California hospitals are preparing the ethical protocol to guide who may get lifesaving care as providers struggle to meet the growing demand sparked by the latest COVID-19 surge.
While hospitals have yet to implement crisis-level care rationing, the steady increase of 40,000 new COVID-19 cases a day continues to threaten hospital capacity. Space and staff are stretched, particularly in Southern California, as the state endures a surge 4 to 5 times the size of the spike in summer.
"The fact that we're not in crisis level in this stage speaks tremendously to the awesome work hospitals are doing to stretch resources," Christopher Meyers, professor emeritus of philosophy and director of the CSU Bakersfield Kegley Institute of Ethics, said during a press conference Thursday morning. "A hospital administrator told me just a tiny bit more pressure and we will cross that threshold."
Hospitals are operating under the contingency standard of care as they convert non-traditional patient care spaces and withhold supplies like oxygen to patients who would normally receive it as a precautionary measure, but would be able to recover without it.
Crisis mode, which is declared by individual hospitals when they deem they can't uphold a professional standard of care, would trigger a triage team and an assessment to determine who gets care when there isn't enough staff, supplies and lifesaving equipment to treat everyone. Some hospitals will use a quantitative threshold related to beds or staffing to cross from contingency to crisis while others use a mix of numerical and qualitative criteria.
In that scenario, decision-making authority would move from the physicians and families to a team of experts who will, in part, use a modified version of the sequential organ failure assessment to determine who is most likely to survive treatment and discharge, Meyers said. SOFA scores consider underlying conditions, prior health problems, blood pressure levels and other metrics used to gauge the strength of a patient's organs.
No patient should be categorically excluded based on things like age or "societal value," authorities said.
"The whole purpose of having a thoughtful ethics-based process is to avoid bias and discrimination," said Carmela Coyle, CEO of the California Hospital Association. "What you do in life does not factor into these scores."
Given that COVID-19 disproportionately impacts people of color and the economically disadvantaged, the assessment was tweaked so the scores didn't negatively impact those communities, officials said.
"It is not about the individual, it is about how to fairly apply the principles to a population so everyone is treated equitably," said Carol Bayley, former vice president of philosophy and director of justice education at Dignity Health.
If a patient is told they will not receive lifesaving treatment, providers start palliative care. Families can review and appeal those decisions, which will be taken up by a separate review council made up of hospital administrators, legal representation and ethics committee chairs.
"We're hoping we don't have to go there," Meyers said.
About 12% of those who test positive for COVID-19 will need hospital care, which at this point translates to 4,000 to 5,000 additional hospitalizations each day, state authorities said. There are currently 23,000 patients being treated for COVID-19 in California hospitals, the majority of which are in Southern California.
About half of the intensive care beds in the southern part of the state are occupied by COVID-19 patients, compared to around 10% in Northern California where some early prevention strategies may have helped curb the spread, officials said.
"Los Angeles, San Diego, Imperial County and the San Joaquin Valley are all places where we have ICU capacity that is not only stretched but well into surge capacity," said Coyle, adding that hospitals are working together to transfer patients where space, supplies and staffing are available.
Thus, social distancing, wearing masks and washing hands are paramount, authorities said, highlighting that mitigation practices need to continue as people start to get vaccinated. California may be on the cusp of the peak of this surge, Coyle said.
"Many of us are very concerned that the circumstances in the southern part of the state are quite dire," she said.
