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What It Means When Hospitals Say They Have To Ration Care


There are more COVID patients hospitalized in the U.S. right now than ever before, and hospitals are issuing warnings that they're getting full and could be on the verge of rationing care. Will Stone explains what that might look like.

WILL STONE, BYLINE: There's only one ventilator left. Someone gets it. Someone doesn't. That's the grim ethical dilemma Dr. Kenneth Krell thought he'd most likely confront in his ICU in eastern Idaho.

KENNETH KRELL: Which is just a nightmare. I mean, I hope to hell we never get to that, but we have to be ready so that we do it equitably and humane.

STONE: Especially because Idaho has one of the lowest numbers of ICU beds per capita in the country. So back in the spring Krell was on a committee that decided how to make these decisions.

KRELL: And came up with a very grotesque, morbid plan of what we would do.

STONE: Krell's talking about something called crisis standards of care. It's a roadmap for hospitals during a catastrophic event. Part of that includes a scoring system for which patients to prioritize if resources are tight. There's no universal template. Plans can vary depending on the hospital, region or state. Idaho's hospitals are now filling up, but Krell says the driving concern is no longer ventilators.

KRELL: That's not our limiting factor. Our limiting factor is staff to take care of them. It's not going to be the ventilator you're short on. It's the nurse and the respiratory therapist.

STONE: Hospitals generally look at staff, space and stuff as they triage. It's more straightforward to count beds and ventilators than how many patients your staff can care for.

JOHN HICK: We cannot use those same structures to apply to situations like staffing.

STONE: John Hick is an emergency physician in Minnesota who helped craft one of the national models for crisis standards.

HICK: You've got elastic ability to stretch that staff a little bit more, a little bit more, a little bit more.

STONE: Nurses start caring for more and more patients. People wait longer for care. They may not get an ICU bed. Staff burn out. Hick describes it as a shift from being able to do everything possible for one patient to maximizing the benefit for many.

HICK: I don't really see these choices as being black-and-white choices about you're going to get care or you're not.

STONE: Instead, Hick says, think of medical care like a cupboard of food that has to last weeks. At first, a patient may get 80% of the care they normally get.

HICK: So, yes, we're rationing care right now in many, many areas in the United States. But we're doing it in an incremental way. And as things get worse and worse, it's going to be 70% and then 60%. Starvation is a painful and often prolonged process.

STONE: And crisis standards of care plans don't just apply to COVID patients. Care is rationed based on the science of who's most likely to survive during the crisis. James Hodge is a law professor at Arizona State University who's helped design crisis care plans.

JAMES HODGE: That's not an ad hoc determination of we value young people over old people, this ethnicity over that ethnicity. Take all that out.

STONE: It's unclear how many hospitals have formally gone to crisis standards of care during the pandemic. Some states do make explicit declarations giving hospitals permission. In other places, an individual hospital may change practices as it sees fit. Dr Kate Butler at the University of Washington says that's OK, but...

KATE BUTLER: A lot of the language has been around, we're almost there - you know, right on the edge of entering crisis capacity. But what I'm worried about is that there's kind of a blurred entry.

STONE: Butler studied how clinicians have handled these decisions during a surge of COVID patients. She found they often ended up in a gray zone.

BUTLER: Where we're not using usual standards but we also haven't declared crisis capacity. That's where we saw the distress coming out and the uncertainty.

STONE: And that informal rationing of care, even if it isn't called that, was already happening, which is exactly what the plans are supposed to guard against - that clinicians at the bedside are forced to decide who gets what.

For NPR News, I'm Will Stone. Transcript provided by NPR, Copyright NPR.

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