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N.J. Starts Thinking Over How to Ration Scarce Ventilators

Elise Young and David Voreacos

(Bloomberg) -- New Jersey will ask medical experts on a bioethics panel to set guidelines for which Covid-19 patients will get ventilators, wrenching decisions that could determine who lives and who dies.

The state medical society and New Jersey’s former epidemiologist will consider the question, State Health Commissioner Judith Persichilli told reporters in Trenton on Thursday.

“That is, I would have to say, one of the more difficult issues that we will be discussing,” she said. “What happens if we don’t have enough ventilators to take care of the patients that we have?”

New Jersey, swept up in a U.S. outbreak that is now the largest in the world, is confronting the ugly choices that China and Italy have had to negotiate in recent weeks. Medical experts and bioethicists have been grappling with the hard choices of which Covid-19 patients should be placed on life-saving ventilators in intensive-care units, and which should be taken off them to make room for others.

Desperate Days

Confirmed infections are rising rapidly in New Jersey. On Thursday, officials reported a 56% jump in new cases, to almost 7,000. Deaths climbed to 81, from 62 a day ago.

By Tuesday, the Hackensack Meridian system’s 17 hospitals had already admitted 746 Covid-19 patients, including 177 on ventilators.

“We are effectively managing the sharp increase in Covid-19 patients in hospitals throughout our network,” Daniel Varga, chief physician executive, said in a statement Thursday. “However, as part of our preparedness strategy, we are having conversations with our experts to develop guidelines that the network may need to implement in the event this changes.”

Governor Phil Murphy told reporters Thursday that the state requested 2,500 ventilators from the federal stockpile but has “no assurances” if or when the full supply will arrive.

“We are not the only place in the world looking for ventilators right now,” Murphy said. “We’re all out there tripping over each other.”

The state’s more than 1,000 ambulatory surgical centers, most of them now temporarily closed, have been asked to turn over personal protective gear and anesthesia equipment that, with the addition of a valve, can serve as ventilators, Persichilli said. She said that officials hoped not to have to set formal triage rules.

Murphy said, “We’re doing everything humanly possible to head this off before we get to that sort of discussion, but we would be remiss and abrogating our responsibilities if we didn’t have that discussion and be prepared in a worst-case scenario.”

Care Denied

The coronavirus’s grip on Italy led the Medical Society of New Jersey’s 30-member bioethics panel “to think about a distributive justice model” and offer it to the state health department, which will take up the framework as early as next week, according to Larry Downs, the society’s chief executive officer.

The pandemic intensified in Italy about 10 days earlier than in the U.S., and doctors in some instances are no longer offering ventilators to patients over 60. Washington state, which confronted the disease outbreak earlier than the New York region, has updated guidelines that specify how hospitals must decide who gets precious ICU care and who must be removed.

The Washington standards, outlined in 50 pages, seek to provide a “transparent, fair, equitable and consistent approach to allocation of scarce resources during a declared emergency.”

The document outlines how hospitals should decide which adults should be placed in the ICU when beds and ventilators are scarce. It considers underlying ailments that “predict poor short-term survival,” such as severe heart, lung or liver disease. Doctors must assess “baseline functional status” and consider general health, cognition and loss of energy or physical ability.

Hospitals also must make daily assessments of every ICU patient, reviewing whether they are improving, unchanged or worsening. For worsening patients, hospitals are instructed to consider palliative care. Washington recommends that the clinical triage teams making such reviews include a medical ethicist and two or three senior clinicians who aren’t primary providers for a patient.

Downs, the executive for the New Jersey medical society, said its panel -- with doctors, nurses, social workers, clergy, lawyers and others as members -- has offered ethics guidance for decades on matters including end-of-life care, brain-death criteria and medical futility.

In the case of coronavirus, he said, the panel devised a patient “scoring” framework, based on objective criteria to “make sure that everyone is treated equally based on how they present clinically.”

Like the governor and health commissioner, Downs said it was his hope that such guidance won’t be necessary.

“The virus, if it has other plans -- we need to be prepared,” he said.

(Updates with Hackensack hospitals in sixth paragraph)

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