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In Vivo
PUBLIC HEALTH

If Pandemic Flu Strikes, Who Will
Get Scarce Ventilators?

If a pandemic similar to the 1918 “Spanish” flu hit New York today, the state projects more than 770,000 people would be admitted to the hospital during a six-week outbreak. Of those, nearly 60,000 would need mechanical ventilators.
   The state has a stockpile of ventilators, but in a severe pandemic, the demand would outstrip the supply. Adding more ventilators to the stockpile would not solve the problem because severe staff shortages are projected, and there would not be enough workers to operate all ventilators.
   Last year, the New York State Department of Health and the New York State Task Force on Life & the Law assembled a group of physicians, lawyers, ethicists and policymakers to draft a plan for fair allocation of ventilators during an emergency.
   The plan calls for hospitals to triage all
patients and deny ventilators to those who score poorly on an assessment that predicts mortality. Many patients on ventilators at the beginning of the pandemic would be taken off against their wishes. (Full details of the plan are available at http://www.health.state.ny.us/diseases/communicable/influenza/pandemic/ventilators/).
   
After the state’s plan was presented to CUMC faculty at a special town meeting sponsored by the Center for Bioethics, InVivo spoke with Neil Schluger, M.D.,
In the winter of 1918, a new influenza virus spread around the world, killing 40 million to 50 million people and possibly as many as 10 percent of the world’s young adults.
In the winter of 1918, a new influenza virus spread around the world, killing 40 million to 50 million people and possibly as many as 10 percent of the world’s young adults.
chief, Division of Pulmonary, Allergy, and Critical Care Medicine and professor of medicine, epidemiology and environmental health sciences, who was a member of the working group that drafted the plan.

Does the plan violate doctors’ basic duty to care for their patients?
There is a real tension here. In medicine you have an absolute obligation to your patient, regardless of what is happening to other patients in the hospital. This plan is radically different and takes a public health approach, where the focus is on the community rather than on the individual.
   The plan asks physicians to do what we generally don’t do – and don’t like to do: deny or withdraw care. There are times when we withdraw care if we think further medical intervention is completely futile. But if we start rationing ventilators, we would need to withdraw or withhold care over the stated wishes of the patient or the patient’s family. Will physicians be able to do that? I don’t think anybody is sure what is going to happen.

Is there anything in the plan that will make this any easier on physicians?
The plan is very careful not to pit one patient against another. This is an issue that always comes up in medical ethics sessions. Nobody wants to abandon one patient for a supposedly worthier one. The plan addresses this potential problem by only pitting a patient against his or her own chance of survival, not against that of another patient’s. That takes a bit of the burden away from the doctor. Still, physicians would be the ones turning off the ventilators. I’ve had to withdraw care from a few patients who subsequently died. In certain cases it is the right thing to do, but few things in medicine have shaken me up as much as having to do that.

What prevents healthcare providers from ignoring the plan?
The plan is totally voluntary. It has no chance of working unless all hospitals in an affected area play by the same rules. Presumably, the governor would declare a state of emergency and put the plan in effect, but every hospital would still have to agree to it.
   A massive educational campaign will have to be undertaken to help physicians and the public understand that more deaths would result from not following the plan and that it is fairest for everyone. It doesn’t favor the wealthy, the young, or the better educated. None of those factors – even to the point of not favoring healthcare workers if they got sick, because they would be out of work for months, just like everyone else – will increase a patient’s access to a ventilator.

What happens to people who are not eligible for a ventilator or are removed from a ventilator?
They would require palliative care. It would be horrible not to give someone a ventilator and then also not provide further care. But palliative care is not something that hospitals have a lot of expertise with. Improving palliative care capacity is going to be a real challenge.

Have there been any medical advances since 1918 that might make a similar virus less lethal today?
Probably not. Our medical arsenal today consists of immunization and treatment.Immunization is not yet a realistic possibility. Making a vaccine for a pandemic influenza is more difficult than making one for regular influenza, and a vaccine specific for the virus would not be available for at least six months after a pandemic starts. On the treatment side, there’s Tamiflu. Nobody knows how this drug will work in a pandemic. In studies with regular flu, patients who took the drug experienced, on average, one fewer day of symptoms. I don’t think this is going to save many lives.
   The two most important advantages we have today are surveillance and containment. Local, national, and international agencies are closely monitoring domesticated animals. Birds infected with avian flu are killed, and that may be having some effect. In Vietnam, there haven’t been too many cases lately of avian flu in humans. We also know how to quarantine more effectively, limiting the activities of people who have been exposed to a sick patient to try to prevent them from spreading the disease.
   Somewhat reassuring is the fact that avian flu has not yet developed a great capacity to spread from person to person. Maybe we’ll get lucky with avian flu and it won’t cause a pandemic. But there is always the next thing around the bend that no one has yet heard of. We won’t be lucky forever.

—Susan Conova

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