Rationing Care as the Omicron Variant Emerges — An ICU Physician’s View By Lara Goitein, MD
As an ICU doctor, when COVID-19 first swept the world, nothing frightened me more than the prospect of rationing care. In many places hit early and hard, physicians were forced to allocate ventilators on a moment-to-moment, case-by case basis — essentially choosing who would be given a chance of survival.
Aside from the obvious tragedy involved for patients, these choices put physicians in an unconscionable position at odds with our responsibility to do our best for each person. I couldn’t imagine looking a patient in the face — struggling to breath, needing my help — and saying: “No, the ventilator goes to someone else.”
We’re now experiencing another surge, fueled by the Delta variant and now potentially becoming more dire with the emergence of the Omicron variant. ICUs are again overflowing with patients with COVID-19, almost all unvaccinated. This time, rationing decisions have become more explicit and formalized. Hospitals and departments of health have created protocols for rationing, to deploy in worst-case scenarios. These remove responsibility from individual physicians and instead distribute ICU beds and ventilators according to objective scores estimating chances of survival.
For example, a protocol might direct that a patient with a low chance of survival should be denied life-saving treatment to free resources for patients with better chances. The protocols apply to all patients, not just those with COVID-19, so if you’re unlucky enough to get in a car accident or have a heart attack at this time, they will apply to you. Now, some hospitals have quietly started to deploy protocolized rationing — something that has never before happened in this country.
But even before protocols are officially triggered, “soft” rationing begins. Decisions about starting or withdrawing life support are often not straightforward under the best of circumstances — particularly for the elderly or patients with underlying chronic illness. In this gray zone, how the physician deals with the patient or family can have great influence.
For example, a physician might say, “He’s very sick, but it’s not hopeless and he’s a fighter,” or alternatively, “The chances aren’t good; would he want to spend the end of his life on machines?”
As resources such as ventilators and ICU beds become scarce and new patients keep coming, physicians naturally lean toward the more pessimistic presentation to make room for patients with better chances of survival — usually unconsciously, because it’s too painful for physicians to acknowledge to themselves how and why their practices are changing.
Moreover, it seems as though some commentators are trying to make a virtue of necessity by suggesting that ventilators for COVID-19 may do more harm than good, or are a sign of futility. Neither is true. Overall, slightly more than half of patients with COVID-19 requiring mechanical ventilation survive. The flip side is grim, but not too far off from mortality from other conditions causing severe acute respiratory distress syndrome, which we treat all the time in ICUs. Although medical care is often too aggressive, as in the over-treatment of terminal illness, the use of a ventilator is not necessarily a sign of that. Of course, some patients with severe COVID-19 might reasonably choose to forgo or withdraw life support depending on their specific situations and preferences, but these decisions should be made in the same careful way as for other critical illnesses.
Physicians and nurses in ICUs are exhausted and overwhelmed by the workload. But perhaps worse is the moral injury they suffer every day — up close and personal. Make no mistake: Rationing, whether explicit or “soft,” visible or hidden, is moral injury to medical providers, and to the public they serve. The fact that many of the patients who require ICU treatment for COVID-19 chose not to be vaccinated adds to the anguish.
Everything possible should be done to allow us to provide the very best care possible to all critically ill patients — from national policies such as use of the Federal Defense Production Act to manufacture ventilators, to national and state efforts to coordinate and distribute staff and resources according to need, to hospital policies such as canceling elective surgeries to free resources that could be used for critical care. Most important, responsibility to one another lies with us as individuals. I beg anyone who hasn’t yet received the vaccine to do so, especially as unvaccinated individuals allow the virus to continue to mutate.
For those of you declining the vaccine to assert your personal freedoms, I ask you to consider whether at this point you’re giving them too much weight. When your personal freedoms are filling our ICUs and preventing your neighbors from getting life-saving care, they’ve gone too far.
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Lara Goitein, MD, is a Harvard trained physician specializing in intensive care and lung medicine. She founded a clinician-directed quality improvement program at a Santa Fe, New Mexico, hospital and served as Vice President of its Medical Staff. Her professional interests include quality improvement in healthcare, end-of-life care, the training of new doctors, physician burnout, and improving communication with patients and families. She is an editorial board member and frequent writer for the medical journal JAMA Internal Medicine, and also writes in the lay press, including the New York Review of Books. Her new book is The ICU Guide for Families: Understanding Intensive Care and How You Can Support Your Loved One (Rowman & Littlefield, Dec. 1, 2021). Learn more at MedicalExplainer.com.
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