New York state health officials recently laid out this wrenching scenario for a small group of medical professionals from New York-Presbyterian Hospital:
A 32-year-old man with cystic fibrosis is rushed to the hospital with appendicitis in the midst of a worsening pandemic caused by the H1N1 flu virus, which has mutated into a more deadly form. The man is awaiting a lung transplant and brought with him the mechanical ventilator that helps him breathe.
New York's governor has declared a state of emergency and hospitals are following the state's pandemic ventilator allocation plan — actual guidelines drafted in 2007 that are now being revisited. The plan aims to direct ventilators to those with the best chances of survival in a severe, 1918-like flu pandemic where tens of thousands develop life-threatening pneumonia.
Because the man's end-stage lung disease caused by his cystic fibrosis is among a list of medical conditions associated with high mortality, the guidelines would bar the man from using a ventilator in a hospital, even though he is, unlike many with his illness, stable, in good condition, and not close to death. If the hospital admits him, the guidelines call for the machine that keeps him alive to be given to someone else.
Would doctors and nurses follow such rules? Should they?
In recent years, officials in a host of states and localities, as well as the federal Veterans Health Administration, have been quietly addressing one of medicine's most troubling questions: Who should get a chance to survive when the number of severely ill people far exceeds the resources needed to treat them all?
The draft plans vary. In some states, patients with Do Not Resuscitate orders, the elderly, those requiring dialysis, or those with severe neurological impairment would be refused ventilators, or admission to hospitals. Utah divides epidemics into phases. Initially, hospitals would apply triage rules to residents of mental institutions, nursing homes, prisons and facilities for the "handicapped." If an epidemic worsened, the rules would apply to the general population.
Federal officials say the possibility that America's already crowded intensive care units would be overwhelmed in the coming weeks by flu patients is small but they remain vigilant.
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