New policies on the fair allocation of ventilators must be established and implemented by hospitals and states in response to the impending threat of shortages during the coronavirus disease 2019 (COVID-19) pandemic, according to recommendations published in JAMA.

According to the authors, under ordinary circumstances, any patient in clinical need of mechanical ventilation can receive this treatment; however, this may not be possible during COVID-19 given shortages of ventilators have already occurred in Italy and may soon occur in the United States. Existing recommendations for the allocation of scarce intensive care unit (ICU) resources during a pandemic contain ethical flaws, such as the exclusion of large groups of patients with certain comorbidities. The objective of this study was to address these ethical concerns and provide a framework for making ethically appropriate decisions to make all patients eligible for access to critical care during COVID-19.

The authors reviewed existing professional society guidelines and state recommendations in which large groups of patients are excluded from access to ICUs when resources are scarce. These patient populations include but are not limited to patients with certain comorbidities such as severe heart failure, severe chronic lung disease, end-stage renal disease, and severe cognitive impairment. The authors explored the ethical flaws of excluding certain groups of patients from receiving access to ventilators and devised a list of recommendations for an improved allocation framework.

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Under the new allocation framework, all patients who meet medical indications for ICU ventilators under ordinary circumstances should be eligible to receive ventilation during COVID-19. Each patient would be assigned a priority score on a scale of 1 to 8, with a lower score indicating a higher likelihood of benefit from treatment. The priority score for each patient would be based on the likelihood of surviving to hospital discharge and the likelihood of achieving long-term survival based on whether there are comorbidities that may influence survival. Additionally, patients such as healthcare workers and first responders would also be given high priority since these individuals can potentially save the lives of others during the COVID-19 pandemic. 

The authors concluded that hospitals and states in the United States should urgently implement policies surrounding the fair allocation of ventilators and other scarce ICU resources to better support dying patients during the COVID-19 pandemic.

Reference

White DB, Lo B. A framework for rationing ventilators and critical care beds during the COVID-19 pandemic [published online March 27, 2020]. JAMA. doi:10.1001/jama.2020.5046