The reality of rationing of care as hospital beds fill up and staff run out

Hospitals in some places are closer to capacity than in others.

In Arkansas, Governor Asa Hutchinson said in a briefing last week that there were only 23 intensive care beds available statewide. “It’s closer than we would like, but it’s better than it has been. And so we continue to monitor this,” Hutchinson said, adding that 27 new intensive care beds will be brought online this this month.

In Kentucky, Governor Andy Beshear exposed the severity of the spread of Covid-19 in his state on CNN last week, saying that while hospitals are not yet on the verge of having to make tough choices about rationing of care, “we’re just at” or “quickly approaching that point.”

“We are in a very difficult situation, Kate,” he told CNN’s Kate Bolduan. “We brought in FEMA, National Guard response teams, we deployed nursing students statewide, we took over hospital testing just to free additional people.”

And in Alabama, a grieving family asked others to get vaccinated after Ray DeMonia, a resident of Cullman, Alabama, died about 200 miles from his home in a Mississippi hospital because there was no had no cardiac intensive care beds nearby. Her daughter Raven DeMonia shared her story with the Washington Post on Sunday.

“Health care rationing is nothing new”

When hospitals are short of beds or when staff are weak, tough decisions have to be made about which patients should be the first to receive care. Overall, hospitals and healthcare systems have plans on the table to deal with patient overflow and make such difficult decisions.

“All hospitals and health systems have plans in place to deal with an increase in the number of patients. These plans may include actions such as adding more beds, including in non-traditional areas of care in a hospital such as a cafeteria or parking lot, moving patients between hospitals, and working with their local health departments and national governments to find alternative care sites, ”Akin Demehin, American Hospital Association (AHA) policy director, wrote in an email to CNN on Friday.

“Sometimes that includes sending patients to hospitals in neighboring states who may have the capacity to treat them,” Demehin wrote. “Another option that some hospitals have taken is to reduce or suspend so-called elective procedures which are not urgent and can be safely delayed for a period of time. “

Yet for the most part, hospital capacity isn’t just about the number of beds occupied – a hospital can usually add beds – but many facilities are much more concerned with having enough staff to care for patients, according to Demehin.

“Hospitals and health systems have entered the COVID-19 pandemic already facing a shortage of skilled caregivers, and the past 18 months have exacerbated this,” Demehin wrote, adding that the AHA called on the administration. Biden to work as a partner to develop strategies to address the health workforce shortage.

Overall, decision-making regarding rationing of care may be different depending on the type of medical facility – a hospital or a private practice.

“There are different decisions, whether it’s a doctor’s office or an emergency room,” Art Caplan, professor of bioethics at NYU Langone Health in New York, told CNN.

“You don’t have the right to be treated by a primary care doctor. There is still no right to health care this way – the doctor has the ability to refuse,” Caplan said, adding for example that some doctors might refuse to take Medicaid as a patient’s insurance or might refuse to treat patients who have not received certain vaccines because that patient could pose a risk to the doctor or the health of other patients .

Yet “in the emergency room there is a federal law that says you have to take anyone, even if they don’t have money, and stabilize them. It’s called EMTALA, and it’s been around for quite some time. time, ”Caplan said.

“Health care rationing is nothing new in the American health care system,” he added. “It’s just Covid which is new, but no rationing.”

Who receives an intensive care bed?

The Emergency Medical Treatment and Work Act or EMTALA requires hospitals with emergency departments to provide a screening medical examination to anyone who presents to the emergency department and requests treatment. The law also prohibits hospitals with emergency departments from refusing to examine or treat people with emergency medical conditions.

Now, during the pandemic, many Covid-19 patients filling hospital beds are not being vaccinated. EMTALA bonds remain in place.

As Covid-19 hospitalizations increase, some overwhelmed hospitals are rationing care

“Hospitals usually don’t consider why a critically ill patient is there,” Caplan said. “The way it might become relevant is if you thought it was a predictor of a bad outcome.”

For example, if a hospital runs out of beds or mechanical ventilators, it may prioritize care for patients who are considered more likely to respond to care and survive – that is, a 26-year-old Covid-19 patient. with no underlying health. the conditions could be a priority for the care of a 90-year-old patient with lung failure and other medical conditions, Caplan said.

“Or, if not being vaccinated and having lung failure puts you at a worse chance of survival compared to someone who just arrived with asthma and lung problems but is vaccinated “said Caplan. “Many places would prioritize the vaccinated asthmatic patient as opposed to the unvaccinated lung failure patient. What they are monitoring are outcomes and the likelihood of success.”

My son was fortunate enough to have a pediatric intensive care bed when he needed it.  He shouldn't have needed luck

In hospitals so overwhelmed that they have to ration care, those decisions should not be based on whether or not a person has chosen to be vaccinated against Covid-19, Dr Anthony Fauci said Thursday.

“If you ask, should you prefer a vaccinated person over an unvaccinated person, this is something that is still widely discussed, but in medicine I know that you do not harm someone because of their behavior. “Fauci, director of the National Institute of Allergy and Infectious Diseases, told CNN’s Anderson Cooper.

“You just don’t do that in medicine,” Fauci said.

Fauci added that the decision of where to direct “scarce resources” must be based on a “medically sound” reason, “not in a punitive way for someone’s behavior.”

“We are in a situation of limited resources”

Throughout the pandemic, Covid-19 has put a strain on the U.S. healthcare system – and hospitals continue to face tough decisions about which patient comes first when staff are low and beds are tight. full.

“We are already making these choices and they are very difficult choices. I work in the intensive care unit. A lot of people have serious illnesses but not illnesses where they will die immediately, but serious illnesses where they need to. ‘an operation and some of these operations are so serious that after surgery they have to be in the intensive care unit for a day or two – heart valve replacement, surgery for serious cancers like pancreatic cancer ”, Dr. Steven Brown, an intensive care pulmonologist at the Mercy Virtual Care Center in St. Louis, CNN’s Ana Cabrera told Thursday.

“If the intensive care unit beds are all filled with patients on ventilators due to their pneumonia, surgeries must be postponed,” Brown said. “We have situations where people can come into the hospital with a heart attack, and they have to stay in the emergency room for long periods of time waiting for a bed to open.”

Unfortunately, in some cases, the fact that a bed becomes free means that a patient has died.

“It’s a sad situation that we haven’t really seen in American history for a long, long time.” Brown said. “We’re in a situation of limited resources right now, and when you have limited resources, we’re in triage situations – and some people can die from it.”

CNN’s Holly Yan, Rebekah Riess, Bonney Kapp and Lauren Mascaren contributed to this report.