Northwell memo calls for rationing ventilators to 'patients most likely to benefit'

By AMANDA EISENBERG and SALLY GOLDENBERG

5-6 minutes

A Northwell Health-branded sign on the facade of North Shore University Hospital | Northwell Health via Facebook

One of New York state's biggest hospital systems released guidelines Friday directing medical professionals on how to manage the limited supply of life-sparing ventilators as the coronavirus continues its deadly stampede through New York.
“The goal of this institutional process is to allocate scarce critical care resources to those patients most likely to benefit,” Northwell Health wrote in a six-page memo titled “Public Health Emergency: Life Sustaining Treatment Decisions for all Patients” and distributed to medical staff.
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The guidance, which was obtained by POLITICO, recommends that medical teams reevaluate patients with advanced illnesses who are breathing through a ventilator for three days if they show no “no clinical improvement.” At that point, the team should consult palliative care specialists to discuss whether to unplug the breathing device — a step the memo describes as “compassionate extubation” — and confer with the hospital’s “clinical triage team.”
The instructions laid out the same steps for patients with prior advanced health problems — chronic illness or some combination of malnutrition, organ dysfunction, cancer and declining functional status — who do not improve within seven days. Those who have been readmitted to a hospital more than three times in the prior six months are also granted “advanced illness” status.
After patients are removed from ventilators, they should be provided medicine “to prevent and treat distressful symptoms” in their final hours, according to the guidance.
Otherwise healthy patients who are intubated should be evaluated by a critical care team after seven days.
Any patient likely to die regardless of medical assistance “should not be offered interventions such as CPR and intubation,” the memo advised.
“Both patient needs and resource shortages can fluctuate daily or even more frequently. Therefore patient re-assessment should occur daily and be documented,” it concluded.
Hospital executives worked with a number of experts last week to create the guidelines for the novel coronavirus, which has thus far claimed more than 1,800 lives in the city, and a Northwell spokesperson said the system is using 75 percent of its ventilators.
“It’s obviously not going to be in place until that situation arises,” said spokesperson Terry Lynam. “I do want to underscore that we have an adequate supply of ventilators right now, and we’re working with our supply channels to purchase more.”
Meanwhile the state is developing its own standards and Northwell may update its guidelines to match those, he added.
Northwell emailed the guidelines to staff members a day after Gov. Andrew Cuomo warned the state is expected to run out of ventilators in a matter of days. Medical experts have pushed for hospitals to put in place such systems so physicians aren’t forced to make those decisions on their own.
Cuomo plans to deploy the National Guard to seize supplies from hospitals that don’t have an immediate need for them.
“If you thought physician burnout is bad now, wait until that starts happening — you’re going to get the equivalent of battlefield shell shock,” said Art Fougner, a medical doctor and president of the Medical Society of New York. “Can you imagine carrying the weight of that burden on your shoulders?”
Other health systems like Maimonides Medical Center and SUNY Downstate have not issued guidance for how to prioritize patients for ventilators.
“We are providing every patient who comes to us all of the care they need to give them the best chance of recovery, without regard to age or previous health status,” said SUNY Downstate, which has been designated as a coronavirus-only facility, in a statement. “Decisions with regard to Do Not Resuscitate orders are left entirely to the patient and their family. We do not hold back life-saving care, including ventilation and resuscitation.”
Arthur Caplan, a bioethicist at the NYU School of Medicine, said those types of policies don’t make any sense.
“You are going to wind up treating people impossible to help — futile,” he said. “The policy of the places I’m familiar with is not ‘first come, first serve,’ but ‘maximize the number of lives you can save.’ That's what you do with organ transplants. People die every day because they are waiting for a liver or a heart. The nation has accepted that system. It has been in place for 40 years.”
He added that policies like Northwell’s allow medical professionals to emotionally prepare for making tough decisions before the tsunami hits.
State guidelines from 2015 proposed ways to “ethically allocate limited resources (i.e., ventilators) during a severe influenza pandemic while saving the most lives,” according to an introductory letter from State Health Commissioner Howard Zucker.
“It is my sincere hope that these Guidelines will never need to be implemented,” Zucker wrote at the time. “But as a physician and servant in public health, I know that such preparations are essential should we ever experience an influenza pandemic.”

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