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After the 2009 H1N1 flu pandemic, a group led by Johns Hopkins University convened meetings of residents in 15 hotel ballrooms across Maryland to answer a terrible question: If there were another pandemic and hospitals were overwhelmed, who would get saved?
The responses now serve as the backbone of discussions that could determine how the most crucial weapon in the arsenal against the coronavirus — ventilators — are allocated if demand exceeds supply.
Ethicists, doctors and state leaders are working on the final plan to present to Gov. Larry Hogan for approval. It will rely on that public input, which emphasized treating those who are likely to survive the disease caused by the pandemic and also likely to be healthy enough to survive longer term.
So far, such a plan hasn’t been needed in the United States, though doctors in New York are beginning to report shortages and doctors and hospitals in Italy and Spain face such tough choices daily. And the coronavirus, which can cause severe respiratory problems, is quickly cutting a nasty swath here, with tens of thousands of Americans sickened, including hundreds of Marylanders.
Hogan said in a tweet Thursday that “this battle is going to be much harder, take much longer, and be much worse than almost anyone comprehends.” Already more than 220 Marylanders have been hospitalized with COVID-19, the disease caused by the coronavirus, though officials haven’t said how many needed ventilators.
U.S. researchers have estimated that the need for ventilators could be many times the estimated 135,000 available nationwide.
“No one wants to use the plan, but we have to have the plan.”
Ruth Faden, founder of the Hopkins Berman Institute of Bioethics
“No one wants to use the plan, but we have to have the plan,” said Ruth Faden, founder of the Hopkins Berman Institute of Bioethics. She took part in the community meetings held in the years after the 2009 flu pandemic.
“Although we dodged a bullet in that case," Faden said, "there was not an expectation we would never face this again.”
The H1N1 pandemic a decade ago was tamped down through mass vaccination and wasn’t as deadly as feared. Today, a vaccine for the coronavirus is a year to 18 months away, federal officials say.
Leaders in medicine and ethics do not want to leave doctors and others on the front lines to make life-or-death decisions about who gets a ventilator on the fly.
Almost every state now has or is formulating a triage plan based on guidance from the U.S. Centers for Disease Control and Prevention and research from the National Academy of Sciences and other sources. Few states besides Maryland included such community participation in the process.
The state’s final plan is still being written by doctors, ethicists, disaster planners and state officials from across Maryland. It’s expected to be completed in the coming days. The document would need approval from Hogan, and he would have to make the order for hospitals to begin rationing equipment.
Hogan’s Maryland Surge Task Force reports there are approximately 1,040 ventilators available in the state. The group is taking a more official inventory of ventilators available in all hospitals and health facilities statewide — and figuring out how many more may be needed.
Officials in New York, now a center of the pandemic in the United States, have said they will need thousands more than are likely to be available. Federal officials have sounded a different note, saying there is not a shortage yet, though President Donald Trump on Friday lashed out at General Motors and signed an order aimed at compelling the company to prioritize the production of ventilators.
In Maryland, "We are actively working with FEMA and the federal administration to acquire more ventilators as needed,” said Charles Gischlar, a spokesman for the state health department.
The Maryland Emergency Management Agency already has asked FEMA for 1,096 more ventilators to supplement what the state has, according to a letter that members of the state’s congressional delegation sent supporting the request.
Many states besides New York are already scrambling to locate ventilators to avoid painful decisions about rationing. Some may be newly manufactured and some may come from the national stockpile. Ventilators could be passed along from one state to the next, depending on which is experiencing a surge of patients.
The competition among states has raised concerns about bidding up the price for the machines, the most sophisticated of which normally cost up to $50,000. Hospitals and manufacturers say hospitals may be able to use far simpler and cheaper versions that cost less than $5,000, and scientists also are exploring ways to produce them for even less.
The Trump administration also is considering a plan to order in bulk, which would also lower the cost. Until then, states are doing their own equipment searches — and planning to ration — in the absence of an overarching federal plan, said Diane Hoffmann, professor of health law at the University of Maryland’s Carey School of Law in Baltimore.
Hoffmann is also director of the Maryland Health Care Ethics Committee Network, composed of representatives from hospital ethics committees. The network plans to help communicate any plans for rationing ventilators to front-line medical workers, as well as the public.
She said the work already done gaining public input gives Maryland a “leg up” in the process of gaining public acceptance for the plan once it’s finished and officials begin a public education effort.
The public needs to know there is a rationing plan so the process isn’t a surprise if they or a family member should need a ventilator and they are scarce, Hoffmann said.
“We have to get the word out," she said. “This process is ethically fraught. Decisions are still going to be hard. We’re talking about taking people who are alive but couldn’t live without a ventilator.”
COVID-19 is a respiratory disease and is mild to moderate in 80 percent of cases. Serious cases could include breathing problems that require ventilators to supply oxygen to the lungs while the body heals.
The community groups years ago debated different allocation systems, rejecting a lottery or first-come, first-served process in favor of first treating those both able to survive COVID-19 and live for at least a year after. The groups also wanted to account for existing inequities such as the higher rates of chronic disease in poor, black neighborhoods because that’s often due to lack of access to care. How the allocations would meet these thresholds isn’t decided but could be a point system.
Simplistically, this would mean a young, otherwise healthy person receives a ventilator instead of an older person suffering from other health problems. But choices are rarely so simple. With the proposed scoring, a high-income, middle-aged white person with no underlying health issues could get a score similar to a low-income, middle-aged black person with high blood pressure because the high blood pressure could be controlled.
If either had end-stage heart disease or advanced cancer, the person would have a higher score. The lower score gets the ventilator, and in a tie, other factors could be considered such as advanced age.
The process of gaining public input included geographic, racial and economic diversity, said Anita Tarzian, an ethics network member and associate professor in the University of Maryland School of Nursing. She did not take part in the panels but reviewed the findings as part of an advisory group working to develop the final plan.
She said the process was tough because there was no pandemic occurring at the time and participants had to imagine something “out of a movie” and then decide who should get care.
“It’s tricky because no matter what you do or how careful you are, you never get 100 percent saying which approach to use,” Tarzian said.
“Nothing is perfect, and the tendency is to say, ‘Let’s make more ventilators and make more staff appear’ and be prepared with all their equipment needs met," she said. “But we don’t have that magic wand. In reality, we will have a triage mode. We’ll have a plan that does a good job at trying to be fair.”
She said now is the time to get details in place, inform the public and even run practice drills for the worst possible scenarios. Tarzian said this means the medical community and state “can’t be distracted” by questions about where resources will come from. They need to look for extra tests, masks and ventilators but plan for not getting all they need.
State leaders have moved aggressively to try to keep people out of the hospitals to begin with. They’ve shut down nonessential services and businesses and closed schools to keep people apart and slow the rate of infection.
Hogan has also called for expanding capacity, making 6,000 hospital beds available for a surge. Officials have not said how many of those must be new beds or instead could be existing beds freed up as elective surgeries and other care are postponed. They would come in part from adding new beds inside hospitals, as well as from new hospitals being set up inside a Baltimore hotel and the city’s convention center.
“Maryland hospitals have done, and are doing, exhaustive preparation and are adapting to changing circumstances,” said Bob Atlas, president of the Maryland Hospital Association. "Hospitals are collaborating with state and local partners to make sure everyone gets the medical care they need, both COVID-19 and other patients.
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“Today hospitals are seeing low volumes as [some] care is being deferred,” he said. “At the same time, hospitals are readying for the expected surge. It’s important to note, not all COVID-19 patients will need a ventilator, an ICU bed or even hospital treatment.”
The hospitals have set up a process to make sure resources such as ventilators, personal protective equipment and even staff will be where they are needed, said Dr. David Marcozzi, who leads COVID-19 preparedness for the University of Maryland Medical System’s 13 hospitals.
Keeping people healthy is key to avoiding rationing care, he said.
The state has been publicizing the need for distancing and hand-washing, and it is seeking more testing so those who are infected can be kept apart from healthy people, Marcozzi said.
If all else fails, Marcozzi said, the plan to allocate ventilators will be ethically based and transparent.