By Mike Carter

The Seattle Times

Washington state and hospital officials have been meeting to consider what once was almost unthinkable — how to decide who lives and dies if, as feared, the coronavirus pandemic overwhelms the state’s health care system.

“We don’t want to do it. We don’t think we should have to do it,” said Cassie Sauer, chief executive of the Washington State Hospital Association, which along with state and local health officials has been involved in refining what Sauer called a”crisis standard of care” — essentially guidelines to health care officials on who should receive treatment and who should be left to die.

“If we have to do this, then we want to do it in a fair and rational and thoughtful way,” Sauer said.

Dr. Vicki Sakata, the senior medical adviser to the Northwest Health Care Response Network, said a group of medical officials and other experts have been discussing how the state would deal with a crisis that overwhelmed the medical system. She prefers to add the word “planning” to the idea of “crisis standard of care” because, in her mind, the goal is to avoid a crisis in the first place.

That said, the state is prepared to act if it has to and has developed guidelines that will be implemented across the system, from the bedside doctor to hospital systems.

“We will do it as a state under an ethical framework that is part of the state plan,” she said. “It will be overseen by an objective team who has been thoroughly briefed on the protocols and processes, and will be undertaken in a transparent and equitable manner.

“But, make no mistake, it will not be pretty,” said Sakata, who is a practicing emergency medicine physician. “That’s why we are taking the steps we are taking now, the social distancing, the hand washing, all of that, so sometime down the road nobody is left having to decide who gets resources, and who doesn’t.”

Sakata said her network, which comprises 15 Western Washington counties, has been working on crisis standard-of-care planning since 2012, and wanted to assure the public that all efforts and resources are being aimed at managing the COVID-19 outbreak so that the health care system doesn’t collapse under the strain of too many patients at once.

The orders restricting gatherings and urging people to practice social distancing is all aimed at slowing the outbreak and spreading the cases that do appear out over time so the system is not swamped.

Sauer said she was talking about the plan in hopes of convincing the federal government to release additional medical stores from the Strategic National Stockpile, where it keeps much-needed ventilators and other equipment necessary to treat the sickest of the COVID-19 victims.

“This is America,” she said. “We have resources. We should not be in this position.”

The New York Times reported on Friday that state and health care officials held a conference call to discuss the triage plan. It reported the plan will assess factors such as age, health and likelihood of survival in determining who will get access to full care and who will merely be provided comfort care, with the expectation that they will die, the newspaper reported.

State Department of Health (DOH) officials told The Seattle Times on Friday they were meeting to further refine guidelines. DOH Director Dr. Kathy Lofy, in an email, acknowledged development of the crisis triage plan.

“Over the past several years, a group of clinical experts in the Puget Sound area developed guidance around how health care might need to be delivered differently during emergencies if supplies, staffing, and or hospital beds become limited,” Lofy wrote. “We are doing everything possible to slow the spread of the virus and increase resources within the health care system so that resources will be available for everyone who needs them.”

DOH spokeswoman Lisa Stromme said the department will release information on the triage guidelines soon, saying it is “one of our top priorities.

“However, it will not be discussed externally until we can discuss it internally in the right way,” Stromme said. “It’s too crucial.”

Sauer is concerned that it is too early to determine whether the social distancing order by state and local officials and the shuttering of restaurants, schools and public places will effectively slow the spread of the virus. If not, Sauer said most projections indicate that regional hospitals will be swamped with COVID-19 patients over the next several weeks.

Some projections put Seattle’s outbreak on the same scale, but just a few weeks behind, northern Italy, where on Thursday alone there were more than 5,300 new COVID cases reported. Italy has reported 41,000 infections and more than 3,400 people have died, some because doctors there have had to make choices like Sauer and her colleagues were talking about in Seattle on Friday.

Sauer said the guidelines are being finalized and she hopes they are never implemented. If they are, then treatments will be allocated to “the greatest number of people who are likely to survive,” with others provided comfort care and allowed to die.

The decision will be made regionally, so no one doctor or hospital will have to make the decision, Sauer said. At that point, it is anticipated that every hospital would be overcrowded and resources would be limited.

The coronavirus has proven to be particularly virulent among the aged and individuals suffering from underlying health problems. If a triage plan has to implemented, Sauer said, decisions will be mostly be based on people in those two categories.

“They will be less likely to receive care, and more likely to die” so that people with a better chance of recovering can live, she said.