Ventilator shortages could force ’war-time triage’ at hospitals

An ER doctor describes possible ethical dilemmas Canadian hospitals could face during the COVID-19 pandemic. ’These are going to be very, very tough times, ethically speaking’
Alanna Mitchell
Person on ventilation machine in ICU
Reportage in Robert Ballanger hospital’s Intensive Care Unit in France. (Photo by: BSIP/Universal Images Group via Getty Images)

The people who treat patients in Canada’s emergency rooms are preparing to face some of the toughest ethical dilemmas of their careers and they’re pleading for guidance. Dr. Alan Drummond, co-chair of public affairs for the Canadian Association of Emergency Physicians and an emergency doctor in Perth, Ont., says the one of the most pressing issues is the use of ventilators. Early studies are showing that up to 97 per cent of seriously ill COVID-19 patients on ventilators don’t recover. Some of those patients remain on the devices for as long as three weeks. 

Dr. Drummond spoke with Maclean’s on March 25, 2020. His comments are below. They have been edited and condensed for clarity. 

It’s not just the machine, it’s the human resources to [run] that machine, it’s the minute by minute or hour by hour manipulation of pressure and volume. [An article recently published in the New England Journal of Medicine] suggests that there are a number of scoring systems to help people decide whether [a patient is] actually going to survive the event, and that if [the patient] is not showing any response after a couple of days of ventilator management, it be withdrawn and the ventilator be made available to the next person. 

There’s no cure [for this disease]. You have to support the body’s organ systems until the virus dissipates and the normal mechanisms return to an equilibrium. All you’re doing is supporting the patient to fight off the disease. A ventilator is part of that—it’s pumping oxygen into the lungs. But as the lungs get stiffer with this disease, that gets harder. And then people can develop secondary pneumonias and die. 

If our ventilator capacity is overwhelmed, what then? Are we prepared to move to a war-time triage system of, you don’t get the ventilator because you’re 85, and you’ve had your life? Or, the ventilator isn’t working after three days, so we’re going to abandon things and move to the next person? These are going to be very, very tough times, ethically speaking, I think. 

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Everybody’s looking for a ray of hope, and everybody’s looking to avoid societal panic, but I think we’ll hit the point in the next two or three weeks when the discussion may well come down to such things as the ethics of ventilation triage. 

I think the other thing we’ll come down to is having very strong goals of care discussions with elderly patients. These are already now being discussed within medical circles, and we have to get our elderly population prepared for the reality, or the potential reality, that they may get sick and may need critical care. Do they really want to go through that exercise for the last three months of their life, only to die anyway? 

And then the other issue is going to be what do we do with people in nursing homes? If you get sick in a nursing home, do we just say, well, do your best, but you can’t come to the hospital? 

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As a society, we’re not there yet. But the question is, will we be there a month from now? And I don’t know the answer to that. Nobody does. 

The medical staff at my own little hospital here, we’re having these kinds of discussions about what we are going to do if something serious happens in three or four weeks, and looking for ethical guidance. 

I’m pretty confident in my own abilities and in my view of life and in the nurses and physicians I work with. I’m confident we will do our best, no matter what happens in the coming weeks or months. We will bring our very best clinical skills to every individual patient. We will have one eye on the stretcher in front of us; we will have another eye on the waiting room and the ambulance off-load base; and we will have the eyes in the back of our head looking at where society is, where society’s greater need is. It can no longer be just the patient in front of you. Now the greater societal need is going to have to become part of the clinical equation in dealing with patients. 

This is a rapidly evolving topic. I don’t think we need a discussion right this very minute, but it’s going to become part of the equation in the next few weeks, I’m fairly sure. We have a couple of ethicists among us and I think they have been preparing the groundwork for that discussion, so we’ll see what happens in the next week or two.

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