• With coronavirus cases and hospitalizations rising around the country, hospitals may soon have to decide which patients can be treated in the ICUs.
• Coronavirus cases have been rising over the past month.
• On Thursday, daily cases hit a new high, with more than 87,000 cases.

Many parts of the United States are seeing record numbers of people hospitalized for COVID-19. Unless this abates soon, some hospitals could be forced to decide which critical patients can be treated in overcrowded intensive care units (ICUs).

Some states are already nearing the point at which they will need to activate their “crisis standards of care” plans to ration care.

In Utah last week, a group of hospital administrators presented Gov. Gary Herbert with a list of criteria doctors would use to decide which patients receive intensive care, The Salt Lake Tribune reported.

This plan, which requires the governor’s approval, would take into account a patient’s condition, likelihood of survival, and age.

If two patients had similar conditions, doctors would prioritize giving ICU care to younger patients, because older patients are more likely to die from COVID-19.

The situation in Utah is not unique.

Across the United States, coronavirus cases have been rising over the past month. On Thursday, daily cases hit a new high, with more than 87,000 cases.

Hospitalizations are also on the rise in all parts of the country, reports the COVID Tracking Project. The rise is especially steep in the Midwest, where the per capita hospitalization rate surpassed the spring peak.

In addition, the Institute for Health Metrics and Evaluation estimates that health systems in 13 states will be nearing their hospital bed capacity by December or January. Health systems in 18 states will be nearing ICU capacity during that same period.

How hospitals decide who gets care

Hospitals can do a number of things to accommodate an influx of patients.

In Washington state during the early COVID-19 peak, healthcare systems worked together to ensure that patients with COVID-19 and ventilators were shared among hospitals, so no single hospital would be overburdened.

Hospitals can also add additional beds, or states can set up field hospitals, as Wisconsin recently did. In some parts of the state, 90 percent of the ICU beds are full.

Beds and ventilators, though, are just one part of the equation. Hospitals don’t always have enough staff to handle extra patients, especially staff that can treat patients who are critically ill.

Staffing shortages can be worsened if doctors, nurses, and other healthcare personnel are unable to report for duty because they or a family member test positive for the coronavirus or if they become seriously ill themselves.

If these measures aren’t enough and the influx of patients exceeds a healthcare system’s capacity, hospitals may have to start rationing care.

Many states have crisis standards of care plans, but these vary widely in terms of what factors are used to decide which patients are treated.

One review of state plans found that the majority included ethical considerations, such as not using race, ethnicity, disability, or similar factors to make care decisions.

However, some plans allowed healthcare workers and other essential personnel to be prioritized to receive care.

All the reviewed plans took into account the functioning of a patient’s organs, which physicians use to predict a patient’s risk of dying.

Certain plans also considered other health conditions — such as heart disease, kidney failure, or cancer — in deciding which patients should receive limited resources.

Having plans in place during a surge in patients enables healthcare systems across a state to be consistent in how care is rationed.

“These plans are put into effect so that there’s not ad hoc rationing, or bedside rationing, so you don’t have people just making one-off decisions,” said Diane Hoffmann, JD, a professor of healthcare law at the University of Maryland School of Law.

“Another reason for a systemwide set of rules is that if everyone follows them, we should maximize the number of lives saved,” she added.

Having a plan also takes some of the pressure off physicians who are directly caring for patients.

The plans typically call for each hospital to have a triage team in place. These are medical experts such as ICU or emergency care physicians or nurses.

“They will review data about all the cases coming into the institution, and be able to evaluate which patients should receive the limited resources,” said Hoffmann. “So the individual physician at the bedside is protected from having to make that decision.”

Letting people choose their level of care

Diana Mason, PhD, RN, a professor in the Center for Health Policy and Media Engagement at George Washington University School of Nursing, says rationing care during the COVID-19 pandemic is not inevitable, especially since we know a lot more now than in the spring about how the coronavirus spreads.

“We shouldn’t have to get to the point of rationing care,” she said. “If people did the right thing, if people wore a mask and did social distancing, we would not be there.”

While the goal of rationing care is to save as many lives as possible, Mason says hospitals should not assume that every patient with COVID-19 wants aggressive care.

In March, when COVID-19 was surging in New York City, Mason was contacted by an older neighbor who was frantic about her local hospital potentially becoming overwhelmed with patients with COVID-19.

“Her greatest fear was not of dying, but of dying alone and breathlessly,” said Mason. “She understood that when you cannot breathe, it is a horrible feeling, and she didn’t want to die that way.”

For some people, such as those who are nearing the end of their life or who have another serious illness, the question may be, “Do I even want to go to the hospital if I get COVID-19?”

Mason says that in the spring, the geriatrics home care program at the Icahn School of Medicine at Mount Sinai in New York City reached out to its clients to ask them this very question.

“There were a lot of people who did not want to go to the hospital,” said Mason. “They thought, ‘I’m already homebound. I’m at the end of my life, and I don’t want to go through that. I would rather die at home with my family around me.’”

For patients with COVID-19 who wanted to remain at home, Mount Sinai provided families with comfort packs. These kits included medications for managing the patient’s symptoms, personal protective equipment, and instructions on how to give the medications and call for help.

These kinds of programs can help patients die with dignity, but Mason says patients should not feel like they are being forced to go home and die an agonizing death alone.

ProPublica recently documented several cases in New Orleans where patients with COVID-19 were sent home to die without hospice support or personal protective equipment for the families. Some people became sick themselves while caring for a family member.

“If hospitals are having to ration care,” said Mason, “they must have a protocol in place for how they will provide comfort care — palliative care — for those who don’t get a ventilator.”

While end-of-life conversations are difficult for both patients and doctors, Mason says thinking ahead can make it easier if you get seriously ill.

“If you don’t already have an advance directive or haven’t identified somebody who could be your healthcare proxy, you need to do so right away,” she said.

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