Four years ago, Clark County Public Health’s Ethics Committee needed a project to work on.
The ethics committee, which consists of a diverse group of community volunteers, settled on creating a ventilator allocation plan in case the county’s ventilator capacity was stressed beyond its capabilities.
The plan did not seem pressing at the moment, but as Clark County Public Health Officer Dr. Alan Melnick told The Columbian last month, “anybody who works in this field can know this stuff happens” when it comes to virus outbreaks.
Wording from a 2017 project summary has proved prescient now that there’s a pandemic.
“The surge of patients requiring intensive care during an influenza pandemic could overwhelm the medical care capacity of many communities, including ours,” the appendix reads. “During a pandemic, shortages of ventilators and other medical equipment could place physicians and other health professionals in conflict with each other when advocating care for their patients.”
While Clark County’s medical care capacity has not been overwhelmed by the pandemic so far, the ventilator allocation plan has properly positioned and prepared the county should a resurgence of cases overwhelm hospitals in the coming months as Washington counties reopen.
The plan, which is in the last stage of finalization and follows state Department of Health standards, would have been difficult to start and complete in the middle of a pandemic. Many voices that were used to sculpt the plan have been busy doing front-line work.
Melnick, who has co-written a book about public health ethics, said working on the allocation plan is challenging but inspiring because community members come together to seek solutions.
In order to complete the plan, the ethics committee sought input from faith leaders of many denominations, atheists, critical care doctors, people with disabilities, The League of United Latin American Citizens and many more groups to make sure the plan was equitable and thorough.
Without any plan in place, a first-come, first-served method is generally used, Melnick said. The ethics committee’s goal, Melnick said, was to create a ventilator allocation plan that would “preserve the most lives, and the most life years.”
Melnick explained how two criteria were tweaked after community input.
The committee originally came up with a primary goal that “everybody should have the opportunity to see every stage of life,” Melnick said. Some people felt like that could be an ageist approach for who gets a ventilator. The committee then changed the plan to make it so that age was a prognostic factor. Age would come into play if the virus in question killed older people at a higher rate than younger people.
In the case of COVID-19, where age is tied to severe complications, age is a scoring factor for ventilator allocation.
Another issue that arose was the scoring of comorbidities, or the presence of a chronic disease or condition in addition to the virus. Some community members worried that if comorbidities were given too much weight, it would lead to racial disparities in who got a ventilator. The plan was changed to differentiate between the seriousness of comorbidities and how long someone is expected to be able to live with their comorbidities. Minor comorbidities that didn’t impact lifespan were taken out of the scoring criteria.
“This is the reason for doing a community deliberation,” Melnick said. “Getting that perspective helps. I think it’s a better plan because of it.”
If the plan ever needed to be activated, it calls for a triage team of a critical care doctor or hospitalist, a critical care nurse, and an ethicist that would decide on ventilator allocation. That way the treating physician would not be in charge of making the decision.
The triage team would not have access to names, race, gender or many other factors that could bring discrimination into play. As Melnick, said, “it would not matter if you are the mayor or the president.”
“These are tough discussions to have,” Melnick said. “When we started working on the plan, I hoped we’d never have to use it, and I still hope we never have to use it.”