Doctors working in intensive care units across the country are beginning to brace for an event that seems inevitable: a crush of COVID-19 cases they are incapable of handling.
This, in turn, will force their participation in an unbearable exercise: deciding who gets the care and attention they need, and who does not. Who lives, who dies.
Michael Kenyon has worked in intensive care for 40 years. Originally from South Africa and now head of ICU at Nanaimo Regional General Hospital on Vancouver Island, Dr. Kenyon has witnessed up close the devastation a new disease can cause. HIV, Ebola, H1N1, MERS – he has seen it all. But COVID-19, well, this could end up owning a special place in the pantheon of the world’s most deadliest diseases.
What keeps him awake now is the same issue intensive care doctors in Italy have been grappling with: a shortage of ventilators. Because the novel coronavirus causes a respiratory ailment, ventilators are a key component in the rehabilitation of those in the most critical state.
Dr. Kenyon occasionally will run a thought experiment in his mind: Nanaimo, a mid-size city on the east coast of the island, is home to roughly 90,000 people. Taking a conservative estimate, say only 25 per cent of those get infected with the virus. That’s 22,500 people. And then say 4 per cent of those people – the figure most often used – require intensive care. That’s 900 people. And most, if not all, will require a ventilator machine.
And most people needing ventilation with COVID-19 generally require it for three weeks.
“What am I going to do with 14 ventilators?” Dr. Kenyon said in an interview. “I can tell you what I’m going to do: I’m going to do what they’re doing in Italy and I’m going to take 70-year-olds off the ventilator, and then 60-year-olds off the ventilator and eventually 50-year-olds off the ventilator, and I’m going to give them to 30-year olds with three kids.”
While this might seem like the calloused attitude of someone hardened by years fighting diseases around the world, the fact is, it’s reality. These are indeed the choices that doctors in Italy have been facing as they struggle to deal with a massive influx of critical-care cases and not enough equipment to properly aid them.
Who lives, who dies?
British Columbia does have a framework in place to deal with this very predicament. It is, according to Dr. Kenyon, a pragmatic and fair plan. And in terms of natural justice, he believes the majority of the public would support it.
Perhaps not surprisingly, the decision of who ultimately gets a ventilator and who does not (in a situation in which there is a lack of them) depends on an array of factors, with age being primary among them. But there are value judgments also: Someone who has had a good long run with no dependents might qualify less than someone who has had a good long run, but has three dependents.
In B.C., the ultimate decision will be put in the hands of a committee, which will include medical ethicists. The doctors put the facts before the committee, along with the pros and cons of various candidates, and the committee is compelled to produce a non-ambivalent answer.
This is a good move. It removes the front-line clinicians from having to make these difficult choices; their lives are stressful enough as it is. Dr. Kenyon says doctors in Italy he has communicated with have told him they have not been spared this task, which has exacerbated burnout during the virus crisis.
Those same Italian doctors have told him that older patients who have been told the ventilator they need to survive has been given to a younger person with children are generally accepting of the decision. “Give it to the young,” they say.
It may not be as easy, however, for the children of those older people to accept that verdict.
This is a moral distress scenario that has a high chance of playing out at hospitals across the country in the coming weeks and months. It will depend on how successful we are as a country in breaking the back of this disease in the next while. Extreme mitigation efforts are key, but so is the ability to source more ventilators, something governments across the country are now trying to do.
It is not unusual for doctors to have to play God in the course of their work. Few of them, however, likely ever imagined having to perform this function on the kind of scale we are now imagining.
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