Welcome to 2021. Stuff’s about to get real.
As bad as December was for new COVID-19 infections, January is almost certain to be worse, and the vaccination program that kicked into action with its first U.S. inoculations Dec. 14 won’t turn the tide anytime soon.
If every American who needs and wants a vaccination is to be inoculated by July, vaccine specialist Dr. Carlos del Rio told CNBC last week, we’ll need to give shots to 3 million people a day — which is approximately the number we’ve managed to inoculate in about three weeks.
At least health officials, local and national, have had the sense to deliver the initial inoculations to those we need to see protected most and first: front-line health care workers, including, most crucially, nurses.
In other words, those with the greatest value and usefulness at this bizarre time are first in line.
But another line may soon be forming at another door: Those already infected with the virus and in dire need of lifesaving care. If models of COVID-19’s spread hold true — and so far, in most instances, they have — that line will be longer than hospitals can possibly accommodate.
Who gets a bed and who doesn’t?
That will not be determined in the same manner as vaccination distribution — by importance to the delivery of health care, or vulnerability, or essential worker status, nor for the sustainment of commerce, or because of leadership, wealth or societal stature — but rather by what’s known as crisis standards of care, the policy that guides a hospital’s admission priorities when it is overwhelmed with critical patients. Crisis standards of care typically matter only on battlefields or in tsunami aftermaths, when the dying vastly outnumber the doctors capable of saving them.
In other words, it’s all about odds of survival. You don’t devote time and effort to someone unlikely to make it at the expense of someone who can.
Yes, survivability is a factor in deciding who is included in this first round of vaccinations. Nursing homes and similar, congregant living facilities that have been hard hit by the virus have been among the earliest to receive inoculations. But, otherwise, the highest priority has been given to those we value most at this time.
The state released a vaccination plan last month that, after health care workers, gives next-in-line priority to first responders, including police and firefighters, teachers and others who work with children, and food and agricultural workers.
But crisis standards of care, or crisis triage, demands that doctors ignore every consideration but the most basic.
But who determines which factors make up the checklist? Age? Comorbidities such as diabetes or chronic respiratory disease? Hospitals typically create their checklists with committees that include experts from different areas within the field of medicine, including doctors, nurses, surgeons. They often also include medical ethicists.
In Kern County, those ethicists are Christopher Meyers, the former longtime director of the Kegley Institute of Ethics at Cal State Bakersfield, and Nate Olson, the institute's current associate director. Olson works with Bakersfield Memorial Hospital, Meyers with Kern Medical and Adventist Health. Other major local hospitals rely on in-house, systemwide ethicists but call Meyers to help with tough, urgent cases.
The ethical implications behind the development of crisis-scenario triage policies are as profound as any Meyers said he’s dealt with in his 30-year-plus career.
“Having to write a policy with a team of other really smart people that will dictate who lives and who dies is ultimately as deep of an ethical question” as one can face, he said.
Among the ethical challenges: Patients with the most comorbidities tend to come from disadvantaged minority communities.
And then there’s this: What happens to a hospital’s thoroughly vetted and parsed scoring model when a celebrity or mega-donor is wheeled through the door with severe breathing problems?
“How do we make sure that policy just doesn't get overridden for their sake?” Meyers said.
Every hospital in the country is now facing these issues, and most have similar triage protocols in place. Many also have an appeals committee that might hear from patients, or the families or doctors of those patients, that have been denied care. Meyers serves on three such appeals committees.
“We're supposed to look only at, was the model properly followed? We're not supposed to bring in their place in the community or anything like social-worth criteria. But, again, concerns about ethical lapses occurring somewhere along the way are real,” he said.
It may be too late for some of the least healthy patients who will fall ill in the coming weeks, but how long crisis triage protocols remain central in hospital decision-making is really up to Americans who’ve been hearing this CDC-approved guidance for months:
Wear a mask. Maintain social distancing. Avoid large gatherings.
“All of this is driven by us. Hospitals are doing everything they can. ... If we can ride it for two or three more months, and get people to take the vaccine, we're done, we're past it,” Meyers said. “People are back to work, the economy is thriving, we're spending money like crazy because it's pent up, sitting in our wallets. We’re waiting to fly somewhere and be with people we love.
“Or,” he said, “we can continue being stupid and spread this thing out for several more months.”
And, perhaps, lay our fate in the hands of a crisis triage committee that will decide if we live or die.