Medical ethicist Dr. Tia Powell on the guidance healthcare workers need.
As more and more patients with Covid-19 infiltrate hospitals, healthcare professionals are being forced to make split-second decisions on how to help them. And those decisions get harder when you throw ventilator shortages into the mix. I talked to Dr. Tia Powell, the director of the Montefiore Einstein Center for Bioethics, about some of these ethical dilemmas. She weighed in on what doctors are facing and what type of guidance might be coming.
Katie Couric: From the beginning of this pandemic, as soon as I found out that hospitals would be overcrowded, and that there weren’t enough ventilators for patients, I wondered about the ethical dilemma many healthcare providers would be facing. As the situation has gotten more dire, I’ve heard that if EMS workers can’t resuscitate you, you go straight to a makeshift morgue. Could you just start by telling us what kind of system is in place for medical professionals, when they literally have to make life and death decisions?
Dr. Tia Powell: I wish I had a better answer for you on that. There is a set of guidance, but it goes in phases and varies by state. In New York State, we have an official guidance document. We’re basically in phase one of that, which calls for getting more ventilators.
The first and best response is: “Let’s get more stuff and see what we can do better.” The governor has done actually a great job of increasing capacity more than I would ever have believed possible.
We keep teetering on the brink and I do think frontline clinicians are really worried about what to do: “Will we run out of ventilators? Or will we just run out of them for the day?” There is no real formal guidance that’s been released that tells doctors how to make these really difficult choices.
So absent of those guidelines, I guess doctors rely on their experience with critically ill patients. I know you’re an expert in end-of-life care. What kinds of things from their training and experience are helping them make these decisions? Because let’s be honest, yes, we want more ventilators, but there aren’t enough and there probably won’t be enough.
And of course, even when you get ventilators, you have to have people who can take care of patients on them. You can’t just solve it with money. A ventilator is actually quite tricky to operate. Even if we’re not there yet, people who have the responsibility for planning and setting up guidance really need to start thinking about it.
There are a couple of things I think are really important. And your listeners could really play a role in helping. I think a lot of families have put off difficult conversations with elders in their family who have chronic medical conditions. People need to have those difficult conversations and say: “What would you want?” For a lot of people, if you add Covid-19 to what they already have, you can say, almost with certainty, “This is not survivable.” And in that case, “Do you want to go to the hospital? Or do you want to be at home with your family?” If this is likely going to be the end for somebody, then making some of those decisions will help make that end peaceful and comfortable.
When people come to the hospital, doctors are trying quickly and carefully to make these decisions. They want to be able to give ventilators to people if they have them, but they also want patients to realize that Covid-19 is just a terrible illness, and the survival data for older people who get sick and need a ventilator — is terrible.
In the best of all possible worlds, people would have that conversation. It’s hard to be surrounded by your loved ones, given how contagious this illness is, but certainly preferable to leaving this earth all alone. I still think about these medical professionals. I was very discouraged when I heard that the New York State guidelines do not prioritize healthcare workers for ventilators. If the healthcare staff is so critically important right now, why is that the case?
It’s a really good question and a lot of reasonable people have debated this. I myself am quite ambivalent about it.
If you are sick enough to need a ventilator, what we’re trying to do is save your life, not get you back at work. If you’re sick enough to need a ventilator, you’re not going to be well enough to go back to work anytime soon. It may be six months before you’re on your feet again.
If you’re an older clinician, we’re really battling just to save your life. What a lot of people say is there are many people who are crucial. And if you’re going to prioritize all that group, you may not have ventilators. So it’s really a tricky set of issues. I think it would break the heart of every clinician to have somebody show up critically ill and not be able to give them the ventilator.
I can’t imagine making that decision. On the other hand, everyone says, if we don’t want this to get completely out of control, we have to make sure that we have health care workers that are taking care of patients.
I think what you really need to do is keep the healthcare workers from getting sick. What we really need to do is prioritize protective equipment for healthcare workers. I don’t think America was sufficiently prepared in the early stages of the epidemic.
There is no good answer to this. I don’t feel comfortable prioritizing all physicians. I think it’s a tough call. If you have a bunch of people and they’re all equally qualified, then maybe prioritize physicians. But you know, young adults who haven’t finished college, they have their whole life ahead of them. I would hate to say goodbye to 22-year-olds. And that’s the kind of awful situation that we could be in. Luckily, I don’t think we’re there yet.
And speaking of the New York state guidelines, I was talking to one physician, and they said that at one point, if you were on dialysis you wouldn’t get a ventilator. But are there any hard and fast kinds of guidelines — like if you have dementia and you’re over 85 — or are they more just kind of broad guidelines?
The New York state guidelines tried to set up a score based on how your organ systems are doing — so many points for kidneys, your liver, your heart, your lungs, and the other.
So that’s what most of the guidance looks like. In the U.S., they don’t set a hard limit on age. The New York marathon runs by my corner and I watch it every year and I am always blown away by the older people running. It’s not always about age it’s about what kind of functional status you have — all that kind of stuff can contribute to how likely you are to survive.
An individual doctor might evaluate a patient, but they aren’t going to always make the ultimate decision on if they get a ventilator or not. Correct?
Correct. If guidelines are implemented, there would be a separate team who would look at the data, who would create a score that suggests the probability of somebody surviving. So it would be a different triage officer — not the one taking care of you — who would make that decision.
We’ve seen so many things happen we never thought would happen, that we want both patients and clinicians to know that some things stay the same. The person at your bedside, your doctor and your nurse, they are still your advocate. They are still knocking themselves out to bring you through.
I think that would also prevent this terrible burden on a single physician from making that decision. I think a lot of physicians are going to have PTSD anyway, and to have to make these split-second life-or-death decisions on their own would be really too much to bear.
There is going to be an unbelievable impact once they stop and catch their breath. You’ve got a whole generation of clinicians who are incredibly traumatized. I think some will rightly feel that they did heroic work and others will really wonder, “Was that right? Did I get it right?” It is so hard to see what the right thing is to do, and that’s why I’d love to see more guidance. There’s going to be a lot of trauma for this generation of clinicians.
Are you seeing a lot of younger patients get this, or are those people with underlying conditions or comorbidities?
So that’s a really good question. And the data is still flowing in. In New York, the majority of people who are getting Covid-19 are younger than 50, and not all of them have underlying conditions. So if you look at who’s getting it, it’s a lot of young people and some of them are really sick and getting hospitalized. But there’s certainly plenty of people who don’t have symptoms or have mild symptoms.
There are plenty of young people who are really sick and whose lives are in peril. But if you look at who actually dies, the older people and the people with comorbidities are the ones that we are not saving. Covid-19 is such a heavy blow, that to stand up after, is really tough.
Are there medical ethicists such as yourself reaching out to other medical ethicists in states across the country to try to give some support if things do get worse and these decisions have to be made by medical professionals?
Medical ethicists are yammering away all day long. Those conversations are absolutely going on across the country.
I’ve been comparing notes and telling people in Illinois and wherever else, what we’re seeing in New York. And we’ve been trying to encourage people ahead of time, in places like Florida, “You really have to take the social distancing seriously.”
Have you ever in your lifetime witnessed anything like this?
I’m going to say I don’t believe any living physician has witnessed something like this. I am old enough that as a young physician I was training at the height of the AIDS epidemic. AIDS killed a lot of people over many, many years, but it never killed so many, so fast.
I think young clinicians coming up today will be shaped for the rest of their lives. They have seen so much death. They are really traumatized by trying to save people, trying to do resuscitation on people who are failing and losing. Some people do get better and get out and that’s great. We’ve definitely discharging people home to heal. But I think the amount of death, and the speed with which this illness has attacked our global population is just unprecedented.
Any other advice for people other than talk to your loved ones?
Stay safe. I think the best thing you can do is stay out of the hospital and take social distancing as seriously as you possibly can.
When people are frightened, there’s a tendency to sort of blame other people. I would love for people to avoid that. Everybody needs help and support. The incidents against Chinese people and Asian populations need to stop. Everybody needs support. Right now we are all up against the gun. I’d love to see more acts of kindness and support.
This interview was edited and condensed.
This originally appeared on Medium.com