Friday, March 20, 2020

Covid-19 reveals a deadly failure of priorities.

This article was published by the disability rights group, Not Dead Yet on March 17, 2020

Diane Coleman
By Diane Coleman

President and CEO of Not Dead Yet

With the looming and imminent threat of insufficient hospital and ICU beds, medical equipment and healthcare staff, I found myself recalling an old favorite TV show from my college years. MASH (mobile army surgical hospital) created both comedy and drama around the reality of having three operating room beds in an army tent on the war front in South Korea. Triage was part of the routine, determining who gets on the operating table first, and who gets the best surgeon (Hawkeye) of the four in the unit. Now and then, when the frontlines had faced a heavy attack and massive casualties poured in, the plot explicitly focused on triage situations. Hawkeye always struggled to do the right thing.

COVID-19 is leading to more and more news reports on the fast approaching reality that the demand for hospital beds and ventilators will exceed supply. New York’s Governor Cuomo was carried on MSNBC yesterday and today, discussing this crisis.

A few years ago, NDY’s research analyst, Stephen Drake (aka my husband, now retired), reviewed New York’s Ventilator Allocation Guidelines, released in 2015. The pandemic guidelines operate on the principles of triage.

The primary goal of the Guidelines is to save the most lives in an influenza pandemic where there are a limited number of available ventilators. To accomplish this goal, patients for whom ventilator therapy would most likely be lifesaving are prioritized. The Guidelines define survival by examining a patient’s short-term likelihood of surviving the acute medical episode and not by focusing on whether the patient may survive a given illness or disease in the longterm (e.g., years after the pandemic). Patients with the highest probability of mortality without medical intervention, along with patients with the smallest probability of mortality with medical intervention, have the lowest level of access to ventilator therapy. Thus, patients who are most likely to survive without the ventilator, together with patients who will most likely survive with ventilator therapy, increase the overall number of survivors.
Within the hospital environment, ventilators would be allocated and, if necessary, re-allocated as the pandemic proceeds. Importantly, the guidelines state:
In its consideration to protect vulnerable populations, i.e., ventilator-dependent chronic care patients, the Task Force determined that these individuals are subject to the clinical ventilator allocation protocol only if they arrive at an acute care facility for treatment.
It would be helpful if disability advocates determine whether similar guidelines exist in their state and, specifically, what they say, in order to inform their communities and ensure that individuals who use breathing support can make the best decisions for themselves if they get sick. (In my opinion, I should not go to an acute care facility if I get sick.)

It’s hard to disagree with the principle of maximizing the number of pandemic survivors but, nonetheless, a few things need to be said.

First, COVID-19 is not the only cause of the shortages we face. I’m on a New York Medicaid advocacy listserv in which one member quoted Judy Wessler, former head of the NY Commission on the Public’s Health System:

Let’s Remember That Since At Least 2006 There Has Been A Tremendous Push In New York State To Close Hospital Beds And Consolidate Hospitals. We Used To Have 4 Beds Per 1,000 And Now We Have Something Like 2.8 Beds Per 1,000. So Now We Have To Play Catch-Up.
Wessler was also quoted in a NY Post article entitled New York has thrown away 20,000 hospital beds, complicating coronavirus fight.

How many states have taken similar steps as they offload their healthcare responsibilities, letting managed care take over and allowing that industry to suck up around 20% of our healthcare dollars and put profits over people? So our shortage of beds and ventilators is not just caused by COVID-19 but also by unacceptable political and fiscal decisions made largely under the public radar.

Second, how will the idealized triage principles be implemented in practice? The NY guidelines call for a triage committee. It will not be the attending doctor. I don’t think we can count on the committee being composed only of doctors like the caring Hawkeye Pierce. And there will be a time crunch. The situation invites biases like ableism and racism to creep in.

Third, we already know that healthcare resources are denied based on disability bias under futility policies, denial of transplants and other practices reported in the National Council on Disability’s bioethics series. In this crisis, further devaluation of our lives is a real threat.

Not Dead Yet was among many organizations that signed onto a National Disability Rights Call To Action on March 3rd. We are all are trying to impress upon policymakers that our lives are valuable. We are not worth-less and we are not expendable!

This pandemic resource shortage will touch people who previously felt safe from healthcare rationing. How we treat people in need is a reflection of the priorities of the policymakers we elect. All too often, the voices of people with disabilities and other justice communities have been drowned out. Perhaps the unnecessary loss of life from this pandemic due to healthcare capacity limits will cause others to join with us in re-evaluating the priorities that got us here.

1 comment:

MÁIRENÍGHRUÁGÁIN said...

A brilliantly worked out analysis of how a health system would prioritise under a shortage of equipment. I see this global epidemic as an opportunity to assess our values as regards what constitutes a useful life. A chivalrous view would be the one that maximises its determination and to survive, The old and the disabled would score here. If the human race was a contest of endurance the very people that are it is suspected going to be neglected or treatment in the case of Covid 19 and already for transplants etc are the winners of the human race. The rat race has its own heroes those who are adaptable to be the well oiled parts of the economic machine. MAKING A CHOICE EVERY DAY AS TO WHO OUR HEROES ARE AMONGST OUR ACQUAINTANCES AND ACTING ACCORDINGLY WILL EVENTUALLY LEAD TO A MORE CIVILIZED APPROACH TO CARE OF ALL HUMAN BEINGS.

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