the component which triggers the immune system of the person receiving it."
How preposterous! This "superpower" we dwell in not even having enough vaccines for pregnant woman and children today!
I'll bet the troops have plenty to eat, and all the high tech gear a young fella or girl duped into joining the killing gang in the first place can possibly get off on! Plenty of supplies for occupying half the world with personel living on nearly 800 military bases worldwide, paying hefty stock dividends to the military/industrial complex investors! Yet, we struggle to provide basic health needs, let thousands die annualy due to lack of health insurance and care. We are having discussions about rationing ventilators while Oshkosh Truck, in my home state of Wisconsin, is drooling with their new multi-billion dollar contract for building death trucks for warmaking. Our priorities are upside down, folks. And we are complicit! We sit and type away, we vote for corporate shills, the latest a black man with a lot of charisma, but a hollow will. We no longer take to the streets. Move.On.org will take care of everything, thank you...
If you think vaccines are safe you might want to listen to this interview with nationally known and well respected retired neurosurgeon Dr. Russel Blaylock:
1/4 http://www.youtube.com/watch?v=--nWrqIspnQ
2/4 http://www.youtube.com/watch?v=nnaiubVJv8E&feature=related
3/4 http://www.youtube.com/watch?v=ktcoJW6mj1U&feature=related
4/4 http://www.youtube.com/watch?v=w5E2N4pliXs&feature=related
"Who should get a chance to survive when the number of severely ill people far exceeds the resources needed to treat them all?"
Is that rhetorical? This is AmeriKKKa. The richest will get a chance to survive. The poor and their children will be tossed onto the midden pile outside town and left as an offering to feral dogs. Was there ever a Question? This is AmeriKKKa, we eat our own here. Nothing more than you would expect from an Empire birthed in Genocide and built by forced human labor under threat of torture and death. My country tis of thee, sweet land of Liberty - defined as the RIGHT of richfilth animals to order the lives of the "meat" they own. That's us.
Don't like it? Change it. The richfilth animals want you dead or in chains. It's you or them and they are playing for "Keeps".