Who gets to live? COVID-19 is causing moral distress among India’s doctors
It was one of the hardest decisions Dr Anand*, who has 25 years of medical experience, has had to make in his professional career. His shift at the ICU in a private hospital in Chennai was coming to an end on May 2 when he found out that there were six COVID-19 patients, whose oxygen saturation had fallen below 80%. “Their respiratory rates were also so high that we knew if they don’t get oxygen or ventilation, they may not make it to the end of the day,” he recalls.
All six of them had to be shifted on priority to the ICU, but there was just one bed available in his hospital. It was a moral dilemma that Dr Anand struggled with. “I had to do risk profiling by age. Is he a breadwinner of the family? I looked at persons who had comorbid conditions like diabetes, two patients were on dialysis,” he says. The decision came down to two patients in the end — a 72-year-old man and a 42-year-old medical representative. Dr Anand says he chose the younger patient. “I gave the chance to him. He has a child who is around five years old. So I knew this person needed to live.”
Despite his decision, Dr Anand says he was despondent, unable to give a bed to the others. But that day was only the first in what would become a daily ordeal, he narrates. “That happened to be the first time. I had so many questions that are still unanswered — did I do wrong, did I choose the wrong person?” says the 54-year-old doctor.
The COVID-19 pandemic in India, particularly the second wave, is causing moral distress among healthcare professionals like Dr Anand, forcing them to choose who gets to live and who may end up dying. The acute shortage of beds that provide high intensity care — such as ICU, ventilator and high-flow nasal cannula equipment — is forcing doctors, nurses and their hospitals to ration these scarce resources, causing an ethical dilemma for many, nearly every single day.
“Every physician wants the best for their own patients. It causes great moral distress for treating physicians to choose between their own patients with regards to allocating a life-saving resource like an intensive care bed or ventilator,” says Dr Priya Pais, who is Convenor of the Hospital Ethics Committee at St John’s Medical College Hospital in Bengaluru
Dr Anand recalls another incident that happened in early May at his hospital. “I had to push two patients on the same bed because they crashed at the same time. So I pushed them to the ICU and told the staff, you please take these patients to the ICU, because I need to intubate one patient, another needs to be put on non-invasive ventilation. They shared a bed for three-four hours until the staff arranged an extra bed,” he says.
The crisis that is unfolding in hospitals across cities and towns in India requires extraordinary decisions. Dr Anand reasons, “When you have a shortage of beds, you have to forego the rules of ICU because these are all extraordinary situations, and you have to make extraordinary decisions. Some may be the right decisions, some may not be.”
Several big cities in India have seen and continue to see families of critical COVID-19 patients desperately seeking ICU, ventilator and oxygen beds, making appeals on social media, using any means they can to get their loved ones the urgent care they need to treat them. With COVID-19 cases rising every day, finding hospital admissions for high intensity care is increasingly difficult as demand outstrips the available resources. Chennai had only 10 vacant ICU beds out of the total 2000 as of May 13, as per the Tamil Nadu government. Finding ICU and HDU beds in Bengaluru is equally bleak, with government hospitals and government medical hospitals in the city reporting no vacancies, as per BBMP data on May 13.
And while many out-patients are turned away by hospitals citing shortage, doctors say their resources are stretched thin for in-patients as well.
Dr Sanjiv Lewin, the Chief of Medical Services at St John's Medical College Hospital, tells TNM that as on May 11, the 1,350-bed institution had over 1,150 occupants. Out of this, over 84% patients have COVID-19. “I have approximately 103 patients in my ICUs and over 64 patients on ventilators round the clock,” says Dr Lewin, “Ventilators are being used 24/7. Unless somebody improves and gets off the ventilator or expires, I am unable to accommodate another. This is a constant cycle of demand on these ventilators. We refuse to allow ventilators and ICU beds to lie vacant. We are constantly shuffling our resources because we are in no position to keep any resource unutilised.”
Putting the acute shortage of these resources into perspective, Dr Priya Pais says St John’s Medical College Hospital ICU has about 15 patients at any time waiting for a single available bed.
The picture is no different in smaller hospitals as well. Dr Zubair*, a pulmonologist who works at a smaller institution in Bengaluru, says all 10 ICU beds in his facility were occupied. “We have to decide among a couple of patients, who gets the ventilator and who doesn’t,” he says.
Hospitals in several towns are also seeing rationing of their resources. Dr Devaprasath Jeyasekharan, Managing Trustee at Jeyasekharan Medical Trust in Nagercoil, says, “From the time the pandemic started, that is exactly the problem we are facing, as an out-patient or as an in-patient. Ours is a kind of a referral centre here for those who are treated at a smaller hospital. When they come here they are high-dependent straight away. High dependent beds require manpower, doctors, as well as supportive measures and other equipment.”
His 200-bed hospital, he says, has the manpower and even beds, with those getting shifted to ICU getting appropriate treatment. But because the facility is running at full occupancy at the moment, Dr Devaprasath explains that they are stretched for resources like medicines and oxygen to treat patients.
“In a place like ours, we have the manpower, we have doctors, we even have beds but the problem is that things required to treat the patients like oxygen, medications which are yet to come in, are grossly lacking. It is not good for the morale of any doctor who is forced to titrate the best option treatment to any patient. We as doctors believe that anybody who is in a bad shape may come around. If they don’t come around because of your inaction, it will always be in the back of your mind, hurting,” Dr Devaprasath says.
Making the hard choice
Several doctors TNM spoke to across cities say they follow a selection criteria similar to what Dr Anand narrated on who gets an ICU bed, a ventilator, or high flow nasal cannula when there are multiple critical patients and limited resources. Despite several hospitals reporting oxygen shortage, doctors say that as of now that they have never had to choose which patient gets the lifesaving gas and who doesn’t. The dilemma is largely limited to intensive care.
“We have to look at who has a better chance of living. It is very difficult, but we have to make a calculated decision,” says Dr Zubair.
Dr P Shravan Kumar, Superintendent at Gandhi Hospital in Hyderabad, explains that COVID-19 patients whose oxygen saturation levels have dropped below 75% despite being given high levels of oxygen, are the ones who are shifted on priority to the ICU. However, when the difficult choice needs to be made on who gets the lone ICU bed, doctors choose youngsters and those who have no comorbid conditions.
“Basically, youngsters must live longer, family issues are more. Those who are newly married, with children, their future may not be settled. Youngsters have to live longer, that is nature’s law. So we are all abiding by nature’s law,” says Dr Shravan, adding, “Youngsters are an asset to society. The future depends on youngsters.”
Explaining a doctor’s rationale, he says that an elderly patient who has multiple cardiac issues, lung issues or may be on dialysis may end up surviving COVID-19, but may later die because of his pre-existing conditions. Dr Shravan says, “Suppose a patient has only COVID-19 and no comorbid conditions, they are the priority for us. Once he/she recovers from COVID-19 he/she will be hale and healthy and recover fast rather than an elderly person with multiple issues. That’s our attitude.”
Dr Latha*, a senior clinician working in a small town in Tamil Nadu’s Kanyakumari district, says, “During disasters, the people who are involved are very many in number. So there is something called triaging. And during a disaster, the strategy changes and the strategy becomes — you still have three groups, but the group that is likely to recover is likely to be given the care as far as possible. And that is to say, somebody who is too ill and is unlikely to survive, the economics do not work towards utilising the resources for that kind of individual because then you would be able to cater to very few.”
Framing guidelines and setting up ethics committees
These utilitarian principles that Dr Latha and others point to are not new. Countries like Italy that were hit hard by the COVID-19 pandemic last year had also drawn up an allocation criteria based on which patient would have the highest chance of surviving.
Foreseeing such a situation of rationing happening in India, St John’s Medical College in Bengaluru had its Ethics Committee draw up guidelines last year on how to allocate scarce resources like ICU beds and ventilators. This was done to ensure ethical allocation of medical resources during the pandemic when demand would exceed available resources, and also to reduce the moral burden upon individual physicians from continuously having to choose one patient while denying others, says Dr Priya Pais, who is the Convenor of the Ethics Committee at the hospital.
Detailing the process of resource allocation, she narrates, “We have a group of physicians who take requests for intensive care beds. They consider each case separately so that every patient in need is given individual, expert consideration."
The committee, Dr Priya says, are made up of senior physicians experienced in managing critically ill COVID-19 patients. They take various factors into consideration including how sick the patient is, the patient's age, comorbidities and probable clinical outcomes if they are shifted to the ICU. The goal is to provide care to those in the 'greatest need', while also aiming to achieve the 'greatest good for the greatest number', she explains.
Dr Priya, however, points out that there is no set algorithm in place when the committee takes a decision. “The physicians who take these resource allocation decisions on a daily basis say that they don't follow rigid protocols because every circumstance is different but these factors are what go into making these decisions.”
For doctors and nurses who are caring for these patients up close, however, the system has helped reduce their mental and moral burden. Dr Sanjiv Lewin says prior to having the ethical guidelines, making the decision on which patient gets a resource (bed, ventilator, high flow nasal flow cannula, non-invasive ventilation, etc) was an traumatising event for the individuals forced to decide.
“It is extremely stressful if they don’t have some guideline of sorts to justify the difficult decisions they are forced to take when demand and need grossly outweigh the available resources. So we brought this out in the first surge itself, our Hospital Ethics Committee had a good discussion and disseminated guidelines to staff on such resource allocation keeping the ethical principle of distributive justice in mind. Such decisions are a huge psychological burden for any doctor and nurse,” the Chief of Medical Services says, “We have had doctors and nurses coming out of their shifts breaking down in tears, angry and feeling guilty they couldn't do enough. Some require psychological and psychiatric counselling because they are taking decisions way beyond their years. So therefore, yes it is so important for us to have some ethical guidelines even though it is imperfect.”
He adds that having such a system in place also ensures that the requests from VIPs or those with connections are stymied. “I hand it over to the triage and war room. They use fundamental ethical guidelines along with triage such as severity, first come first serve, in patient versus emergency patient crashes, age among other parameters to guide their decisions. Such a system relatively shields them from external pressures to an extent in an attempt to be objective, even thick skinned, taking necessary facts and figures and then deciding which is relatively morally more acceptable for all of us concerned. Otherwise, we are under tremendous pressure to help people. Everybody is in the same boat. It has been one of the toughest times our teams have faced,” says Dr Lewin.
Unlike St John’s Medical College, most hospitals — big or small, government or private — don’t have guidelines for their healthcare professionals to follow while making decisions on allocations. A paper published in the Indian Journal of Medical Ethics had in April 30, 2020 recommended, “Local guidelines must be developed to support healthcare providers in making rationing decisions that are relevant and acceptable to the community.” In addition, the authors of the paper also called for the government to focus on setting up clinical ethics consultations for any healthcare provider or team faced with a moral conflict.
But having guidelines on rationing is a contentious subject. Dr Devaprasath Jeyasekharan says his hospital will not be drawing up guidelines on rationing decisions. “Who are we to decide who will live? Someone who is 75 years old may have another 10 years of good quality life, he may be able to settle his family etc so we can’t say that he is better than a diabetic who is 48 years old. So we are not making such decisions unless it is a comatose patient who has had two days of oxygen therapy and other things and his oxygen hasn't picked up. That man will probably not make it. So trying to waste 15 litres of oxygen on him will not be a good idea. We are not making any initial criteria on who should make it and who should not,” emphasises Dr Devaprasath.
A paper titled ‘Allocating scarce intensive care resources during the COVID-19 pandemic: practical challenges to theoretical frameworks’ published in The Lancet in April 2021, notes that triage decisions based on utilitarian principles may end up discriminating against disadvantaged groups.
“Those who are poor and less educated suffer from worse health status and higher mortality, and they are therefore at a higher risk of serious disease when falling sick with COVID-19. Triage decisions based on maximisation of benefits would additionally disadvantage these individuals. Similar observations are true for those who are racially disadvantaged and for disabled people,” the paper states. The authors call for applying principles promoting fair equality of opportunity when confronted with rationing decisions, and ensuring equity for vulnerable populations.
But guidelines or no guidelines, doctors say taking the call is always hard and painful on who gets a scarce bed, and by extension who gets to live, and who doesn’t.
Dr Priya explains it’s by no means an easy task even for the team that takes the final decision on who gets an ICU bed. She says, “These decisions are difficult to make because they know the consequences of refusing a patient - that he or she might die if they don’t make it in. It is distressing to have to break the news to patients and their families, who are desperate. It is challenging for the entire healthcare team, not just to make these decisions, but also abide by them when our whole focus is on providing the best possible treatment to every patient in our care.”
Dr Zubair says, “It is very difficult, we are not gods, we don’t know who will live and who won’t. If we had ventilators for everyone, nothing better than that. We can give the best to everybody, irrespective of age, caste, creed.”
*Names changed on request