This story first appeared on the ProPublica website.
Florida health officials are drawing up guidelines that recommend barring patients with incurable cancer, end-stage multiple sclerosis and other conditions from being admitted to hospitals if the state is overwhelmed by flu cases.
The plan, which would guide Florida hospitals on how to ration scarce medical care during a severe flu outbreak, also calls for doctors to remove patients with a poor prognosis from ventilators to treat those with better chances of survival. That decision would be made by each hospital.
The flu causes severe respiratory illnesses in a small proportion of cases, and people who need ventilators and are deprived of them could die without the breathing help the machines provide.
In June, Florida Surgeon General Ana M. Viamonte Ros sent the draft guidelines (PDF), which already had undergone a series of internal revisions, to 16 state medical organizations for comment.
But the state has not yet publicized the guidelines or solicited input from the general public.
The Health Department released a version of the draft plan at the request of ProPublica.
The document, drawn up by a team from across Florida that included Orange County Health Director Dr. Kevin Sherin, addresses one of the most delicate issues in medicine: what to do if the number of severely ill people needing ventilators and other treatment dramatically exceeds what is available.
The goal, the plan says, is to focus care on patients whose lives could be saved and who would be most likely to function better if they were given whatever resources were available. It says those decisions are not to be made based on patients’ perceived social worth or social role, but the plan calls for different rules for some populations.
The list of conditions that disqualify hospital admission would be applied to most people only in the two most severe levels of a pandemic. However, they would be applied in the first level of a pandemic for people transferred to hospitals from “other institutional facilities” such as nursing homes and mental-health centers.
Novel H1N1 Influenza Deaths by Age, Florida.
All deaths in reported laboratory-confirmed novel H1N1 influenza cases. Influenza may not be the attributable cause of death in all cases. Approximately 25% of deaths are in people with no clear underlying medical condition, 121 deaths in those with laboratory-confirmed novel H1N1 influenza reported. 11 deaths were newly reported (12:00 p.m. October 6, 2009 to 12:00 p.m. October 13, 2009) (Data from Florida Department of Health)
A flood of patients
Florida’s planning effort reflects a growing acknowledgment that the nation’s hospitals would be unable to cope with the flood of patients that a severe influenza pandemic such as the one that gripped the United States in 1918 would unleash. That resource gap is in the spotlight now, as the country is battered by a second wave of pandemic H1N1 influenza, informally known as the swine flu.
“What we have seen are real stresses, particularly on the emergency departments,” Thomas Frieden, Centers for Disease Control and Prevention director, said in a news conference last week.
The H1N1 flu is much milder than the 1918 flu, but a small percentage of H1N1 patients, including some who have no risk factors and are young and healthy, develop severe breathing problems requiring mechanical ventilation and life support.
So far, intensive-care units have not been overwhelmed with people in need of breathing support.
“That’s something that we’re tracking closely,” Frieden said.
In Winnipeg, Manitoba, all regional critical-care beds were full at the peak of the outbreak last spring, and in Mexico, patients experienced long delays before being admitted to ICUs. Four died before being transferred from the emergency room.
Florida health officials think that the number of severely ill flu patients will likely remain at a manageable level, provided residents gets vaccinated, that they follow advice about not spreading germs and about when to stay home (see myflusafety.com) and the existing flu strain does not mutate into a more virulent form.
In the case of a much more severe scenario, Florida’s draft guidelines would call for hospitals to turn away anyone whose doctor has signed a “Do Not Resuscitate” order, which instructs rescuers not to revive a patient whose heartbeat or breathing stops. A recent report from a panel of national experts convened by the Institute of Medicine urged states not to use DNR orders for this purpose, because they reflect preferences and foresight about end-of-life planning “more than an accurate estimate of survival.”
The report also stressed that clinical scoring systems used to predict survival are imperfect and need more research.
The Florida plan calls for intensive-care patients and those using ventilators to be reassessed with a clinical scoring tool after 48 to 72 hours. Those whose prognoses have significantly worsened would be taken off the machines or discharged from critical care to make way for others who may have a better chance of survival. They would be given palliative care to keep them comfortable if needed.
Preliminary analysis of hospitalized adult H1N1 patients.
Analysis of 1400 patients hospitalized in states within the CDC’s Emerging Infections Program Network surveillance system. Results are approximate and indicate that more than 45% of patients had no underlying chronic condition. Obesity, a possible risk factor for severe illness with H1N1 infection, was not included in the analysis. In an additional analysis of 500 hospitalized children, the most common underlying conditions were asthma, chronic lung disease, neurologic or neuromuscular diseases, and sickle cell or other blood disorders. (Source: U.S. Centers for Disease Control and Prevention)