Worst Case: Choosing Who Survives in a Flu Epidemic

最近，纽约州医疗健康部门公布了一项针对教会医院医务人员的新规定。

H1N1流感病毒逐渐蔓延，并迅速恶化为全国性的流行病。一个32岁的甲流患者不幸引发了阑尾炎并发症，他同时还患有囊肿性纤维化症，只有依靠呼吸器的辅助他才能勉强活命，{wy}的希望就是等到移植手术所需的合适的肺。

纽约政府要求紧急状态下所有医院必须遵守的呼吸器分配指导原则，这一原则制定于2007年。即在医疗资源极度紧张的情况下，把呼吸器留给那些最有希望康复的病人。1918年流感大爆发时有数以千计的人感染了肺炎，指导原则就是为应对这种情况制定的。

先前提到的那个病人，囊肿性纤维化已使他的肺病进入了晚期，这就意味着他已被列入了高危名单。根据指导原则，即使他病情稳定，并有好转的迹象，他也不得不把呼吸器留给那些更有希望康复的人。即使医生也知道他会好起来，他们也不得不这么做。

医护人员会按这个指导原则办？他们会吗？

近年来，很多州和地方政府以及xx退伍军人医疗健康管理局都私下制定了预案以应对这个棘手的问题：当病人超过医疗资源的承受限度时，谁该获得活下去的机会？

方案也因州而异。在一些州，那些在DON名单内的人，包括一些无法自理的老人、需要透析或者神经损伤的病人都将不能配给呼吸器，有些州甚至禁止他们去医院接受xx。犹他州则把流感过程划分了阶段，在流感开始阶段，指导原则只适用生活在残障保护机构、疗养院和监狱里的人们。如果疫情进一步恶化，适用范围就会扩大至普通大众。

xx官员称未来几周全国加护病房被流感病人挤爆的可能性非常小，但是仍然不能掉以轻心。

指导原则并未吸引公众太多的注意力。早在2007年草拟方案之时，纽约就公开了45天的建议期，但并未收到修改意见。要不是国家档案法有要求，医疗健康部门都不会发布这份90页的解释材料。

Mary Buckley-Davis是一位有着30年临床经验的呼吸疾病专家，2007年他曾致信政府说如果这样要求医院拿去病人的呼吸器，那么将会“引发一场暴乱”。“世上不会有任何方法”来平息这些“放弃xx”家庭的愤怒。

州和xx政府辩解道，指导原则是所有防疫措施的{zh1}一步，它将{zd0}限度的利用稀缺资源并使公众利益{zd0}化。他们称，统一分配比放任资源随意争抢的效果要好很多。

“不要单看一个病人，把眼光放得远大些，想想全社会的病人。” 健康和公共事业部门的Rear Adm. Ann Knebel如是说。

但是有专家质疑这项计划是否可以公平、有效地施行？它是否符合伦理道德？是否可以落实到偏远地区？

几乎所有的计划都是为了应对可能到来的大规模伤亡事件。由伤重程度和存活概率将患者分为不同的优先等级。不过，大多数质疑声都集中在两个附加条款上。

一个是“排除标准”，一些重症患者因此将得不到医院的正常xx。而另外一个“{zd1}生存权”，限制一些病人使用医疗资源。一旦规则开始施行，未康复的病人只能被迫放弃xx，把医疗资源让给那些康复中的病人。

9·11事件后，有杂志发文讨论了遭遇生化恐怖袭击后的伤者处理方案，这可以算作是指导原则的雏形。这篇文章的作者是Dr. Frederick Burkle Jr.他曾作为救援官员参加了越南战争、海湾战争以及冷战时期英国防核打击计划，他说这些思想都来自他的亲身经历。在海湾战争时，他曾有一次要求正在做手术的外科医生去救另外一个更有希望救活的人，之后才回来继续xx先前的病人。

安大略省的禽流感和其他流行传染病防疫计划就是以Dr. Burkle的思想为核心的，这项计划始于SARS肆虐之后。它与美国明尼苏达州一个医生组织的指导原则十分相似。

但Dr. Burkle的思想与其还是有很大区别的。Dr. Burkle在文章里说要以更加灵活的形式提供更好更有效的医疗服务，而不是撒手不管病人。

一些州的指导原则要求极其苛刻，遭遇严重疫病时只使用单一死板的标准来划分。这令Dr. Burkle很苦恼，道：“我对我妻子说，我亲手打开了怪兽的笼门。”

现在问题更加严重了。一些州的防疫计划要求，如果病人在2到5天还没有康复迹象的话，就强制撤去呼吸器。而研究显示，正常情况下甲流病人都需要使用呼吸器一到两周才能康复。

也有人持相反意见，他们称无论从经济还是道德方面看指导原则对公众都是有益的，尽管他们对一些病人漠然处之并拒其于门外。

正常情况下，从病人的身上撤去生命辅助设备，如果未经家属同意，那么就等同于谋杀。纽约教会医院的医护人员说，如果没有相应的法律保护，他们一定不会按指导原则的要求去做。

而且假如病人自己拥有呼吸器，指导原则中并没有相应的处理办法。这一问题是由Dr. Kenneth Prager提出的，他是胸腔内科医生同时也是一位伦理学家。他说：“撤去病人呼吸器的做法是如此的决绝，甚至没有为之后可能出现的情况留下处理、应对的余地。”

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.

The triage plans have attracted little publicity. New York, for example, released its draft guidelines in 2007, offered a 45-day comment period, and has made no changes since. The Health Department made 90 pages of public comments public this week only after receiving a request under the state’s public records laws.

Mary Buckley-Davis, a respiratory therapist with 30 years experience, wrote to officials in 2007 that “there will be rioting in the streets” if hospitals begin disconnecting ventilators. “There won’t be enough public relations spin or appropriate media coverage in the world” to calm the family of a patient “terminally weaned” from a ventilator, she said.

State and federal officials defend formal rationing as the last in a series of steps that would be taken to stretch scarce resources and provide the best outcome for the public. They say it is better to plan for such decisions than leave them to besieged health workers battling a crisis.

“You change your perspective from thinking about the individual patient to thinking about the community of patients,” said Rear Adm. Ann Knebel of the Department of Health and Human Services.

But some health professionals question whether the draft guidelines are fair, effective, ethical, and even remotely feasible.

Most existing triage plans were designed for handling mass casualties. They sort injured victims into priority categories based on the urgency of their medical needs and their potential for survival given available resources. Much of the controversy over the state plans focuses on two additional features.

These are “exclusion criteria,” which bar certain categories of patients from standard hospital treatments in a severe health disaster, and “minimum qualifications for survival,” which limit the resources used for each patient. Once that limit is reached, patients who are not improving would be removed from essential treatment in favor of those with better chances.

A version of these concepts was outlined in a post-9/11 medical journal article that suggested ways to handle victims of a large-scale bioterrorist event. The author, Dr. Frederick Burkle Jr., said he based his ideas in part on his experiences as a triage officer in Vietnam and the gulf war and on a cold war-era British plan for coping with a nuclear strike. Dr. Burkle said that during the gulf war he once instructed surgeons to halt an operation and work on another patient who was more likely to survive. Surgeons later returned to the first patient.

Dr. Burkle’s ideas were key aspects of guidelines Ontario authorities drew up after SARS to plan for avian flu and other pandemics. This approach and one by a team of Minnesota doctors were modified by groups developing similar guidelines in the United States.

There were important distinctions. Dr. Burkle’s original paper did not anticipate withdrawing care from patients and stressed the need to reassess the level of supplies “sometimes on a daily or hourly basis” in a fluid effort to provide the best possible care.

Some states’ triage guidelines are rigid, with a single set of criteria intended to apply throughout the severe phase of a pandemic. That disturbs Dr. Burkle. “I have said to my wife, I think I developed a monster here,” he said.

Recent research highlights the problem of a one-size-fits-all approach to triage. Many state pandemic plans call for hospitals to remove patients from ventilators if they are not improving after two to five days. Studies show that people severely ill with H1N1 flu generally need a week to two weeks on ventilators to recover.

There is also controversy over what values and ethical principles should guide triage decisions, how to engage the public, and whether withdrawing life support in the hospital and withholding it at the hospital door are distinct.

Normally, removing viable patients from life support against their or their families’ will would be considered murder. The New York-Presbyterian Hospital employees who participated in the recent exercise said they would not comply unless given legal protection.

They also never figured out what to do with that hypothetical patient who had his own ventilator, said Dr. Kenneth Prager, a pulmonologist and ethicist. “The issue of removing patients from ventilators,” he said, “was so overwhelming that it precluded discussion of further case scenarios.”

Sheri Fink, an M.D., is a staff reporter at ProPublica, the independent nonprofit investigative organization.