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<\/figure><\/li><\/ul>\n\n<\/figure>\n\n\n\nDeadly protocols lay ahead targeting US seniors already<\/strong> COVID-19 selected by design (w\/males in all age ranges suffering double the death rate of females) in a nation with limited (for profit) hospital capacity and macabre epidemiological projections.<\/em>\n\n\n\n\n
\n\n\n\n\nDespite all the cheap rhetoric of protecting the most vulnerable, seniors and those with pre-existing medical conditions (who really are the MOST vulnerable) are actually being targeted for the dung heap under the euphemism of ‘triage’ by medical death squads in all but name only. As bad as all that is, it’s consistent with what has already been going on in most nursing homes for decades. Residents are visibly obsequious and fawning toward medical staff because they fully realize the difference between life & death can be as slight as how fast a nurse\/CNA responds to the bedside help button. The contemporary COVID-19 triage protocols are even worse. If you’re over 65. and become infected with the virus, without an ICU slot, it’s a 95% likelihood YOU DIE! You’re deemed to be past your pull date…even if you’ve never missed a health insurance premium payment. You might as well hitch a ride on the nearest ice floe.\n\n\n\n\n
\n\n\n\n\nImagine (not much of a stretch under current circumstances) the police or fire dept. refused to respond to your emergency because you were over 65 and they were out of water…had been low on water FOR YEARS! How would you feel if the perp who murdered your spouse was only sentenced to a few months because the victim was over 65? What if the library wouldn’t reserve books for you because your remaining years were discounted? Should seniors be permitted to vote or their ballots devalued proportionate to their actuarial life expectancy? Like infants, should seniors have fewer civil\/human rights than their contemporaries? If so, where is the breakdown of their social contract’s demise codified? This all smacks of the ‘ethics’ of Nazi death camp procedures where the youngest, eldest and infirm were sent to the ovens first. Our hospitals have begun to resemble Nazi inspired abattoirs. The thought provokes dread rather than hope, their saintly nomenclatures now feel like obscenities.\n\n\n\n\n
\n\n\n\n\nIn the Chinese city of Wuhan, the epicenter of the coronavirus pandemic, doctors made life-or-death decisions last month when 1,000 people needed ventilators to support their breathing, but only 600 were available.\n\n\n\n\n
\n\n\n\n\nIn Iran, where numerous high-level officials have been infected, doctors sought unsuccessfully to get the international community to lift sanctions so they could purchase more of the lifesaving machines.\n\n\n\n\n
\n\n\n\n\nAnd in northern Italy, doctors last week took the painful step of issuing guidelines for rationing ventilators and other essential medical equipment, prioritizing the young and others with the best chance of survival.\n\n\n\n\n
\n\n\n\n\nSuch tough choices couldd be ahead for the United States, a nation with limited hospital capacity and grim epidemiological projections estimating that as many as 40 per cent to 60 per cent of the country\u2019s population of 327 million could eventually become infected.\n\n\n\n\n
\n\n\n\n\n\u201cWe are looking at a new war no one as seen before. We have never fought a virus like this with this potential consequence,\u201d New York Gov. Andrew Cuomo said Sunday afternoon. He warned, \u201cIt is only a matter of time before ICU beds are full.\u201d\n\n\n\n\n
\n\n\n\n\nThe situation in the U.S. is more complicated than in many other nations due to this country\u2019s diversity, deep political and economic divisions and decentralized decision-making. The Centers for Disease Control and Prevention has laid out general principles for how to allocate scarce resources in a pandemic response plan, but leaves most of the details to individual states and institutions. The result is a patchwork of approaches \u2013 with some states proposing broad ethical principles to determine need, and others assigning priority scores using detailed algorithms for patients based on their condition, preexisting health problems and age.\n\n\n\n\n
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\n\n\n\n\n\nCOVID-19 Robotic Sterilizer<\/p>\n\n\n\n\n\n
\n\n\n\n\nIn an extreme outbreak, rationing would raise tortured questions: Should someone with a terminal cancer or serious heart disease get more or less priority? Should the CEO of a hospital or a health worker be able to jump the queue? What about pregnant women? How should prisoners or undocumented immigrants be considered? All things being equal, would a lottery or coin flip be an equitable approach?\n\n\n\n\n
\n\n\n\n\n\u201cThese are really hard decisions,\u201d said George Anesi, a critical-care specialist at the University of Pennsylvania. \u201cIn a public health emergency, you shift from a focus on individual patients to how society as a whole benefits and that\u2019s a big change from usual care.\u201d\n\n\n\n\n
\n\n\n\n\nFor now, the number of U.S. cases is limited \u2013 3,020 cases of confirmed coronavirus infections and 60 deaths as of Sunday \u2013 and hospitals still have capacity to handle more sick if the virus\u2019s spread is slowed using strategies such as social distancing. But the situation is evolving quickly and experts say it\u2019s impossible to predict how many people might become seriously ill and whether they could overwhelm the system\u2019s capacity, as happened in parts of Italy, Iran and China.\n\n\n\n\n
\n\n\n\n\nMany of the state plans were written following the global devastation of the SARS outbreak in 2002 and Hurricane Katrina in 2005. Some are still in draft form, and none has never been activated in a real crisis. State health officials and hospital leaders say they have been urgently updating them in recent days to address the unique aspects of the pandemic.\n\n\n\n\n
\n\n\n\n\nArthur Caplan, a bioethicist at NYU Langone Medical Center who has served on numerous national and international panels addressing resource allocation during Zika, Ebola, and avian flu outbreaks, said no single approach is more \u201cright\u201d than others. But he said that transparency is critical as the crisis develops.\n\n\n\n\n
\n\n\n\n\n\u201cThe public will accept triage and rationing if they understand the process,\u201d Caplan said. \u201cBut if it\u2019s secretive or looks like favoritism to politicians or the rich, they will not accept that \u2013 whatever the rules are.\u201d [Oh, really? NOT here–NOT if you’re excluding me and my spouse and my neighbors and classmates–NOT by a long shot!] Seniors have no less right to life than any human<\/em>!\n\n\n\n\n
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\n\n\n\n\nWhile much about covid-19, the disease caused by the novel coronavirus, is still a mystery \u2013 its origin, how exactly it spreads \u2013 one thing doctors are sure about is how it kills. It attacks the lungs, leading to respiratory distress. And in these situations, access to oxygen therapy with a mask or nasal cannula for milder cases, or to mechanical ventilation for more severe illnesses can give a patient\u2019s body time to fight the virus and mean the difference between life and death.\n\n\n\n\n
\n\n\n\n\nThe earliest reports from China estimated that about 6% of patients needed ventilator support. But those numbers were misleading, experts says, because so many people never made it to hospitals, or were simply unable to gain access to ventilators. About 25% of those who died had been placed on ventilators.\n\n\n\n\n
\n\n\n\n\nNewer information from Italy in a March 4 email from University of Milan physicians Maurizio Cecconi, Antonio Pesenti, and Giacomo Grasselli to other critical care doctors around the world showed a much higher number \u2013 10% \u2013 requiring mechanical ventilation.\n\n\n\n\n
\n\n\n\n\n\u201cThis happens like a bomb that explodes,\u201d Grasselli said in an interview. \u201cIt happens all of a sudden and keeps growing and growing.\u201d\n\n\n\n\n
\n\n\n\n\nGrasselli said that in his region there were barely enough ventilators and beds to go around but that many patients required 15 days to three weeks of ventilator support. \u201cClearly when resources are not enough for the number of patients, you have to prioritize patients who have the highest chance of survival,\u201d he said.\n\n\n\n\n
\n\n\n\n\nThe Italian critical-care society sanctioned the idea of placing age limits on access to intensive treatments, and said doctors should \u201cprivilege greater life expectancy.\u201d\n\n\n\n\n
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\n\n\n\n\nAngelo Pan, head of infectious disease at Italy\u2019s Cremona hospital, said the high number of patients needing ventilators \u2013 about 25% of the 170 people with coronavirus at his hospital in early March \u2013 was straining resources.\n\n\n\n\n
\n\n\n\n\n\u201cI don\u2019t want to be too pessimistic,\u201d Pan said, \u201cbut I think this is going to be a problem for all the health care systems.\u201d\n\n\n\n\n
\n\n\n\n\nBy many accounts, the United States is ill-prepared for a such a situation.\n\n\n\n\n
\n\n\n\n\nA 2005 federal government report estimated that in the event of a pandemic like the 1918 flu, the nation would need mechanical ventilators for 740,000 patients. Currently 160,000 ventilators are available for patient care, with at least an another 8,900 in the national stockpile, according to a February estimate by the Center for Health Security at Johns Hopkins.\n\n\n\n\n
\n\n\n\n\nHospital officials and doctors interviewed in several states emphasized that rationing is a last resort and that they have begun to experiment with other ways to increase capacity.\n\n\n\n\n
\n\n\n\n\nInitially, they said, patients would likely be transferred from more crowded, urban facilities such as Johns Hopkins in Baltimore and the University of Pennsylvania Health System in Philadelphia, which routinely operate at 80% to 90% capacity, to community or rural hospitals that may have more intensive-care beds.\n\n\n\n\n
\n\n\n\n\nIf the number of victims surges beyond that capacity, they say, they may try novel approaches such as having two patients on one ventilator. Tubing for ventilators, which is usually thrown out, could be sanitized and reused. Other types of hospital equipment, such as those used for sleep apnea, could be repurposed as makeshift ventilators. Only if those strategies fail and the sick continue to exceed capacity would rationing protocols be put into place.\n\n\n\n\u2013 \u2013 \u2013\n\n\n\n\n
\n\n\n\n\nIn normal times, U.S. hospitals operate mostly on a principle of first come, first served \u2013 \u201clike getting concert tickets\u201d as one clinician put it. In a mass casualty situation, this all goes out the door.\n\n\n\nAmericans generally agree that in a crisis, the goal should be doing the greatest good. But that concept has shifted depending on the era, setting and culture. During World War II, the greatest good might have been getting soldiers back out to the front lines. When the Titanic hit an iceberg, it was all about saving the women and children, while the men were left to die on the sinking vessel.\n\n\n\nU.S. ethicists have historically talked about saving the most lives as doing the greatest good. But with greater recognition these days of factors such as quality of life and burdens on the health-care system, the discussion has shifted from maximizing lives saved to maximizing life years. Saving one child may outweigh the \u201cgood\u201d of saving two elderly adults, according to the cold arithmetic of life expectancy.\n\n\n\nIf a patient is not getting better, has little path to survival, at what point are we willing to move an intervention rather than lose two lives? <\/a>\n\n\n\nLee Daugherty Biddison, an associate professor of pulmonary and critical care at Johns Hopkins Medicine, said the idea is to give priority to those \u201cmost likely to live a long life after they got though the current epidemic\u201d: \u201cThe thinking is, \u2018Am I going to survive the flu to die of advanced cancer in three months?\u2019 \u201d\n\n\n\n\n
\n\n\n\n\nDeciding between lives saved and life years is among the most tortured decisions that doctors will ever make, Anesi said. \u201cDifferent value steps could push people to different decisions,\u201d he said. Another tough call would be to take a ventilator away from one patient and move it to another, who may benefit more.\n\n\n\n\n
\n\n\n\n\n\u201cIf a patient is not getting better, has little path to survival, at what point are we willing to move an intervention rather than lose two lives?\u201d he said.\n\n\n\n\n
\n\n\n\n\nSuch questions are addressed in many state pandemic strategies, including New York state\u2019s highly regarded 52-page planning document \u2013 which notes that the U.S. Department of Homeland Security \u201cviews pandemic influenza as both the most likely and most lethal of all threats facing the United States.\u201d\n\n\n\n\n
\n\n\n\n\nPhilip Rosoff, professor emeritus of at Duke University\u2019s medical school and chair of its hospital ethics committee from 2005 to 2019, compared the New York strategy to a battlefield triage plan \u2013 except that in the latter there is a finite beginning and a reasonably finite end. But in the case of covid-19, he said, \u201cno one really knows if and when this really ramps up.\u201d\n\n\n\n\n
\n\n\n\n\nThe plan\u2019s basic outlines are simple and \u201cfairly draconian,\u201d Rosoff explained. \u201cIf you are in respiratory failure and there is a ventilator available and an ICU bed, and you meet certain medical criteria, you go on the ventilator. You have a certain amount of time to get better. If you don\u2019t, we\u2019ll take you off and give it to someone else.\u201d\n\n\n\n\n
\n\n\n\n\n\u201cIf you take it off someone who is not doing very well,\u201d he added, \u201cthe reality is they die.\u201d\n\n\n\n\n
\n\n\n\n\nTo avoid conflicts of interest and the emotional toll of life-or-death judgments, many state plans call for a senior, supervisory doctor or panel of doctors \u2013 similar to a \u201cthree wise men\u201d protocol developed in Britain for this scenario \u2013 who is different from the one caring for the patient.\n\n\n\n\n
\n\n\n\n\nBut state and hospital plans often vary widely in how they deal with issues such as a patient\u2019s age.\n\n\n\n\n
\n\n\n\n\nSome states do not set specific age cutoffs for ventilators during rationing, while others explicitly exclude access for older people, with access barred to those ranging in age from 65 to 85. A Minnesota panel, for instance, recommended prioritizing children over adults, and young adults over older adults, while the New York group did not use age as a criteria alone.\n\n\n\n\n
\n\n\n\n\nMost plans include a list of serious conditions that would exclude someone from getting a ventilator if rationing were in effect, and many conditions are more common in the elderly, such as severe cardiac issues, kidney failure, and metastatic cancer.\n\n\n\n\n
\n\n\n\n\nIn Maryland, avoiding discrimination is a major concern for those who drafted the guidelines, Daugherty Biddison said. She explained that disasters \u2013 epidemics, wars and attacks \u2013 tend to exacerbate society\u2019s inequalities and in discussions about how to ration resources, there\u2019s been tension among politicians, the public and ethicists about how to protect vulnerable groups.\n\n\n\n\n
\n\n\n\n\nA person with advanced diabetes is likely to have a shorter life span than someone with well-controlled diabetes. However that may be because the second person has greater access to medical care.\n\n\n\n\n
\n\n\n\n\n\u201cSo if you were to say, \u2018Look, you are unwell because of diabetes and you\u2019re also not going to get a ventilator,\u2019 you are double penalizing someone who didn\u2019t have access to care,\u201d Daugherty Biddison said.\n\n\n\n\n
\n\n\n\n\nSo while New York\u2019s guidelines exclude people with renal failure from getting ventilator support in an emergency, Maryland\u2019s guidelines include them in the pool of people who would be eligible.\n\n\n\n\n
\n\n\n\n\nThere\u2019s also variation in whether health-care personnel get priority. New York\u2019s working group felt strongly that health care workers should not be prioritized because the group is so large that it would result in denying access to everyone else, including children.\n\n\n\n\u2013 \u2013 \u2013\n\n\n\n\n
\n\n\n\n\nThe most painful cases, providers acknowledge, are situations in which a patient will be taken off a ventilator or will not get one.\n\n\n\n\n
\n\n\n\n\nRosoff from Duke believes that part of planning for a larger coronavirus outbreak in the United States should involve ensuring comfort to dying people who will go without the benefit of advanced intensive care. Such situations could be especially agonizing as family members may be absent due to the risk of contagion.\n\n\n\n\n
\n\n\n\n\n\u201cWe have very effective means of making that a comfortable, peaceful death,\u201d he said, citing things such as supplemental oxygen, morphine, chaplains and people trained to talk to those nearing death.\n\n\n\n\n
\n\n\n\n\nDaugherty Biddison said transparency about how care may be rationed in a pandemic situation may change how doctors talk with their patients about end-of-life decisions.\n\n\n\n\n
\n\n\n\n\n\u201cI don\u2019t think there will be a scenario where someone will say, \u2018Do you want a ventilator or should I give it to a 6-year-old?\u2019 That\u2019s not going to happen,\u201d she said. \u201cBut I do think if you\u2019re in this situation, at least people can contextualize their stress on the system and can make a decision accordingly.\u201d\n\n\n\n\n
\n\n\n\n\n\u2013 \u2013 \u2013\n\n\n\nThe Washington Post\u2019s Loveday Morris in Lodi, Italy, Tiffany Leung in Hong Kong and Magda Jean-Louis contributed to this report.\n","protected":false},"excerpt":{"rendered":"Deadly protocols lay ahead targeting US seniors already COVID-19 selected by design (w\/males in all age ranges suffering double the death rate of females) in a nation with limited (for profit) hospital capacity and macabre epidemiological projections. Despite all the … Continue reading