WEBVTT - What Happens If We Run out of Ventilators? 0:00:15.356 --> 0:00:22.436 Pushkin from Pushkin Industries. This is Deep Background, the show 0:00:22.476 --> 0:00:25.476 where we explore the stories behind the stories in the news. 0:00:25.916 --> 0:00:30.756 I'm Noah Feldman. We're continuing our ongoing coverage of different 0:00:30.756 --> 0:00:36.276 aspects of the coronavirus pandemic. Today, our topic is medical 0:00:36.356 --> 0:00:40.596 ethics and how they apply in a crisis. There have 0:00:40.636 --> 0:00:43.116 been reports of doctors in some countries around the world 0:00:43.196 --> 0:00:47.516 having to ration care, including ventilators, for patients who are 0:00:47.516 --> 0:00:51.156 sick with the coronavirus because they don't have sufficient supplies 0:00:51.436 --> 0:00:55.116 to care for everyone. It looks at least possible that 0:00:55.156 --> 0:00:58.036 the same thing could be happening here in the United States. 0:00:58.596 --> 0:01:02.036 The situation is especially pressing in New York, where there 0:01:02.076 --> 0:01:04.876 is a shortage of ventilators and where the possibility of 0:01:04.916 --> 0:01:09.996 splitting ventilators has been considered by some hospitals. What happens 0:01:10.036 --> 0:01:12.996 when hospitals have to decide who gets a ventilator and 0:01:13.036 --> 0:01:16.236 who doesn't. What happens at the end of life, when 0:01:16.276 --> 0:01:18.956 we're trying to figure out what sort of heroic measures 0:01:18.956 --> 0:01:21.156 should be used to save people who are close to 0:01:21.236 --> 0:01:24.876 dying from the coronavirus. To discuss these issues, I'm joined 0:01:24.916 --> 0:01:29.156 today by doctor Lydia Dugdale. She's an Associate Professor of 0:01:29.196 --> 0:01:32.636 medicine and director of the Center for Clinical Medical Ethics 0:01:32.676 --> 0:01:37.316 at Columbia University. She's practicing medicine on the front lines 0:01:37.556 --> 0:01:40.516 of this pandemic, both in the hospital and in the 0:01:40.556 --> 0:01:43.276 temporary tent that Columbia University has set up in its 0:01:43.316 --> 0:01:46.956 own parking lot to deal with the overload of Corona cases. 0:01:47.556 --> 0:01:50.436 She's also the author of a forthcoming book, The Lost 0:01:50.596 --> 0:01:56.236 Art of Dying. Lydia, thank you so much for joining me. 0:01:56.476 --> 0:01:59.916 I wonder if we could begin by talking about something 0:01:59.956 --> 0:02:02.156 that I think the whole world is focusing on now, 0:02:02.236 --> 0:02:05.756 but that you do every day, and that is the 0:02:05.796 --> 0:02:11.316 fundamentals of medical ethics. How do you go about thinking 0:02:11.356 --> 0:02:15.556 in a systematic way about the rationing questions that may 0:02:15.596 --> 0:02:18.876 not have quite yet emerged in the United States, but 0:02:19.036 --> 0:02:21.076 which are on the edge of emerging, and which have 0:02:21.156 --> 0:02:25.356 already emerged in lots of other countries. Medical ethics typically 0:02:25.396 --> 0:02:29.236 focuses on the doctor patient relationship. That's really the core 0:02:29.756 --> 0:02:34.036 of what we do in non crisis times. As such, 0:02:34.116 --> 0:02:38.916 we tend to focus on principles of beneficence and non maleficence. 0:02:39.476 --> 0:02:44.956 Beneficence is doing good for patience, and non maleficence is 0:02:45.316 --> 0:02:49.116 not doing harm, So that's sort of that hippocratic It's 0:02:49.156 --> 0:02:52.956 typically called the hippocratic idea of first doing no harm 0:02:52.996 --> 0:02:55.756 to one's patience. So that's what we talk about in 0:02:56.356 --> 0:03:02.196 non crisis times in medicine. However, with this current coronavirus pandemic, 0:03:02.836 --> 0:03:07.716 we've shifted the current framing for medical ethics to more 0:03:07.836 --> 0:03:11.876 of a public health fix, which takes into account different 0:03:12.076 --> 0:03:15.596 principles and they're sort of a different framing for how 0:03:15.636 --> 0:03:19.476 we think about decisions, and we tend to focus more 0:03:19.596 --> 0:03:22.276 on a duty to care for everyone, so there's more 0:03:22.276 --> 0:03:26.276 of a community bent to things. There is a commitment 0:03:26.276 --> 0:03:29.556 to stewarding resources, this is what we've heard about a 0:03:29.556 --> 0:03:31.676 lot in the media, making sure we have enough equipment. 0:03:32.156 --> 0:03:36.316 There's certainly a duty to plan governments. Healthcare administrators are 0:03:36.316 --> 0:03:40.436 expected to anticipate foreseeable crises and sort of come up 0:03:40.436 --> 0:03:42.956 with a plan to respond to these. There's also a 0:03:42.996 --> 0:03:46.156 commitment to distribute of justice, making sure that we have 0:03:46.276 --> 0:03:51.276 allocation protocols in place that will meet the most needs 0:03:51.316 --> 0:03:54.476 possible in a way that is most fair. And then, 0:03:54.476 --> 0:03:57.156 of course transparency is fundamental to this. We want to 0:03:57.156 --> 0:03:58.996 make sure that the public knows what we're doing in 0:03:59.036 --> 0:04:03.316 these unique situations when everyone's already on edge. We want 0:04:03.316 --> 0:04:04.876 to do everything we can to sort of shore up 0:04:04.916 --> 0:04:08.996 public trust so that everyone knows that the healthcare system 0:04:09.356 --> 0:04:12.196 and the policymakers still have their back and will really 0:04:12.236 --> 0:04:15.436 work to prioritize their health and well being. Could we 0:04:15.556 --> 0:04:19.676 drill down to what you called allocation protocols, which I'd 0:04:19.716 --> 0:04:21.996 take it as a fancy way of saying who gets 0:04:22.036 --> 0:04:26.596 which medical supplies or medical technologies when and products? The 0:04:26.596 --> 0:04:30.116 allocation part and protocol implies that you'd have a kind 0:04:30.156 --> 0:04:32.876 of model or an algorithm that you would follow in 0:04:32.876 --> 0:04:37.316 individual instances. Now, those things are super tricky and they 0:04:37.356 --> 0:04:40.236 require sort of unveiling a lot of the values that 0:04:40.276 --> 0:04:42.956 you were talking about. So would you talk a little 0:04:42.996 --> 0:04:45.996 bit about how you think about allocation protocols. Let's use 0:04:46.036 --> 0:04:50.836 an example that's really concrete, the example of ventilators. So, 0:04:50.956 --> 0:04:53.636 hospitals all over the country right now and over the 0:04:53.716 --> 0:04:57.156 last few weeks have been debating how to handle the 0:04:57.156 --> 0:05:01.316 possibility of a ventilator shortage. It's worth pointing out, though, 0:05:01.356 --> 0:05:04.956 that perhaps more than an actual ventilator shortage. There's a 0:05:04.996 --> 0:05:08.636 concern that we would have a shortage of healthcare personnel, 0:05:08.676 --> 0:05:12.716 particularly respiratory therapists and critical care doctors who know how 0:05:12.716 --> 0:05:18.276 to manage these very complex and sophisticated devices. However, having 0:05:18.316 --> 0:05:22.516 said that, assuming that there is a ventilator shortage or 0:05:22.516 --> 0:05:25.956 that there will be one, hospitals are trying to figure 0:05:25.956 --> 0:05:28.996 out what is the best way to make sure that 0:05:29.036 --> 0:05:33.236 we save the most lives possible. That's really the driving 0:05:33.316 --> 0:05:37.316 question here. And even though there has been certainly a 0:05:37.356 --> 0:05:41.396 lot of concern expressed that these allocation principles are going 0:05:41.436 --> 0:05:46.236 to cut off the elderly or not serve those with disabilities, 0:05:46.556 --> 0:05:51.236 that's not at all the aim of these allocation protocols. 0:05:51.276 --> 0:05:54.836 In New York State, for example, there was put forward 0:05:54.876 --> 0:05:57.956 in twenty fifteen by the New York State Department of 0:05:57.996 --> 0:06:02.556 Health allocation guidelines for ventilators in the event of a 0:06:02.596 --> 0:06:06.116 flu epidemic. New York was trying to anticipate how they 0:06:06.116 --> 0:06:08.236 would meet the needs of New Yorkers, particularly in this 0:06:08.556 --> 0:06:12.076 congested urban area, if flu were to sort of go haywire, 0:06:12.716 --> 0:06:15.476 and a lot of hospitals around the country currently have 0:06:15.716 --> 0:06:19.476 looked back to those twenty fifteen guidelines as a starting point, 0:06:19.796 --> 0:06:22.316 and there are other other similar guidelines out there, so 0:06:22.356 --> 0:06:26.196 we're sort of wrestling with these and then applying them 0:06:26.396 --> 0:06:30.236 to COVID. So, of course, coronavirus and the way it's 0:06:30.276 --> 0:06:32.996 playing out does not look exactly like influenza in a 0:06:33.036 --> 0:06:36.996 typical season, so we're having to adapt these guidelines. The 0:06:37.036 --> 0:06:40.436 formula that you used was the goal of saving the 0:06:40.436 --> 0:06:44.356 most lives possible, and I guess what I want to 0:06:44.356 --> 0:06:47.636 ask you about is if we really are committed to 0:06:47.636 --> 0:06:50.436 saving the most lives possible, then our protocol is presumably 0:06:50.476 --> 0:06:53.956 going to ask how likely is this person to survive 0:06:54.436 --> 0:06:58.636 if given the scarce ventilator, and if you're younger and healthier, 0:06:59.236 --> 0:07:03.196 that probably on the whole enhances your chances of surviving. 0:07:03.876 --> 0:07:06.996 What's your view about how we should think that through. 0:07:07.556 --> 0:07:10.516 So the score that a lot of us are looking at, 0:07:10.716 --> 0:07:14.156 or at least studying and considering, is something called the 0:07:14.156 --> 0:07:19.276 SOFA score. SOFA it stands for the Sequential organ Failure Assessment, 0:07:19.796 --> 0:07:23.116 and this is a score interestingly that doesn't take age 0:07:23.236 --> 0:07:27.596 into account, but it does take into account the health 0:07:27.956 --> 0:07:31.596 of six organ systems. So the SOFA score looks at 0:07:31.636 --> 0:07:34.756 the lungs, the heart, the kidneys, the liver, the brain, 0:07:34.956 --> 0:07:39.396 particularly with regard to mental status, how alert is an individual, 0:07:39.636 --> 0:07:42.796 and also blood clotting, so you know, doctors will call 0:07:42.796 --> 0:07:46.396 this the hematologic system. So the SOFA score takes into 0:07:46.396 --> 0:07:50.156 account that the healthy functioning or lack of health of 0:07:50.196 --> 0:07:54.876 these six organs, which in times of severe infection what 0:07:54.956 --> 0:07:59.156 we might call sepsis, we often see a sequential failing 0:07:59.396 --> 0:08:02.956 of these organs. And then we look at these triage 0:08:03.396 --> 0:08:06.036 sort of allocation guidelines tend to look at the SOFA 0:08:06.036 --> 0:08:10.996 score how it changes over time. So if a SOFA 0:08:11.036 --> 0:08:15.756 score gets progressively worse day after day after day, that 0:08:15.836 --> 0:08:19.556 trajectory tends to be only in one direction. Now, if 0:08:19.556 --> 0:08:22.876 a SOFA score starts to show improvements, then we think 0:08:22.876 --> 0:08:25.676 differently about an individual patient. So as you say, the 0:08:25.796 --> 0:08:29.916 SOFA analysis doesn't mention age, it's not listed as a 0:08:29.956 --> 0:08:33.236 consideration there. And I guess I have two questions about that. 0:08:33.316 --> 0:08:36.316 One is if you had two identically placed patients with 0:08:36.356 --> 0:08:39.596 respect to SOFA, but they were very disjunct with respect 0:08:39.636 --> 0:08:42.116 to age. You know, one was I don't know, a 0:08:42.116 --> 0:08:44.836 healthy eighteen year old and the other was a healthy 0:08:44.956 --> 0:08:48.276 for their age. But you know, eighty year old under 0:08:48.436 --> 0:08:50.916 current protocols, would that mean that you would not be 0:08:50.996 --> 0:08:54.396 able to have a preference for the eighteen year old 0:08:54.436 --> 0:08:56.036 over the seventy year old or the eighty year old 0:08:56.316 --> 0:08:58.716 simply because it's not in the sofa score. Or do 0:08:58.796 --> 0:09:01.476 you use the sofa score in a flexible way where 0:09:01.516 --> 0:09:03.116 if sofas are equal, and then you have to make 0:09:03.156 --> 0:09:07.156 an allocation decision, you could then consider other factors. The 0:09:07.236 --> 0:09:10.916 New York State guidelines from twenty fifteen, the only look 0:09:10.956 --> 0:09:14.236 to age as a tiebreaker if it's a child versus 0:09:14.236 --> 0:09:17.076 an adult, that's the only time. And they do that. 0:09:17.116 --> 0:09:20.556 They base those guidelines on our societal preference for caring 0:09:20.596 --> 0:09:24.476 for children. If it's two adults with equal sofa scores 0:09:24.556 --> 0:09:26.836 and equal need let's say, and let's say it's not 0:09:26.836 --> 0:09:30.236 even removal, but it's just applying a ventilator and there's 0:09:30.276 --> 0:09:33.676 only one ventilator left, then it's a lottery system according 0:09:33.676 --> 0:09:36.716 to these New York State guidelines. Again, every hospital is 0:09:36.716 --> 0:09:39.356 adapting these guidelines slightly differently. I think a lot of 0:09:39.356 --> 0:09:41.436 the protocols are going to end up being quite similar, 0:09:41.476 --> 0:09:45.556 and there are efforts underway to study these nationwide. But 0:09:45.676 --> 0:09:48.556 I think most people are loath to sort of make 0:09:48.596 --> 0:09:51.356 a strict age cut off and say or not even 0:09:51.356 --> 0:09:53.636 a cutoff, but to just say the older person should 0:09:53.676 --> 0:09:56.276 not get it and the younger person should get it. So, 0:09:56.316 --> 0:09:57.916 like I said, a lot of the preference is often 0:09:57.916 --> 0:10:00.636 given to children. Otherwise it tends to be a lottery system. 0:10:01.436 --> 0:10:03.716 Some of the state protocols, as reported and as they 0:10:03.756 --> 0:10:05.876 appear to be written, and I'm thinking of the Alabamber 0:10:05.916 --> 0:10:10.596 Procolling particular, seemed to say that people certain severe disabilities 0:10:10.996 --> 0:10:14.476 would be lower on an allocation list. Where does that 0:10:14.516 --> 0:10:18.556 fit within sort of standard good medical medical ethics. I 0:10:18.596 --> 0:10:22.156 suppose I would have to know what you mean by disabilities. 0:10:22.756 --> 0:10:26.996 So many of the protocols do have exclusion criteria. There 0:10:27.036 --> 0:10:32.996 are particular illnesses that we specify, and if patients came 0:10:33.036 --> 0:10:36.116 in with those illnesses, we would not allocate a ventilator 0:10:36.156 --> 0:10:40.956 to them. But the exclusion criteria that most commonly are 0:10:41.036 --> 0:10:46.236 discussed our exclusion that suggests that death is imminent. So, 0:10:46.316 --> 0:10:50.276 for example, a person comes in with a severe bleed 0:10:50.396 --> 0:10:55.196 in the brain that almost certainly will cause death, such 0:10:55.236 --> 0:10:57.796 a person would not be given a ventilator according to 0:10:57.836 --> 0:11:03.036 these allocation guidelines in crisis situations because death is imminent, 0:11:03.716 --> 0:11:06.716 So the exclusion criteria that are most commonly used are 0:11:06.756 --> 0:11:10.036 ones that really are quite close to the point of death. 0:11:10.316 --> 0:11:12.396 So the language that they used, I'm quoting from the 0:11:12.396 --> 0:11:16.276 Alabama protocol here. There are some patients for whom the 0:11:16.276 --> 0:11:20.036 possible should not offer mechanical ventilator support, and those include 0:11:20.036 --> 0:11:22.956 heart failure, respiratory failure, metastatic cancer. So that fits what 0:11:22.996 --> 0:11:26.396 you're describing. And then it also says that quote persons 0:11:26.396 --> 0:11:31.076 with severe mental rechardation, advanced dementia, or severe traumatic brain 0:11:31.156 --> 0:11:35.396 injury may be poor candidates for ventilator support. So it's written, 0:11:35.716 --> 0:11:39.516 you know, it's not written as mandatory. It's maybe poor candidates. 0:11:40.156 --> 0:11:43.276 And maybe if you have advanced dementia, that's highly probable 0:11:43.276 --> 0:11:45.956 that you will die sooner, and so perhaps that's an explanation, 0:11:45.996 --> 0:11:49.156 and ditto for traumatic brain injury. I suppose the language 0:11:49.156 --> 0:11:52.636 that motivated the disability rights advocates to bring a complaint 0:11:53.276 --> 0:11:57.996 was the formulation that says persons with severe mental rechardation. Yeah, 0:11:58.036 --> 0:12:00.076 I think many of us are very uncomfortable with that 0:12:00.196 --> 0:12:02.756 sort of an assertion. The criteria of most hospitals with 0:12:02.796 --> 0:12:06.356 which I'm familiar is not to look at specific aspects 0:12:06.436 --> 0:12:11.236 of mental ability, cognitive ability and even know what you're 0:12:11.236 --> 0:12:13.716 saying about dementia. Dementia is a disease that easily last 0:12:13.796 --> 0:12:16.796 ten years, So we have to be careful about how 0:12:16.796 --> 0:12:20.476 we use these terms. And that's why many hospitals are 0:12:20.516 --> 0:12:22.716 most comfortable with when we know death is imminent. This 0:12:22.756 --> 0:12:25.236 person is really going to die within hours. Those are 0:12:25.236 --> 0:12:28.796 the people that in times of crisis, we would consider 0:12:28.836 --> 0:12:33.436 withholding ventilators from if there were a ventilator shortage. We'll 0:12:33.476 --> 0:12:45.156 be back in just a moment. May ask you the 0:12:45.516 --> 0:12:49.836 difference from the standpoint of standard medical ethics between removing 0:12:49.956 --> 0:12:54.796 someone from a ventilator in order to enable another person 0:12:54.836 --> 0:12:59.756 to have that ventilator, as opposed to allocating that ventilator 0:12:59.836 --> 0:13:02.876 in the first instance to somebody on the basis of 0:13:02.916 --> 0:13:05.716 criteria that are in a protocol. Do you see those 0:13:05.716 --> 0:13:09.876 two things typically as different in some important way or 0:13:09.916 --> 0:13:15.476 do you think of them is basically equivalent ethically and morally. 0:13:15.916 --> 0:13:19.796 The arguments that are typically used is that they are 0:13:19.836 --> 0:13:25.876 the same emotionally, they are hugely different, and the idea 0:13:25.876 --> 0:13:29.116 of removing a ventilator for both a patient's family and 0:13:29.236 --> 0:13:32.516 for the treating team, the medical doctors. It takes an 0:13:32.636 --> 0:13:37.156 enormous emotional toll, which is why most people right now 0:13:37.156 --> 0:13:39.756 with this coronavirus pandemic want to try to avoid doing 0:13:39.796 --> 0:13:42.996 that no matter what, because there's already enough moral distress. 0:13:43.596 --> 0:13:46.076 It's already difficult enough. The last thing we want to 0:13:46.076 --> 0:13:49.156 do is add to that by removing patients from ventilators. 0:13:49.356 --> 0:13:51.356 So the sort of the better move is to try 0:13:51.356 --> 0:13:54.836 to allocate them up front. Right, So, going back to 0:13:54.876 --> 0:13:57.756 the sofa scores that we discussed earlier in this conversation, 0:13:58.596 --> 0:14:02.556 the only sofa scores again, in many of these triage protocols, 0:14:02.556 --> 0:14:04.956 I can't speak for all, the only sofa scores that 0:14:06.596 --> 0:14:11.036 those having to allocate ventilator would rely upon. Our sofa 0:14:11.076 --> 0:14:15.436 scores that show progressive worsening. Anyone who is sort of 0:14:15.636 --> 0:14:19.916 holding his or her own or showing any evidence of improvement, 0:14:19.956 --> 0:14:22.676 there would never be any consideration given to removing a 0:14:22.756 --> 0:14:25.476 ventilator from that person. And if you push me further 0:14:25.516 --> 0:14:27.876 and you say, well, still, what if what if we 0:14:27.916 --> 0:14:31.876 get to the point where all ventilators are allocated, everyone 0:14:32.156 --> 0:14:35.516 who is failing, you know, has died and the only 0:14:35.516 --> 0:14:37.916 people left on ventilators are people who are sort of 0:14:37.916 --> 0:14:41.236 holding their own or improving, and still someone comes in 0:14:41.316 --> 0:14:44.516 who needs one, then it's probably going to revert to 0:14:44.556 --> 0:14:48.196 a first come, first serve scenario because there's no other option. 0:14:48.276 --> 0:14:51.116 We're not going to cut short someone's life who is 0:14:51.116 --> 0:14:54.196 a possibility of life in order to give someone else 0:14:54.236 --> 0:14:57.076 a possibility of life. That just wouldn't That wouldn't be right, 0:14:57.076 --> 0:15:00.596 and no one, no one would be comfortable with that. Again, 0:15:00.636 --> 0:15:02.836 that the idea is to help as many people as 0:15:02.876 --> 0:15:05.556 possible and to save as many lives as possible, not 0:15:05.796 --> 0:15:09.636 in any way to jeopardize someone's life. That that's never 0:15:09.676 --> 0:15:12.836 the goal. So the first in time rule, which is 0:15:12.876 --> 0:15:16.436 really a luck rule, would then kick in as well, 0:15:16.476 --> 0:15:19.636 because we don't have anything better to do at that point. Yeah, Frankly, 0:15:19.676 --> 0:15:22.276 I don't know that you know the protocols get to 0:15:22.356 --> 0:15:24.476 that level. I think you know there are so many 0:15:25.076 --> 0:15:28.516 patients in any given hospital on any day that are 0:15:28.676 --> 0:15:32.516 languishing on a ventilator that are not showing improvement, and 0:15:32.636 --> 0:15:37.836 it's it's specifically because everyone holds out hope and frankly, 0:15:37.876 --> 0:15:41.396 as I've written about, don't want to have to face 0:15:41.516 --> 0:15:44.476 mortality that we often keep trying. We keep trying and 0:15:44.556 --> 0:15:48.076 keep trying. That's sort of the way that we've all 0:15:48.116 --> 0:15:52.476 been socialized, both physicians and Americans. Can I just ask 0:15:52.516 --> 0:15:56.636 you about ventilator splitting, which you know we're not there yet, 0:15:56.676 --> 0:16:00.116 but again, it seems like one of the possible responses 0:16:00.676 --> 0:16:04.276 Leaving aside the technology of whether it's doable, does it 0:16:04.356 --> 0:16:08.636 strike you as problematic from an ethical perspective? Where is 0:16:08.636 --> 0:16:11.596 it simply a matter of the probabilities it's more likely 0:16:11.596 --> 0:16:13.556 to help the people than just helping one of them, 0:16:13.876 --> 0:16:16.436 We should take a crack at it. Sure. I mean, 0:16:16.516 --> 0:16:19.796 it's been reported in the New York Times that Columbia 0:16:19.836 --> 0:16:26.396 Presbyterian pioneered this, So it's definitely doable. It's enormously complex, 0:16:26.916 --> 0:16:29.596 much more difficult cult than having a single patient on 0:16:29.716 --> 0:16:34.316 event later, but it works and if it comes to 0:16:34.356 --> 0:16:38.076 that we can do that. It's possible. It wouldn't automatically 0:16:38.076 --> 0:16:42.396 double the number of ventilators that we have because patients 0:16:42.436 --> 0:16:46.516 have to have similar needs, because they share single United 0:16:46.596 --> 0:16:50.956 ventilator settings which are highly tailored to each individual patients. 0:16:50.996 --> 0:16:54.476 So there are a lot of factors that would need 0:16:54.516 --> 0:16:57.076 to be tailored. There but it would certainly increase our 0:16:57.156 --> 0:16:59.996 ventilator capacity if it came to that. Can I ask 0:17:00.036 --> 0:17:02.796 you what are you seeing? I mean, what are the 0:17:02.876 --> 0:17:06.596 ethical issues that ethicis are most pressed about right now 0:17:06.636 --> 0:17:08.916 that you are most pressed about right now? What are 0:17:08.916 --> 0:17:12.156 the challenges that you've seen that are uncertain where it's 0:17:12.156 --> 0:17:13.636 not so simple just to say, well, we know what 0:17:13.716 --> 0:17:15.676 to think about this because we have a protocol in place. 0:17:16.436 --> 0:17:19.516 The question of whether to resuscitate a particular patient is 0:17:19.556 --> 0:17:22.316 really on a lot of people's minds. Some of the 0:17:22.396 --> 0:17:27.556 arguments against that are that resuscitation is very, very messy, 0:17:28.076 --> 0:17:32.996 and it leads to body fluids and aerosolization, which is 0:17:32.996 --> 0:17:35.476 where the virus goes into the air and spreads everywhere, 0:17:35.836 --> 0:17:39.836 and so it significantly increases the amount of virus that's 0:17:39.916 --> 0:17:44.636 around and infectious and able to make the healthcare worker sick. 0:17:45.116 --> 0:17:49.156 Any resuscitation attempt requires an enormous team size and a 0:17:49.156 --> 0:17:52.436 lot of personal protective equipment. The so called ppe that 0:17:52.996 --> 0:17:56.036 everyone has heard that there's been a shortage of so 0:17:56.396 --> 0:18:00.516 between the risk and the danger of it, the fact 0:18:00.516 --> 0:18:02.836 that we've already stopped doing a lot of procedures in 0:18:02.836 --> 0:18:05.196 the hospital in this current moment that lead to this 0:18:05.276 --> 0:18:08.516 aerosolization of the virus. A lot of people feel that 0:18:08.556 --> 0:18:13.236 we should not be doing CPR. Some people feel that 0:18:13.396 --> 0:18:19.196 no patient with coronavirus should have resuscitation. In my view 0:18:19.236 --> 0:18:21.796 and in the view of many many ethicis that is 0:18:21.956 --> 0:18:26.036 far too extreme. Certainly, we're having patients come in who 0:18:26.276 --> 0:18:31.276 could easily be resuscitated with good outcomes, and so I 0:18:31.316 --> 0:18:36.476 would be very uncomfortable with a blanket restriction on resuscitating 0:18:36.596 --> 0:18:40.036 anyone who walks in with coronavirus. Having said that, it's 0:18:40.076 --> 0:18:45.716 not uncommon for patients with coronavirus to have a cardiac arrest, 0:18:45.836 --> 0:18:49.836 meaning their heart stops and they die for a successful 0:18:50.076 --> 0:18:54.396 resuscitation attempt, and then for a repeat cardiac arrest, so 0:18:54.436 --> 0:18:56.996 they die again. That's something we're seeing quite a bit. 0:18:57.636 --> 0:19:01.316 And many people feel that if a patient is dying again, 0:19:02.156 --> 0:19:04.116 even though we've tried to bring them back, but they 0:19:04.156 --> 0:19:07.196 die again rather imminently, that this is someone who does 0:19:07.236 --> 0:19:12.356 not show long term good odds for survival. This question 0:19:12.476 --> 0:19:15.916 is probably more pressing right now for doctors on the 0:19:15.956 --> 0:19:19.476 front lines than even the question of ventilater allocation. That's 0:19:19.516 --> 0:19:21.716 completely fascinating, and I will say I think it's almost 0:19:21.756 --> 0:19:24.756 completely underreported. You said that you think it's too extreme 0:19:24.916 --> 0:19:30.596 to say, given those risks, we shouldn't resuscitate people who 0:19:30.596 --> 0:19:34.116 have cardiac arrest on corona the first time at least why. 0:19:34.196 --> 0:19:36.236 I mean, the risk is not only to the people 0:19:36.276 --> 0:19:39.116 in the room, that's the healthcare workers, but it's also 0:19:39.116 --> 0:19:41.676 to everybody else in the hospital, because once i'm these aerosolis, 0:19:41.716 --> 0:19:44.356 you don't have a perfect seal around the hospital rooms. 0:19:44.516 --> 0:19:47.836 I mean, it's you're creating a huge externalized risk for 0:19:47.916 --> 0:19:51.996 everybody else. And if resuscitation has a high probability of 0:19:51.996 --> 0:19:54.756 working in the individual case, and yet we know that 0:19:54.836 --> 0:19:57.836 it often doesn't last in other words, that people then 0:19:57.916 --> 0:20:00.996 have to they die again, it seems like a perfect 0:20:00.996 --> 0:20:03.996 case to say, well, gee, we're just not going to 0:20:04.036 --> 0:20:06.876 do it under these circumstances. What am I missing there? 0:20:07.676 --> 0:20:09.996 So you're missing the forty year old who comes in 0:20:09.996 --> 0:20:13.236 with a heart attack, which still happens, and hospitals are 0:20:13.276 --> 0:20:15.356 testing patients as they walk in the door, and he's 0:20:15.396 --> 0:20:18.436 COVID positive and he has a cardiac arrest in the 0:20:18.516 --> 0:20:23.116 emergency room. Do you not resuscitate him because he's not 0:20:23.196 --> 0:20:25.676 dying of the coronavirus. He's dying of a heart attack, 0:20:25.876 --> 0:20:27.716 that's right. What we don't want to do is get 0:20:27.716 --> 0:20:30.876 the black X on people's names because they have coronavirus 0:20:30.956 --> 0:20:34.316 when they would be so easy to resuscitate them. I see. 0:20:34.316 --> 0:20:36.796 So what you're really describing is maybe there should be 0:20:37.596 --> 0:20:40.436 pulling back on resuscitating people who are dying of the 0:20:40.476 --> 0:20:45.916 coronavirus and are probably going to die again after being resuscitated. 0:20:46.076 --> 0:20:47.556 I don't know that I'd want to go on record 0:20:47.596 --> 0:20:50.316 as saying I'm advocating for it, but I will definitely 0:20:50.356 --> 0:20:51.916 go on record as saying this is something people are 0:20:51.956 --> 0:20:54.276 very concerned about right now. It's one of the top 0:20:54.316 --> 0:20:58.876 ethical issues we're debating in a book. You actually opened 0:20:58.916 --> 0:21:01.676 your book with a kind of a graphic, if I 0:21:01.716 --> 0:21:04.956 may say so, a description of a resuscitation in a 0:21:04.956 --> 0:21:08.396 pretty standard case. This is not a coronavirus situation, And 0:21:08.556 --> 0:21:11.436 the strong takeaway for the reader is that we do 0:21:11.516 --> 0:21:15.556 this much, much too much. Anyway, Does that affect you're 0:21:15.596 --> 0:21:18.676 thinking about this situation at all. The whole way that 0:21:18.716 --> 0:21:22.556 the coronavirus pandemic has been discussed has been a focus 0:21:22.636 --> 0:21:28.876 on delaying death, and there's been very little reported about 0:21:28.876 --> 0:21:32.316 how we should actually use this as an opportunity to 0:21:32.356 --> 0:21:35.556 think about our mortality and start to get our advanced 0:21:35.596 --> 0:21:37.756 directives in order, and not to mention all the other 0:21:37.796 --> 0:21:41.596 documents and share our passwords with our significant others. Things 0:21:41.596 --> 0:21:43.636 like that. That's not so much a part of the 0:21:43.636 --> 0:21:47.236 conversation right now. So, yes, I've reflected on my book 0:21:47.356 --> 0:21:51.836 a lot. I do think people would die much better 0:21:51.916 --> 0:21:54.556 deaths if they had a lot more preparation and if 0:21:54.556 --> 0:21:59.356 they started preparing now rather than waiting until they're sitting 0:21:59.396 --> 0:22:03.156 in the emergency room with coronavirus or whatever other disease. 0:22:03.916 --> 0:22:07.156 Because this coronavirus pandemic too shall pass, but there will 0:22:07.196 --> 0:22:10.636 be something else for all of us. Moves us to 0:22:10.676 --> 0:22:14.036 think about these things now and to plan for them. 0:22:15.436 --> 0:22:19.876 One last question about their resuscitation issue. If a decision 0:22:19.916 --> 0:22:24.076 were taken on, for example, not resuscitating some people who 0:22:24.076 --> 0:22:27.276 are close to dying from coronavirus, would that be a 0:22:27.276 --> 0:22:30.196 decision that was taken at individual hospital levels, would it 0:22:30.196 --> 0:22:33.676 be taken at statewide levels? Would it be a federal decision? 0:22:33.756 --> 0:22:38.236 How do the mechanics of implementing an ethical intuition like 0:22:38.316 --> 0:22:41.436 that work themselves out in the real world, most of 0:22:41.476 --> 0:22:44.516 them are at hospital levels. I was on a call 0:22:44.596 --> 0:22:47.556 with an ethesis from California, and it sounds to me 0:22:47.676 --> 0:22:50.716 that the u SEE system in California is coming up 0:22:50.716 --> 0:22:53.796 with the guidelines that they expect many other hospitals in 0:22:53.836 --> 0:22:57.116 California to adopt. But at the end of the day, 0:22:57.156 --> 0:23:00.236 it's going to be an individual hospitals legal counsel who's 0:23:00.276 --> 0:23:06.156 comfortable with supporting and individual hospitals clinicians and practitioners through 0:23:06.316 --> 0:23:10.596 this time. Having said that Governor Cuomo in New York 0:23:10.596 --> 0:23:15.676 State where I practice, granted civil and criminal immunity to 0:23:16.036 --> 0:23:20.876 healthcare practitioners on Friday, backdated to March seventh, to give 0:23:20.916 --> 0:23:25.516 protections obviously not for anything that was ill intentioned, but 0:23:25.836 --> 0:23:28.996 to give protections for anything that may result during this 0:23:29.076 --> 0:23:31.036 time when we are working as hard as we can 0:23:31.076 --> 0:23:33.516 to save lives. Yeah, and that which was advocated for 0:23:33.516 --> 0:23:35.396 were very strongly by two of my colleagues at Harvard 0:23:35.436 --> 0:23:38.836 Law School, Glen Cohen and Andrew Crispo, as part of 0:23:38.836 --> 0:23:42.356 a broader team, is aimed at just making sure that 0:23:42.396 --> 0:23:44.276 of all the worries that you the physicians have, you 0:23:44.316 --> 0:23:47.156 don't also have the worry about being suitor being prosecuted. Well, 0:23:47.196 --> 0:23:49.436 thanks to your colleagues for that. Thank you so much 0:23:49.516 --> 0:23:52.716 for talking through these really, really hard questions with us. 0:23:53.156 --> 0:23:55.436 I think it's super useful for me and for listeners 0:23:55.876 --> 0:23:57.196 to get a sense of what it's like on the 0:23:57.236 --> 0:23:59.156 front lines, and what are the issues you're struggling with, 0:23:59.556 --> 0:24:01.676 and also how you're thinking about the big picture issues 0:24:01.716 --> 0:24:04.476 that we hope you won't have to confront, but you know, 0:24:04.476 --> 0:24:06.356 if we're not lucky, you may indeed have to. Thank 0:24:06.356 --> 0:24:09.996 you so much for your time. Thank you. Speaking to 0:24:10.036 --> 0:24:13.956 doctor Lydia Dugdale really brings home the difficulties that are 0:24:13.996 --> 0:24:17.756 facing medical ethicists as they try to make extremely challenging 0:24:17.836 --> 0:24:22.636