A powerful strain of avian influenza has generated concern about a possible pandemic, though scientists do not know with certainty whether or when a pandemic will occur. However, the better-prepared New York State is, the greater its chances of reducing morbidity, mortality and economic consequences. In a pandemic, many more patients could require the use of mechanical ventilators than can be accommodated with current supplies. A federal ventilator stockpile exists, and New York State plans to buy additional ventilators that would meet the needs of patients in a moderately severe pandemic. In a disaster on the scale of the 1918 influenza pandemic, however, stockpiles would not be sufficient to meet need. Even if the vast number of ventilators needed for a disaster of that scale were purchased, a sufficient number of trained staff would not be available to operate them. If the most severe forecast becomes a reality, New York State and the rest of the country will need to confront the rationing of ventilators.
An ethical framework must guide recommendations for allocating ventilators in a pandemic. Key ethical concepts are the duty to care for patients and the duty to use scarce resources wisely. Maintaining a balance between these two sometimes competing ethical obligations represents the core challenge in designing a just system for allocating ventilators.
The workgroup recommends an ethically and clinically sound system for allocating ventilators in a pandemic, containing the following elements:
1) Pre-triage requirements: Facilities must reduce the need for ventilators and expand resources before instituting ventilator triage procedures.
2) Patient categories for triage: All patients in acute care facilities will be equally subject to triage guidelines, regardless of their disease category or role in the community.
3) Implications of triage for facilities: State-wide consistency will prevent inequities; chronic care facilities will maintain different standards from acute care facilities.
4) Clinical evaluation: Clinicians will evaluate patients based on universally applied objective criteria, and offer time-based trials of ventilator support.
5) Triage decision-makers: Supervising physicians will take responsibility for triage decisions. Primary care clinicians will care for patients and will not determine ventilator allocation.
6) Palliative care: Palliative care will play a crucial role in providing comfort to patients, including those who do not receive ventilator treatment.
7) Appeals process: Physicians and patients require a means of requesting review for triage decisions; ethics committee members and others should be prepared to assist in the appeals process.
8) Communication about triage: Government and clinicians need to provide clear, accurate and consistent communication about triage guidelines. Data gathering and public comment can help improve the triage system.
The workgroup recommends that these guidelines be reviewed in public settings, including medical centers and community forums, with the explicit goals of encouraging education, comment and revision. After such public review, NYSDOH should incorporate improvements to these recommendations, and issue the revised document as a set of voluntary guidelines for acute care facilities.