Monday, October 19, 2009

Florida hospitals to implement 'death panels' in pandemic

Florida plan advises hospitals to bar some patients in event of severe flu pandemic

Outbreak would limit some hospital care

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Florida health officials are drawing up guidelines that recommend barring patients with incurable cancer, end-stage multiple sclerosis and other conditions from being admitted to hospitals if the state is overwhelmed by flu cases.

The plan, which would guide Florida hospitals on how to ration scarce medical care during a severe flu outbreak, also calls for doctors to remove patients with poor prognoses from ventilators to treat those who have better chances of surviving. That decision would be made by the hospital.

The flu causes severe respiratory illnesses in a small percentage of cases, and patients who need ventilators and are deprived of them could die without the breathing assistance the machines provide.

In June, Florida Surgeon General Ana M. Viamonte Ros sent the draft guidelines — which had already undergone a series of internal revisions — to 16 state medical organizations for their feedback.

But the state has not yet publicized the guidelines or solicited input from the general public. The Florida Department of Health released a copy of the draft plan at the request of ProPublica, a nonprofit news organization, which provided it to the Sun Sentinel.

The document addresses one of the most heart-rending issues in medicine: What to do if the number of people in need of ventilators and other treatment dramatically exceeds what is available.

The goal, the plan says, is to focus care on patients whose lives could be saved and who would be most likely to improve. While it says those decisions are not to be made based on patients' perceived social worth or role, the plan calls for different rules for some populations.

The list of conditions that disqualify hospital admission would be applied to most people only in the two most severe levels of a pandemic. However, they would also be applied in the first level ofa pandemic for patients transferred to hospitals from "other institutional facilities," such as nursing homes and mental health facilities.

Florida's planning effort reflects a growing acknowledgment that hospitals across the nation would be unable to cope with the flood of patients that a severe influenza pandemic, like the one that gripped the nation in 1918, would unleash. That resource gap is in the spotlight now, as the country is battered by a second wave of pandemic swine flu, also known as the H1N1 virus.

"What we have seen are real stresses, particularly on the emergency departments," Thomas Frieden, commissioner of the Centers for Disease Control and Prevention, said at a press conference last week.

The H1NI virus is much milder than the 1918 flu, but a small proportion of H1N1 patients, including some who have no risk factors and are young and healthy, develop severe breathing problems requiring mechanical ventilation and life support.

So far, intensive care units in the U.S. haven't been overwhelmed with people needing ventilators.

"That's something that we're tracking closely," Frieden said.

In Winnipeg, Canada, all regional critical care beds were full at the peak of the outbreak last spring, and in Mexico, patients experienced long delays before being admitted to ICUs. Four died before being transferred from the emergency room.

Florida health officials believe that the number of severely ill flu patients will likely remain at a manageable level, provided residents get vaccinated, that they know when to stay home and when to seek medical care (visit or call 877-352-3581 for information), and that the existing flu strain does not mutate into a more virulent form.

In the case of a much severer scenario, Florida's draft guidelines call for hospitals to turn away anyone whose doctor has signed a "Do Not Resuscitate" order, which instructs rescuers not to revive a patient whose heartbeat or breathing stops.

A recent report from a panel of national experts convened by the Institute of Medicine urged states not to use DNR orders for this purpose, because they reflect preferences about end-of-life planning "more than an accurate estimate of survival."

The Florida plan also calls for intensive care unit patients and those using ventilators to be reassessed after 48 to 72 hours.

Those whose chances of survival have significantly worsened would be taken off the machines or discharged from critical care to make way for others who may have a better chance of survival. If needed, they would be given palliative care to keep them comfortable.

One goal of Florida's plan is to "reduce or eliminate" the legal liability of health care workers who, in good faith, deny or withdraw treatment from some patients in an emergency. The plan includes sample executive orders that the governor could issue to shield workers and authorize hospitals to implement the guidelines.

The draft document also outlines how the health care system should stretch critical resources before moving to ration care.

The guidelines suggest reusing supplies, canceling surgeries that are not absolutely necessary, training staff to perform additional tasks and drawing on stockpiles. The general public's responsibilities include treating certain sick family members at home and monitoring public health messages.

Florida's draft guidelines aim to provide the "greatest good for the greatest number" when doing the best for all patients is no longer possible.

That goal needs to be balanced with an effort to distribute scarce resources in the least discriminatory way, said professor Ken Goodman, who directs the University of Miami bioethics program and the Florida Bioethics Network.

"Among the ways we can do that is to somehow take the evidence about what we think works and bolt it to the values that I think are uncontroversially shared: Namely, life is good, suffering is bad."

He said that methods included in the draft are still imperfect: "It's a very difficult problem to figure out how the world of science can help ensure that our strategies for allocating resources are fair and effective."

Viamonte Ros will have final approval authority and the plan will remain voluntary and subject to review, according to Doc Kokol, the health department's information officer.

The Florida health department's original goal was to have a final draft of the plan ready by December.

But with public health workers scrambling to cope with other aspects of the H1N1 pandemic, that is now unlikely, state officials said.

"People would like to have that policy," said Goodman, who chaired an ethics meeting on these issues at Jackson Memorial Hospital in Miami last week. He said that staff at the hospital have drawn up their own draft plan to cope with a potential surge of patients needing care. Florida plans to accept public input after the guidelines are revised by health officials. Kokol wrote in an e-mail that that "will likely include regional meetings for public input as well as electronic receipt of comments."

In many states, that type of input has been largely absent. Groups of doctors, lawyers and ethicists have hammered out the plans with little engagement with the public or with groups that represent children, the elderly and those with chronic illnesses or disabilities.

When Utah tested a similar plan in late August, the drill revealed difficulties that Florida clinicians and patients are likely to encounter.

Utah family physician Pete DeWeerd had to tell a mock patient's mother that her 7-year-old daughter, who had cerebral palsy and was suffering from the flu, would be turned away from the hospital and likely die.

"I don't like to tell you this," he said he told her, "it feels unfair, but our list is our list is our list." He added: "It was awful. You get a huge lump in your throat."

Dr. Tom Kurrus, medical director of St. Mark's Hospital in Salt Lake City, called it "emotionally draining" when mock patients and family members yelled, screamed and took issue with who was denied treatment.

"The major weakness in our preparedness had to do with security," he said.

Kurrus said that although the exercise was covered widely in Utah's media, the public isn't aware that the disaster plans call for rationing.

"Even with the scenarios played out and the discussions entertained, they still don't understand," he said. "It's, 'Why can't I get into the hospital, why can't grandma get put on a respirator?'"

Goodman, the University of Miami ethicist, said open conversation about the complex, value-laden decisions that will determine who receives treatment in the most extreme circumstances is crucial, and that hospital, state or federal guidelines should always be subject to revision.

"This should be an ongoing process that includes new evidence as it becomes available and that includes, in an open society, the participation of citizens," he said.


ahrcanum said...

In preparing for the worst, sometime the worst of humanity comes out having to make horrible decisions on who lives and dies. Kind of like the health care reform bill, eh?

Anonymous said...

I was at the MountainStar hospital's drill in Utah. It was a SCARY. It was great practice for the hospitals but I don't think that the public understands what could happen if it were a real senerio.