Who gets to live? How doctors make impossible decisions as COVID-19 surges

The word “triage” stems from the French trier, which means “to sort.” The idea was popularized in the late 1700s during the French Revolution, when Napoleon Bonaparte’s campaign into Egypt and Syria led to a large number of wounded.

A French military surgeon, Dominique Jean Larrey, came up with the idea of sorting casualties for care based on the severity of the soldiers’ wounds, regardless of their rank. (Larrey even treated enemy soldiers—earning him a reputation that spurred the Prussian calvary to save his life when he was captured.)

Two centuries later, the goal of triage in emergency medicine remains the same: to provide the greatest amount of good for the greatest number of individuals. But as large parts of the United States face soaring numbers of coronavirus cases, medical staff are grappling with how to stay true to this principle.

Eighteen states are currently in what’s considered the “red zone” by the White House coronavirus task force, meaning they had more than 100 new cases per 100,000 people last week. Additionally, 14 states currently have more than 70 percent of their ICU capacity occupied.

Texas has stopped reporting which of its hospitals have exceeded their capacity for COVID-19 patients. But signs point to a caseload crisis: One children’s hospital in Houston is now admitting adult patients, and the U.S. military is sending medical staff to help support the state’s beleaguered doctors. This week, a county in Texas announced its COVID-19 unit was full, and transfers to other overwhelmed hospitals were becoming impossible. “Our doctors are going to have to decide who receives treatment, and who is sent home to die by their loved ones,” the Starr County Memorial Hospital said in a news release.

In Arizona, intensive care unit beds are 90 percent full, morgues have run out of space, and counties are ordering refrigerated trucks to store additional bodies. In the midst of this surge, Arizona is the first state to enact crisis care standards—protocols for when healthcare systems are so overwhelmed by a catastrophic event that they can’t provide normal care to patients.

Such dire straits raise important questions: how best to care for patients when there aren’t enough resources to go around—and who has to make those triage decisions.

The balancing act

Triage is fundamentally about balancing consequences, says Nathaniel Raymond, lecturer at Jackson Institute of Global Affairs at Yale University, where he teaches disaster response. One of the terrible realities of triage, he says, is that decisions are zero sum: Treating one person usually means not treating another. So it’s important that before an emergency, medical systems have agreed on how these decisions will be made fairly, and have communicated those guidelines transparently both to health care providers and the public.

The first principle of triage is to make ethical decisions. Raymond calls it a “Star Trek problem, between Kirk and Spock,” referring to the 1982 movie in which the starship officers had to choose between serving “the needs of the many” versus the needs of one person.

“Ethics in any setting, but especially triage, exist for one purpose: To identify the conflicts,” Raymond says. “Ethics will not eliminate tragedy. In some cases, the application of ethics will contribute to it.”

During the pandemic, medical staff have tried first to rapidly expand hospital capacity. At the Veteran’s Affairs Ann Arbor Healthcare System in Michigan, this meant building walls, piping, and ductwork to make negative pressure COVID-19 wards, where air is captured to try to avoid viral spread. But pulmonary care physician Hallie Prescott says that wasn’t enough. To work well, triage plans must be vetted and practiced in advance. Otherwise clinical decision-makers will be put under a huge amount of stress.

As cases began materializing in Michigan in March, Prescott was part of the triage team responsible for allocating scarce resources if the need arose. The team ran through mock scenarios such as running out of ventilators, and prepared the system to activate crisis standards of care. Fortunately, they haven’t yet had to do so.

“Having to tell a family that due to the circumstances, you’re not able to offer certain treatments—the thought of having those conversations is a strong motivation to do everything possible to avoid shortages in the first place,” she says.

Planning ahead also helps hospitals innovate. As COVID-19 hit New York, Kathy Hibbert, the director of medical intensive care units at Massachusetts General Hospital in Boston, helped set up a highly unusual system: MGH and other regional hospitals worked together to transfer not only sick patients, but also resources such as ventilators between competing hospitals based on their capacity and need. During the peak of Boston’s surge, that helped MGH cope with 500 patients in their ICU. This kind of cooperation between competing institutions is rare.

“To my knowledge, it’s never happened before,” Hibbert says. She recommends that doctors in other hard-hit areas start contacting their counterparts now, “even if they’re not yet in a capacity crunch, so lines of communication are open.”

A plan for the darkest moments

Prescott knew there was a chance that her hospital in Michigan might be overwhelmed with COVID-19 patients—and then staff would need to know how to decide who to treat first.

In the U.S., the National Association of EMS physicians incorporated widely accepted best practices into the SALT Mass Casualty Triage Algorithm in 2006. This method sorts patients into three categories based on the severity of their condition, assesses what patients in each category need, and then provides lifesaving interventions. To help eliminate bias, Prescott’s hospital decided that patients would receive a score to place them in one of three categories, but within each category, they would be treated in random lottery order. She says the triage team tried to be as specific as possible about the rules and their intricacies, “so everyone can see they’ve been fairly applied.”

Even with plans in place, though, the moral distress of choosing between patients exacts a mental toll on physicians, many of whom are already struggling with burnout during this extended crisis. Even before the pandemic, the United States had a nursing shortage—to say nothing of the lack of respiratory therapists, physical therapists, and doctors.

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“The scarcest resource is not stuff, the scarcest resource is actually people,” says Julia Lynch, a University of Pennsylvania professor of political science researching health policy.

This spring, Lynch examined 68 triage guidance documents around the country; only 37 addressed staffing shortages. Medical professionals in Texas, Michigan, Pennsylvania, and Massachusetts told National Geographic that such shortages were currently limiting their abilities to provide care, and the U.S. Centers for Disease Control and Prevention anticipate healthcare facilities may experience staffing shortages during the pandemic.

“It’s easier to produce a ventilator than a skilled ICU nurse,” says Deena Kelly Costa, assistant professor in the School of Nursing at the University of Michigan. “It takes two to four years to finish your degree, at least six months of experience to be proficient. That’s a long time.”

To make matters worse, hundreds of foreign doctors have reportedly had their visas put on hold by the Trump Administration, despite an exemption that’s supposed to allow their entry. “That hits our most under-resourced hospitals the hardest, as they rely on people with visas to bring doctors to underserved areas,” Hibbert says.

How to weigh a life

This inequality in resources directly affects patient care. As the U.S. faces an escalating curve of COVID-19 cases, Raymond says it’s essential to consider how “decades of compounded racial disparity contribute to vulnerability.”

“It’s really important to recognize we are rationing medical care all the time—in the US, we fundamentally ration it by ability to pay,” says Lynch. She believes that long-standing disparities in access to healthcare have likely worsened the pandemic, because lacking regular and appropriate healthcare has left many Americans with pre-existing conditions that put them at risk for severe cases of COVID-19.

In Arizona, for example, triage decisions involve scoring each patient based on a medical assessment that includes considering the patient’s likelihood of dying within one and five years. While this decision is hypothetically made without regard to race or ethnicity, people of color are more likely to have conditions such as heart disease that limit their life expectancy.

Like many health researchers, Lynch has been discouraged watching the ways coronavirus has deepened structural inequities. “I thought surely if other people knew inequality was causing people to die, they would take it more seriously,” Lynch says. She hopes coronavirus is finally demonstrating “how awful the consequences of severe inequality are.”

In the face of such inequality, Raymond says coordinated federal leadership is especially important—and currently lacking. He worries about conflicting triage standards, adding “we’ve already seen this with testing”—for example, the preferential allocation of scarce tests to professional athletes. Raymond believes that a national rule-based system with transparent standards is more likely to treat all patients fairly, ensuring care doesn’t just go to the richest or the most well-connected.

In the midst of America’s crisis, doctors working in low-resource settings can offer valuable lessons, says Tammam Aloudat, a Syrian doctor who is deputy executive director of the Access Campaign at the medical aid nonprofit Doctors Without Borders/Médecins Sans Frontières (MSF).

"My last mission was in a pediatric hospital in the south of Niger, where we had 700 beds and almost all patients had severe malnutrition or malaria, and quite high mortality,” Aloudat says. “Doctors on the ground needed to make judgments that lead to some surviving and others not, depending on their situation and the available care—and that is an extremely difficult task and a very traumatic one.”

He suggests hospital administrations should consult doctors and the community to help providers make fair decisions. Medical professionals should also discuss their patients together on a regular basis and make collective decisions. When trying to decide whether to remove a COVID-19 patient who’s not improving from a much-needed ventilator, having multiple opinions can help distribute the moral and mental burden of removing care.

While Aloudat agrees with Raymond on the importance of having a rule-based system, he emphasizes the importance of not being too prescriptive. Rigid rules can become overly restrictive when applied to ongoing pandemics because it’s not always clear which patients will deteriorate or improve, he says: “People on the ground have the best knowledge of their patients.”

Aloudat suggests adopting a justice-guided but utilitarian approach. His example: During the 2015 Ebola outbreak in West Africa, testing capacity lagged, but clinicians had to decide which patients would be admitted to the hospital where they would certainly be exposed if they weren’t already ill. MSF’s solution was to develop a new ward, where people waiting for test results could be quarantined from the community.

“Previous generations of medics didn’t have to do this balancing in the U.S.,” Aloudat says. But now, every decision seems to come with a cost: “In a low-resource setting, on all levels of care there’s always more demand than supply. One has to choose.”