Inside the outbreak: Disaster medicine

Reports that hospitals in Italy have had to ration medical care amid the worst COVID-19 outbreak in Europe have people around the world wondering: What if we run out of doctors or medicine? Who gets cared for, who is left to die, and who decides?

The rumors out of Italy proved unfounded. The mayor of one town in the region of Lombardy told The New York Times a lack of equipment “forced the doctors to decide not to intubate some very old patients,” but a physician in that city disputed the claim and said the situation had not reached that level. Lombardy’s resources are stretched thin, but the central Italian government is providing needed backup, the Journal of the American Medical Association reported.

Still, the questions raised by the worries in Italy deserve attention sooner rather than later, according to medical ethicists. Preparing for the scarcity of medical resources ahead of time will help healthcare workers prevent another situation like Hurricane Katrina in 2005, when doctors reportedly resorted to euthanizing some patients to free up already limited resources.

“I think they made bad decisions in New Orleans because they hadn’t thought about it ahead of time,” said Daniel Sulmasy, acting director of Georgetown University’s Kennedy Institute of Ethics.

To that end, one Italian medical group released guidelines to help guide doctors through decisions related to rationing treatment. The Italian College of Anesthesia, Analgesia, Resuscitation, and Intensive Care (SIAARTI) said it wanted to relieve the doctors from the responsibility of some of the “emotionally burdensome” choices they may have to make.

The document, released 10 days ago, outlines procedures for “disaster medicine,” with decision-making processes similar to those used by soldiers on a body-littered battlefield. The writers included a 15-point list of recommendations for doctors faced with an “imbalance between needs and available resources” as they attempt to guarantee treatment for patients with the best chance of recovery. At one point, the writers suggest “it may be necessary to place an age limit on entry into intensive care.”

Ryan Nash, director of the Ohio State University Center for Bioethics and Medical Humanities, said the decision of soldiers to save a wounded comrade requires close assessments of individual cases, not sweeping utilitarian rules like age limits. But he recognized the shortage of necessary equipment could still lead to difficult decisions.

“In the case of pandemic, you have to deal with the reality of the resources that you have,” Nash said. “If you have the scenario of no ventilators … you can ask, which of my patients on a ventilator is not going to survive?”

Although age could play a role in the decision, he said officials should base the final call on the situation and “best clinical judgment,” not an age cutoff.

Sulmasy said the SIAARTI guidelines address that complexity by including other criteria such as the presence of other illnesses and the previously expressed wills of the patients.

“Age is certainly a criterion, but the overall criterion has to be prognosis … whether the person is going to benefit from being on the ventilator or not,” he said. “They’re only saying to do this if nothing else works.”

The document also advises doctors to seek a second opinion and, when possible, to make decisions with the patient and his or her family. Sulmasy said the document from SIAARTI isn’t “a statement of what they are doing. It’s a statement of what they might have to do if they reach the point of being totally overwhelmed.”

Meanwhile, the United States is reacting to its own medical emergency through social distancing. State officials encourage compliance with the cautionary measures as one way for people to care for the elderly and medically vulnerable and avoid overwhelming hospitals in the country. Although young people can contract COVID-19 with minimal side effects, they could spread the disease to the elderly, who are at a higher risk of death. When Washington Gov. Jay Inslee banned gatherings of over 250 people on Wednesday, he gave no specific legal penalties for breaking the ban, but added, “You might be killing your grandfather if you don’t do it.”

Intentional deaths

Recent data from Belgium shows the number of euthanasia deaths in the country has increased at alarming rates since the early 2000s, putting the country’s elderly and disabled at risk of unnecessary early deaths. According to the 2019 report, the number of euthanasia cases hit 2,655 last year, a 12.6 percent increase from 2018. In 2003, the country recorded 235 acts of euthanasia.

The Australian Care Alliance, which opposes assisted suicide, analyzed the Belgian data and found almost 17 percent of the country’s euthanasia deaths in 2019 involved people who did not expect to die soon. Before 2019, Belgian doctors had euthanized three children with disabilities or medical conditions, and they added a fourth last year. Patients with mental disorders such as dementia or depression accounted for 50 of the euthanasia deaths in the country last year.

In January, a jury acquitted three doctors on charges of performing unlawful euthanasia on a troubled 38-year-old woman. The case—the country’s first public prosecution of “mercy killing”—did not deter other doctors from the practice. The numbers show Belgian providers have become more lax in their use of assisted suicide. —L.H.

Across the nation

Tennessee: The state House Health Committee approved a bill on Tuesday that would require people prescribing abortion-inducing drugs to inform women that the effects of the drug can be reversed. The bill is now heading to the full House for a vote.

Ohio: Federal judges on Wednesday heard oral arguments about a state law that would make it a fourth-degree felony for doctors to perform abortions because the baby has a Down syndrome diagnosis.

Utah: On Thursday, the state legislature approved a measure that would protect most unborn babies from abortion if the U.S. Supreme Court overturned Roe v. Wade. Two days earlier, an ultrasound requirement bill passed in the state Senate even after all six female senators walked out in protest.

Oklahoma: By 36-8 vote, the state Senate approved a bill that would protect babies from abortion after they have a detectable heartbeat or brain waves—usually around six weeks of gestation. The bill still needs approval from the House. —L.H.

Double-double Valentine

A couple in the U.K. beat 32 million–to-1 odds when the mother gave birth to her second set of Valentine’s Day twins. Identical sisters Ella and Ava were due April 7, but concerns about the pregnancy led doctors to deliver them by emergency cesarean section on Feb. 14, The Sun reported. Their older sisters, unidentical twins Lola and Lexie, celebrated their fifth birthday that same day.

The newborns weighed a little more than 3 pounds at delivery. “The first time we could pick them up and cuddle them was three days later in the intensive care unit,” said their mother, Joanna Gregory. “They would not have survived if it hadn’t been for the staff at both hospitals—they saved their lives. They are unbelievable, and I can’t thank them enough.”

Babies born at about 32 weeks of gestation can generally survive thanks to today’s advanced medical technology. —L.H.