Who gets the ventilator when there are limited numbers? Who takes priority when beds fill up?
- Doctors have asked Sydney Health Ethics, a centre at the University of Sydney, to construct guidelines on how to prioritise patients and resources
- The request comes amid concerns ICUs will be overwhelmed by COVID-19 patients
- The guidelines provided serve as a framework, not a set of rules
These are the difficult decisions doctors — particularly those in intensive care units (ICUs) — are expected to regularly face as the coronavirus pandemic worsens.
With the virus already putting pressure on Australia’s healthcare system, some medical professionals have turned to ethicists to help direct the process.
Sydney Health Ethics, located within the University of Sydney, was approached by an ICU doctor to come up with a series of ethics guidelines to help deal with the unprecedented crisis.
“We’re concerned about how the guidance in the future might be implemented,” centre director Angus Dawson told The Drum.
Mr Dawson said decision-making dramatically shifted when hospitals moved from normal practice to “pandemic practice”.
“Once we are in a pandemic situation and we are responding to a particular event and we have constraints placed upon the resources we have, then we have to do something different,” he said.
“Clinicians will always do what’s best for their patient, but if they’re all doing that, there’s no system for resource allocation in place.”
Former director of the intensive care unit at St George Hospital, George Skowronski, said the decisions doctors were likely to face due to the pandemic would be “way outside” what any of them would have experienced before.
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“We’ve never faced the kind of resource constraints that we potentially could face in this situation,” he told The Drum.
Dr Skowronski, a contributor to the guidelines, welcomed their release.
“The more we can prepare the better we will do the job,” he said.
He said medical professionals had been keeping an eye on what was happening internationally.
“What we’re doing at this stage is looking at the best evidence we can find from the experience overseas to try to be able to predict who is likely to benefit, who is likely to survive, who is likely to get the best long-term outcomes,” he said.
Researchers warn of difficult times ICUs face
The ethics request comes amid mounting pressure on ICUs due to the COVID-19 pandemic.
Earlier this month, The Grattan Institute’s Stephen Duckett warned ICUs could run out of ventilators and staff by April 11 if cases continued to double every three days.
“That’s what really, really concerns me — we almost have no time!” he told The Drum.
Mr Duckett compared potential case numbers of COVID-19 and the amount of ICU beds they would require to current availability of beds.
He also tested what would happen if resources were boosted.
“If we double the number of ICU beds, that buys us three or four days,” he said.
“If we halve the proportion of people going into an intensive care unit, that gains us three days.
“These add up, of course, but they still leave us in April.”
He said the information should have been a wake-up call for the Government to enforce a shutdown of all things that were not “truly essential”.
Government secures access to private equipment, staff
One third of Australia’s intensive-care capacity is in the private sector.
Today, the Federal Government struck a deal with the country’s 657 private hospitals to expand hospital bed numbers by 34,000 to tackle the pandemic.
The deal also opens up access to private hospital staffing and equipment, such as ventilators.
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Speaking to The Drum today, Mr Duckett said he was not sure there was a need to subsidise private hospitals.
“There are lots of other industries which would put their hand up and say we’d like to be subsidised for not doing anything,” he told The Drum.
“I’m not entirely sure this was a necessary step. It’s certainly not a well targeted step.”
How do we determine who gets what?
There were several different proposals put to the Sydney Health Ethics team about how to choose who gets priority in an ICU.
“It’s not saying ‘this is a list in a particular order’,” Mr Dawson said.
“It’s trying to say to people these are the kinds of things you’re going to have to think about and it’s good to think about them in advance.”
“What we are suggesting is that the number one issue ought to be trying to get the best possible value out of any resource that we have.
“That would be used to prioritise [patients].”
In cases of potential “tie-breakers”, Dr Skowronski said it would be reasonable to take social issues into account.
This would include prioritising First Nations communities due to existing healthcare disadvantages.
Mr Dawson said he hoped his team’s ethics guidelines would not even need to be used.
“This is all about prep for what needs to happen in the event of resources being truly constrained,” he said.
“If we’re lucky and we don’t have numbers turning up then they won’t come in to play, because the normal practice won’t have changed.”
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