Viewpoint: Let triage panels buffer clinicians from life-or-death ventilator decisions

Creating triage committees, responsible for allocating ventilators in hospitals facing a shortage, can help shield clinicians from having to make those distressing decisions, three clinicians from Harvard Medical School in Boston and Boston Children's Hospital argue.

In a perspective article published March 23 in The New England Journal of Medicine, the three clinicians wrote that it is likely the U.S. will likely face a ventilator shortage during the COVID-19 pandemic. Acute care hospitals in the U.S. have about 62,000 full-function ventilators and about 98,000 basic ventilators and 8,900 in the national stockpile. Depending on how successful social distancing and isolation measures are, the number of patients needing ventilation could range between 1.4 and 31 patients per ventilator during the pandemic.

Several states, particularly the hardest hit, have been planning for a shortage. New York recently allowed hospitals to use one ventilator for two patients if needed. The federal government has been exploring deals with private companies for ventilator production.

U.S. clinicians soon may have to withdraw ventilator support from one patient to give it to another who is more likely to survive and respond to treatment. Removing a ventilator from a patient who needs it means the patient will likely die within minutes, making support decisions truly life-or-death, the authors wrote.

And "the angst that clinicians may experience when asked to withdraw ventilators for reasons not related to the welfare of their patients should not be underestimated — it may lead to debilitating and disabling distress for some clinicians," they wrote.

Instituting a triage committee of volunteers who are respected clinicians and leaders in the medical community can help lift the burden of these tragic decisions from a clinician's shoulders. The committee should have the flexibility to consider factors unique to a given situation, the authors said.

"As circumstances change and the availability of ventilators increases or decreases, the committee can adjust its rationing criteria to produce the best outcomes," the authors wrote.

The committee should also take on the role of communicating with family members and loved ones when the decision is made to take a patient off a ventilator, they said. This will ensure the message is clear and accurate and help prevent misunderstandings.

"Creation and use of triage committees, informed by experience in the current pandemic and prior written recommendations, can help mitigate the enormous emotional, spiritual, and existential burden to which caregivers may be exposed," the authors said.

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