Doctors in Alaska, Idaho and Montana face agonizing ethical questions

Kristen Solana Walkinshaw, a physician on the coronavirus triage committee at Providence Alaska Medical Center in Anchorage, found her team last weekend making one of the most agonizing decisions of their careers. With the delta variant surging, the hospital was overwhelmed, and the doctor-on-call had paged the group for guidance.

Four patients needed continuous kidney dialysis, her colleague explained, but only two machines could be made available. How should I choose?

“This is the worst it’s been for us,” Solana Walkinshaw said, and “it’s not over.”

Rationing medical care, one of the most feared scenarios of the pandemic, is becoming a reality in a few parts of the United States as coronavirus infections remain at surge levels. On Thursday, Idaho officials announced the state was taking the extraordinary step of activating crisis standards of care statewide, giving hospitals the power to allocate — and potentially even deny — care based on the goal of who could benefit the most when faced with a shortage of resources such as ventilators, medications or staff. The decision will affect both covid and non-covid patients in a health-care system that is fraying.

In Montana, St. Peter’s Health in Helena moved into crisis standards Thursday, and Billings Clinic, the largest hospital system in the state, warned it could be next. In California’s Fresno County, the interim health officer has said the jurisdiction is at “a tipping point,” but the arrival of out-of-town nurses and medical teams helped stabilize the situation for the moment.

Hawaii’s governor on Sept. 1 signed an order releasing health-care facilities and health-care workers from liability if they have to ration health care.

“I’m scared,” Steven Nemerson, chief clinical officer of Saint Alphonsus Health System in Boise, which has run out of ICU beds, said at a news conference Thursday. “I’m scared for all of us.”

Crisis standards do not always result in rationing, but they give providers more flexibility in how they prioritize care as well as legal protection when they do. State and institution rationing plans are often based on a scoring system of how the brain, heart, kidneys, liver and other major organs are functioning to help make decisions, but they can differ enormously in their details. Many also take into account a patient’s “life stage” as a proxy for age, and some, usually as tiebreakers, look at their role in society — such as whether the patient is a health-care worker or a politician with an essential responsibility during the crisis. Last month, a critical care task force in Texas floated the idea of taking vaccination status into account — but the authors dismissed their own suggestion as a theoretical exercise following a public backlash.

The threat of rationing has been ever-present during the pandemic, with individual hospitals and Arizona and New Mexico declaring crisis standards for short periods in 2020. But perhaps because of the natural ebb and flow of infectious disease, the fact that shutdowns meant that less trauma and other non-covid care was needed, or thanks to creative redistribution of resources by health officials, the need to ration has been rare.

The latest wave may be different.

The outbreaks are more dispersed, affecting many parts of the country at the same time. Hospital officials say a high number of nurses and other medical staffers, exhausted from 1½ years of stress, have quit and are unwilling to come back. That has made staffing, even more so than equipment in some cases, a barrier to care.

The country has averaged about 153,000 new covid cases and 1,940 deaths each day this week. Cases declined nationally over the past week and appear to have peaked in the South, but growing outbreaks are hitting the Midwest and Mountain states.

President Biden has pledged to surge federal medical staff in places that are overwhelmed. Additional equipment has been reallocated or ordered in many places, and states and regions are activating emergency patient transfer systems to balance the load. But the politicization of the pandemic poses a different challenge.

Bruce Siegel, president and CEO of America’s Essential Hospitals, a trade group of more than 300 hospitals, called the current crisis a “preventable” one based on reluctance to embrace vaccines, mask-wearing and social distancing and people falling prey to a flood of misinformation about the virus and immunization.

“We’re at a place I don’t think U.S. health care has been at in over 100 years,” he said. “We simply don’t have capacity in large parts of the country.”

‘The net is gone, and people will fall from the wire’

With the United States’ wealth and advanced technology, hospitals in typically operate in a state of abundance that allows them to take patients on a first come, first served basis and still treat everyone to high standards.

That changed in Idaho in recent days.

Jim Souza, chief physician executive at the state’s largest health system, St. Luke’s, described having to squeeze bags for up to hours at a time to provide oxygen for patients while awaiting a mechanical ventilator to become available; having to leave patients on oxygen treatments in unmonitored areas where staffers might not be able to hear alarms; and stopping all surgical procedures, including those they know may result in “permanent disability or pathology,” such as those for breast or endometrial cancer. St. Luke’s is part of the region of Idaho where crisis standards were activated Sept. 7 ahead of the expansion to the rest of the state on Thursday.

“The net is gone,” Souza said, “and people will fall from the wire.”

Idaho is one of the least vaccinated states, with about 40 percent of residents fully immunized. Gov. Brad Little (R) has resisted mandating masks or imposing other coronavirus restrictions. A doctor who called coronavirus vaccines “fake” was recently selected for a regional health board.

At Kootenai Health in Coeur D’Alene, being in crisis standards has meant the ability to put patients in converted classrooms and other open spaces in the hospital. Elective and urgent surgeries have been delayed, and patients’ vital signs are not being checked as often. While the hospital has not had to directly ration care yet, it is bracing for that possibility in the next few weeks following a 10-day fair around Labor Day during which there were no mitigation efforts, and the reopening of schools, few of which have mask mandates, around the same time.

Robert Scoggins, chief of staff of the hospital, said Wednesday that one priority is to stand up a pediatric ICU unit for what they expect may be an inevitable wave of children becoming infected. It has been a challenge because the hospital does not have one. That has meant that adult critical care specialists like him have had to get additional training in pediatric advanced life support.

“Our big concern is that the regional pediatric ICU capability could be overwhelmed,” he said.

Idaho’s crisis plan calls for examining a patient’s medical status first and foremost when making decisions about rationing. It then prioritizes children through 17 years of age, pregnant women, adults from younger to older and patients who “perform tasks that are vital to the public health response of the crisis at hand.” All else being equal, a lottery would be used. Patients not offered certain treatments would receive palliative care.

Peter Mundt, a spokesman for Gritman Medical Center in Moscow, Idaho, said that while the hospital has been able to manage nearly all its covid patients in-house, patients with other urgent issues are suffering. The critical access hospital system has previously prided itself on being able to transfer patients having a heart attack, stroke or a major trauma due to an accident in less than an hour to a higher-level facility, usually to Kootenai. These days, because Kootenai has been full, patients have had to go other states — one patient was transported more than 800 miles to Sacramento.

“This is a very serious situation for us,” he said.

‘I never thought I would see anything like this’

The situation in Montana, up until about a few weeks ago, was so stable that hospitals were able to take many of its neighboring states’ transfer patients.

As of this week, however, Billings Clinic, which owns the regional hospital and 16 critical access hospitals, was operating at 150 percent ICU capacity and had called for help from the National Guard.

“We are very close to flipping to crisis standards,” Billings Clinic CEO Scott Ellner said Thursday.

He said the clinic convened a team, led by an ethicist, to make decisions about care in the coming weeks should they become necessary.

“We may have to remove some equipment, a ventilator or a bed from one patient to another patient because that patient is more likely to survive,” Ellner, a physician for 25 years, said. “I never thought I would see anything like this.”

In Helena, the state capital, St. Peter’s Health announced Thursday that it had moved to crisis standards. Chief Medical Officer Shelly Harkins said that both the ICU and the morgues were completely full.

“For the first time in my career, we are at the point where not every patient in need will get the care that we might wish we could give,” she said.

Harkins explained that the hospital is receiving only a limited allocation of some drugs used to treat covid patients.

“Earlier this week, we had enough of the medication to treat one patient with a full course, but we had multiple patients that qualified for it. … Do you give it to just one patient, the lucky one, and let the others go entirely?”

She said that in this situation they split the doses.

Harkins said oxygen and other treatments are sometimes being provided without “eyes on” or continuous monitoring typically given in the ICU because of space, staffing and equipment constraints.

“This is risky,” Harkins said. “But the alternative is, the patient doesn’t get the oxygen they need, and they die.”

‘We sadly may not have room now’

Leaders at Providence Alaska Medical Center announced this week that they had implemented crisis standards of care, telling residents directly in a letter published online and dated Monday that the emergency room was overflowing to the point that people have had to wait in their cars to be seen and the hospital had run out of staffed beds.

“If you or your loved one need specialty care at Providence, such as a cardiologist, trauma surgeon, or a neurosurgeon, we sadly may not have room now,” Solana Walkinshaw warned.

Alaska is fourth in the nation for average daily new cases per capita and lags behind many other states in the vaccination effort, with about 48 percent of eligible residents fully vaccinated. About 29 people are hospitalized with covid-19 for every 100,000 Alaskans, according to data compiled by The Washington Post.

Internal medicine hospitalist Ryan Webb and Solana Walkinshaw are two of10 doctors and a clinical ethicist who have volunteered to be on call 24/7 for a triage committee, created specifically to make decisions about the rationing of care. Interpreting guidelines from the state about the crisis standards, committee members have had to make difficult choices about which patients get care.

Lately, many decisions have been about which patients the hospital can accept. With 223 adult hospital beds, it accepts patients from rural areas without the adequate resources for medical care. But delays of minutes or hours in the normal triage process have become days long, Webb said.

“That problem is more acute in a state like Alaska where some of our sending facilities have an 800-mile air flight that the patient is going to have to endure and survive,” he said. “There isn’t anywhere else for them to go.”

The influx of these tragic calls has become so burdensome that other doctors will be asked to join the committee. Webb and Solana Walkinshaw said they had never encountered such a frightening situation. Despite having both worked through mass casualty events with an influx of patients — for Webb, the Aurora, Colo., movie theater shooting, and for Solana Walkinshaw, a 2010 plane crash — neither has felt prepared for the recent surge, which they foresee getting worse.

“Many of us are very afraid,” Webb said. “We’re faced with a situation that we really never expected to be in.”