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Who Gets A Ventilator Or An ICU Bed? Colorado Issues Crisis Guidelines For Health Care Workers

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Gov. Jared Polis' Expert Emergency Epidemic Response Committee has issued updated crisis standards of care guidelines, which include recommendations for how healthcare workers should make decisions about who receives things like ventilators or ICU beds if the state's healthcare systems hit capacity during the COVID-19 pandemic.

Dr. Matthew Wynia is the Director of the Center for Bioethics and Humanities at University of Colorado Anschutz Medical Campus. He discussed the guidelines with KUNC's Colorado Edition.

Interview Highlights

These interview highlights have been lightly edited for length and clarity.

Erin O'Toole: Who would be using these guidelines to make decisions in these hospitals?

Dr. Matthew Wynia: There are some folks who might be under the impression that if there's a need to make these kinds of triage decisions that their doctor would be looking at them and saying, "are you worthy of a ventilator or not?" And that's not the preferred way to do this.

Nationally the consensus is that your doctor should be able to advocate for you as their patient. The bedside team should be insulated from making these kinds of decisions if it comes to that.

The state is putting together crisis triage teams with senior people on them. They would be informed by objective data. They would not in most instances even know your name, or your race, or your religious identity or sexual orientation or whether you have a disability, or whether you have health insurance or whether you're a VIP.

So the governor would be treated the same as anyone else in the state under these guidelines. The triage team would not even have access to the information about who they're looking at. The same thing happens with the organ transplantation system. That ensures the equity of application of the guidance across the whole state.

This crisis triage team may need to make a decision about who gets a ventilator or an ICU bed. Walk us through the four steps for how that decision would be made.

We're hopeful that the first step is the determinative one, because that's the step that is entirely objective and based on clinical criteria. We need to find the people who are most likely to benefit from getting that resource. If you're thinking about a ventilator, for example, you want to know if the person we're looking at is going to die if they don't get the ventilator and if they do get it, if they will survive.

If you have someone who is probably going to pass away no matter what, that person would be de-prioritized. Likewise, if you have someone who's probably going to survive, even if they don't get the ventilator, that person too, would be de-prioritized compared to the person in the middle, who is liable to die and will survive only if they get access to that scarce resource.

The next step comes if there is a tie. We hope that we don't need to use this at all. We hope there won't be a lot of ties and that it will be obvious. There are a number of people for whom getting on a ventilator is not going to help and it's just going to prolong the dying process.

I hate to say this because it's kind of depressing but the survival rate for people with COVID-19 who need to be put on a ventilator is very poor, even if they get put on the ventilator. We sometimes talk about ventilators as though if you get one, you're going to make it and if you don't get it, you won't.

The reality, sadly, is that more than half of the people put on ventilators end up dying. In some studies, it's 85 or 90 percent of people who are put on ventilators for COVID-19 still end up dying. So we are hopeful that we will not have a lot of tiebreakers because we want to use the ventilators we have for the people who have a chance at long-term survival.

But the secondary criteria are looking at: Is the person necessary for the response to the epidemic? Is it a healthcare worker, a first responder, someone who if we can get them back in the fight, they can go on to help save additional lives? We're also looking at children as getting some priority over older people as a sort of secondary criterion if we need to have a tiebreaker.

There are steps beyond those tiebreakers. If you've got three or four or five people, all of whom are essentially equal in terms of the likelihood that they will benefit and all of whom are equal in terms of any of the other tiebreakers, we would turn to a random allocation process that really is the only fair way to decide who might get access to something like a ventilator. You're literally talking about flipping a coin or using a random number generator to make that decision.

Knowing this, is there anything that patients or loved ones of patients should know about advocating for patients under these circumstances?

The most important thing right now is for folks to understand how rapidly this disease can come on and become very serious. We have had a number of people who are looking okay, for a day or two. And then within just a few hours, they can decompensate very quickly.

So you should have an advance directive: Name someone who would be able to make decisions for you in the event that you're no longer able to speak for yourself, because you really can't breathe. Everyone in the state ought to have an advanced directive right now.

I don't care how old you are, you ought to have someone named as your medical-durable power of attorney for health care. So if you get this and it gets bad, there's someone who is there to speak for you.

This conversation is from KUNC's Colorado Edition from March 18. You can find the full show here.

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