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Who lives and who dies? If overwhelmed, Oregon hospitals already have a guide

In Oregon, where officials say current isolation methods should keep infection rates low enough for the system to handle, hospitals have had a plan for years.

PORTLAND, Ore. — A chilling conversation happening in hospitals across the country stems from one basic question: if and when a surge of COVID-19 patients overwhelms our healthcare system and doctors simply don't have the equipment and the man-power to help everyone who needs it, how do those doctors decide who lives and who dies?

In Michigan, a hospital confirmed a letter leaked on Twitter indeed laid out their policy of prioritizing those with the best chances of recovery

In Washington, disability rights advocates filed a formal complaint with the U.S. Department of Health and Human Services' Office for Civil Rights because new state guidelines reportedly include a line about considering a patient's "baseline functional status" and indications of declines in energy, physical ability and cognition.

In Oregon, where officials say current isolation methods should keep infection rates low enough for the state’s system to handle, hospitals have had a plan in place for years.  

Last updated in June of 2018, the Crisis Care Guidance lists major state health agencies, like the Oregon Health Authority and the Oregon Medical Association, and major hospitals like OHSU, Legacy Emanuel and Providence Health, as co-sponsors.

In its 60-plus pages, it lays out official, state-sanctioned guidance for how Oregon’s hospitals should handle two main types of public health crises: severe outbreaks of infectious disease, like a pandemic, and mass trauma events, like a major earthquake.

Specifically, it walks through how hospitals overwhelmed with too many patients should choose who gets life-saving treatment and who doesn't.

Calling for a "just plan" with "evidence-based, objective measures to predict likelihood of survival", it reads, “As a general principle, in order to save the greatest number of lives, life-saving interventions should be provided first to those most likely to benefit ... This may mean that patient choice for life-sustaining interventions cannot be accommodated when there are others who can more readily benefit from those same interventions.”

To accomplish that goal, the guidance recommends a team of doctors and healthcare experts, separate from those actually administering the care, refer people with “confirmed advanced disease or severe injury for which the average life expectancy is less than six to twelve months… to less aggressive care rather than aggressive, critical care.”

The guidance lists examples of qualifying conditions. They are:

  • cancer with spread to distant parts of the body
  • heart failure
  • liver disease
  • neurologic disease
  • other conditions with an average life expectancy of less than six to twelve months

Toward the end of the guidance, in the “frequently asked questions” section, it adds “age, non-life-threatening disability and ‘social worth’ are NOT exclusion criteria.

KGW reached out to communications representatives for every major metro-area hospital about the guidance.

None wanted to do an interview. Some responded via email.

Friday, Michael Foley, director of integrated communications with Kaiser Permanente, wrote “We have not established directives of this type. We have purchased more ventilators.”

He later added the group has purchased 350 ventilators.

Gary Walker with Providence Health & Services wrote “I’m told there’s a statewide collaboration on this to establish the same objective criteria across health care organizations in Oregon. Work has been ongoing and continued today.”

Monday, Dr Richard Leman with the Oregon Health Authority confirmed healthcare experts across the state are essentially curating information in the guidance to highlight sections most relevant to COVID-19.

First, they're highlighting strategies aimed at keeping infection rates low, so hospitals aren’t overly taxed.

Second, they’re zeroing in on guidance that helps hospitals make more efficient use of the supplies and equipment they have on hand.

“We’ve actually got some COVID-specific strategies… that show how to provide the most effective care possible with the resources available so we can take care of a lot more people, even if they’re pretty sick," Dr. Leman said.

As a last resort, he added, they are making sure hospitals are clear on the best criteria to use if and when they have to ration care.

“There are doctors and nurses and ethics experts who are currently using the newly available information that we have about COVID in order to… be able, if we do get to a situation where critical care resources are limited, to use those in a way that is just,” he said.

He said staff at Oregon's hospitals, who are co-sponsors on the original guidance, are reviewing initial update now, adding he expects a more finalized version to be compiled “within days”.

Jake Cornett is hopeful it happens soon.

“We really need leadership to make clear that people with disabilities have equal value to other Oregonians,” said Cornett, executive director of Disability Rights Oregon.

In a phone interview Friday, Cornett talked about a letter he sent to Governor Kate Brown's office last week.

It describes how, even before the COVID-19 pandemic, people with disabilities, especially those who are older, "have often fought ingrained attitudes about the inherent value of our lives to receive healthcare."

With gratitude, the letter acknowledges state laws that flat out ban such discrimination but adds "this virus is unlike any thing we have seen before."

It makes a plea for the governor and the Oregon Health Authority to circle back with hospitals and make sure staff are clear on Oregon’s stance.

“Before the full force of this crisis hits Oregon's hospitals … we would encourage them to make more clear, more definitive statements and to remind hospitals and health care providers of this requirement under the law,” Cornett said.

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