Sunday, May 28, 2023
This article is intended for internists, infectious disease physicians, intensivists, emergency physicians, pulmonologists, and other physicians caring for patients in the context of a pandemic such as coronavirus disease 2019 (COVID-19) as well as hospital administrators.
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A pandemic respiratory virus has gripped the United States, including the area served by Community Healthcare Trust Incorporated (Community), a large, integrated health system that includes several area hospitals, multiple specialty and subspecialty groups, and primary care clinics. The best models and estimates regarding the pandemic are dire. Although uncertain, they suggest that infections will peak in 18 days and that, if so, patient need for critical resources, such as ventilators, could exceed the current total capacity. As a result, Community has to plan for the worst while hoping to increase capacity and that state and local public health measures and "shelter in place" orders can stem the tide of infections.
Community has decided to create a team to develop institutional policy on how to allocate scarce resources in the event the pandemic is as bad as models predict. Dr Giles, an internal medicine physician and ethicist for Community, has been asked to join this team and lead the drafting of the policy.
Dr Giles just got off the phone with Dr Stead, a critical care colleague and friend in a smaller community in another state. Dr Stead was distressed, relaying that staffing is strapped, as a number of employees are home ill, on quarantine, caring for ill relatives, or engaged in childcare because of school closures intended to prevent spread of disease. Almost every intensive care unit bed is occupied by a patient receiving mechanical ventilation, and new patients are arriving regularly at the emergency department (ED) in respiratory distress. Dr Stead noted that among the patients currently in his ICU whose condition is most dire is the grandmother of the hospital's director of social work. A half dozen of her friends and family members were in the lobby wanting to go to her bedside; meanwhile, he just evaluated an elderly leader in his church and a 24-year-old patient with asthma and severe viral pneumonia for possible admission from the ED. The elderly man's brother (a health professional) keeps mentioning the Emergency Medical Treatment & Labor Act (EMTALA).
Dr Giles can only imagine what his hospital soon may be facing. What ethical considerations and principles should guide Dr Giles in drafting the policy?
