A scarcity of life-saving resources during COVID-19 pandemic
Anticipated shortage of intensive care unit (ICU) beds and mechanical ventilators in the United States is urgent. Pandemic experts warn that healthcare providers and consumers aren’t ready — practically or emotionally — for the rationing of care in a worse-case COVID-19 scenario.
Broaching the topic of who will receive lifesaving care and who won’t in a pandemic is an understandable struggle. There is no good time for this conversation.
To ease the dialogue, I offer personal and professional advice. If infected with SARS-CoV2, my immunocompromised teenager and my elderly mother with lung cancer might each need a ventilator to survive. For 20 years, I have studied how crisis leadership, risk communication, and public engagement strengthen community resilience to disasters. And, in 2012-2014, colleagues and I convened over 300 Maryland residents into small groups to deliberate what community values ought to guide ventilator rationing during a health disaster. In 2018, we also explored public views in Texas.
Drop the math and humanize the problem: Experts use figures to discuss scarcity: the projected numbers of severely ill people versus the existing supply of ICU beds and ventilators. But, most people think in binary, human terms: the crisis will/won’t happen; it will/won’t affect me. If the public is to prepare for the grim prospect of rationed care, then officials should speak in immediate personal terms, and give things to do that increase safety and reduce helplessness: e.g., insulate vulnerable groups from infection; talk as a family about what constitutes a good death; discuss as a community how to endure painful circumstances that outpace our ability to control them.
Directly address people’s fairness concerns: Authorities should be transparent about the framework guiding medical resource allocation: e.g., who developed it, what are its principles, what will trigger it, how it will be applied, and how it will impacts be monitored. Authorities should forecast that allocation priorities will likely change as the pandemic ebbs and flows. The public is concerned about potential practitioner biases, discriminatory behaviors, and people “gaming” the system. Thus, officials should explain how the framework will be applied fairly, with evidence backing up their assertions.
Share the agony of having to decide: Authorities often over-reassure the public believing, in error, that bad news could panic people. The public deserves candidness because decisions about finite resources will directly affect them. Plus, they can still prevent worse case scenarios through physical distancing. Decision-makers should acknowledge the angst and ambiguity in any tragic choice and ask communities to bear the burden with them. The public should hear that every other option has been exhausted before one patient receives a ventilator when another equally in need goes without.
Clarify that all patients will receive care, ventilator or not: Scarcity of lifesaving resources in the COVID-19 pandemic is a stark proposition. The public will take their minds there if led compassionately. They also have the wisdom to share. Shifting the discussion from scarcity to generosity, some have asked: What supportive care will be available for the patients who must forego a ventilator altogether, because none is available, or for the patients who must give up equipment because it offers no lasting benefit and others’ lives depend upon it? Health authorities thus should share the plans for maintaining the dignity and comfort of all patients struggling with COVID-19 infection.
Start talking to us now and keep talking: Leaders should set expectations now before patients and families walk into a health facility where triage is already the reality. Consistent and repetitive messages — in press conferences, in media reports, during patient admission, and at the bedside — are critical. Otherwise, decisions that have tragic consequences can appear arbitrary, hasty, and unevenly applied. Top decision-makers and frontline health workers should become equally conversant in the allocation framework now, using a common language to relay it to the public.
Empathize with the distress this topic triggers: The COVID-19 response involves complex operations, clinical calls, and other technical matters. But it is also a highly emotional event riven with courage, suffering, loss, self-sacrifice, and other feelings. Top officials discussing scarcity conditions with communities should seek counsel from professionals trained to help others during hard times. Behavioral health experts and faith leaders can suggest words that comfort, calm, and build resilience.
Delaying this dreaded conversation can inflict greater human suffering in the end, than shortages could alone. I know what I want to hear right now, and later, sadly, if it came to that.
Monica Schoch-Spana, Ph.D., a medical anthropologist, is a senior scholar at the Johns Hopkins Center for Health Security, Johns Hopkins Bloomberg School of Public Health.