What Should Triage Doctors Do When Patients Can’t Breathe?

There’s a way to balance ethics and reason when we decide who lives and who dies

In March, David Lat, the founding editor of the website Above the Law, spent six days on a ventilator in critical condition in the intensive care unit at New York University Langone medical center. He and many others infected with COVID-19 wouldn’t be alive today without a ventilator.

How do triage doctors determine who gets a lifesaving machine and who doesn’t, if supply doesn’t meet demand? I researched this topic when I realized I could be hospitalized myself, if I became infected, considering my respiratory and immune system issues.

What I learned was sensible but I felt it missed the mark.

The state of NY, researchers at Johns Hopkins University, and other entities developed protocols to guide hospitals in how they decide which patients receive ventilators and which don’t, if a pandemic like COVID-19 increases the gap between demand and supply.

Ultimately, triage doctors are making decisions regarding who lives and who dies. My empathy for the people who may be put in this position flows like a raging river.

The majority of protocols stipulate that triage teams at hospitals will not account for race, gender, sexual preference, socio-economic status, and other discriminatory factors when determining who receives a ventilator.

Ethicists tend to favor a lottery for rationing ventilators, which is the most equitable method for allocating life-saving medical equipment, but most protocols guide decision-making based on calculations of a patient’s short-term likelihood of survival of the acute medical episode—not whether a patient may survive an illness or disease in the long term.

Whether you agree with life and death decisions being made by life expectancy, these guidelines beg a question that I believe few, if any, organizations have answered well enough.

How do hospitals implement a ventilator rationing protocol that balances moral principles with logical reasoning?

What if we considered a hybrid model for rationing ventilators in a time of crisis? What if there were a protocol that aimed to find an equilibrium between what’s right and what makes sense?

My moderate proposal:

• Any patient under 85 years old is placed in a lottery, which, again, is the most moral and ethical method in itself.
• Anyone 85 or older is not provided a ventilator but, if doctors determine the patient will not survive, the hospital offers the patient care, monitoring, and spiritual support, which they can accept or decline.
• As state health experts acquire and validate new intelligence about the virus and its spread, the governor advises hospitals to adjust the age threshold by, as an example, two or three years at a time according to the direction of the findings. For example, if the infection rate in a state continues to climb rapidly and immediate efforts to increase the ventilator supply aren’t sufficient, the protocol guides triage teams to reduce the cut-off age to 83 or 82, and so on.
• If and when the governor determines that the gap between ventilator supply and demand is diminishing in their state, the protocol advises triage doctors to increase the age threshold accordingly.

I don’t wish upon anyone the responsibility of determining the appropriate initial age threshold for such a protocol but a hybrid approach provides balance between morality and reality, and in my own centrist philosophy, an outcome built on compromise is an outcome worth fighting for.