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APRIL 15, 2020 — The COVID-19 epidemic has put unprecedented strain on the US healthcare system. Equipment is running out, physicians are falling ill, and case numbers are still growing exponentially from day to day.
To accommodate this increase in volume, the Centers for Medicare & Medicaid Services, along with many state agencies, has issued directives that nonessential care be discontinued, in the hopes that those resources and personnel can be redeployed to fight the spreading coronavirus.
This is a well-intended move but it has not been well executed. The term “essential care” is amorphous and ambiguous. It has left patients and hospital systems wondering what should and should not fall under that potentially wide umbrella. It’s also important because decisions will almost certainly be made about how and in what order to restore services as the pandemic abates.
Efforts to determine what care should qualify as essential have devolved into emotional appeals and publicity campaigns for different interest groups hoping that the squeaky wheel will get the grease. These efforts are understandable but they undermine the fundamental purpose of restrictions on nonessential care, which is to limit resource utilization. Instead, they’re designed to secure as many resources for a particular group of patients, regardless of whether funneling resources to that group is the best use of those resources in a time of scarcity
To determine which care should be proceeding in the age of COVID-19, we need to dispense with terms like “necessary” and “essential” and instead focus on the purpose of limiting care provision.
Two Critical Resource Questions
The goal should be to divert as many resources as we can to fight COVID-19. That can be condensed into two questions:
What lifesaving procedures must we do? Our healthcare system has a responsibility to protect patients from the terrible outcomes of serious health issues whenever possible: lifesaving surgeries, chemotherapies, etc. These are the actions that must be taken, even if they take resources away from COVID-19 patients.
What else can we do? In other words, what non-emergency/non-life-sustaining medical care can be undertaken or gradually restored without drawing significant resources away from the COVID-19 effort?
Ultimately, the challenge is: How can we achieve the most good with limited resources? On the one hand, there’s a global pandemic that we know will kill people, including healthcare workers, thereby stretching our resources thin. On the other hand, there are patients with chronic and critical healthcare needs, many of which cannot safely be ignored for months while resources are diverted to COVID-19 patients.
These two basic considerations of what we must do and what else we still can do combine into a two-part framework that is simple but potentially useful. The framework doesn’t try to answer the question of which particular medical services should be continued, but instead provides a structured, ethical way to think about which sorts of services should be considered essential and which services might be offered even if not deemed essential. This framework also provides guidance for thinking about the order in which services are to be restored in hospital settings as the pandemic abates.
The first question to address using this framework is: Does delaying treatment worsen a life-threatening or debilitating prognosis?
If yes, the treatment is probably essential. This covers a substantial segment of healthcare; emergency care, aggressive cancer treatments, dialysis, and organ transplants are all examples of services that would qualify.
Cosmetic procedures and many elective procedures would not satisfy this criterion. Tommy John surgery (ulnar collateral ligament reconstruction), which received some media attention because two Major League pitchers received the surgery at the end of March as other elective procedures were being canceled, would not qualify. While not receiving the surgery would delay the recipients’ return to athletic activities, such ligament tears are often chronic, and the long-term prognosis doesn’t worsen over the span of a few months.
Quality of Life vs Critical for Survival
Meeting this threshold requires that postponing care will not worsen a life-threatening or debilitating prognosis. This doesn’t necessarily rule out all elective procedures. Certain oncologic surgeries, for example, are deemed elective because they don’t need to happen on an emergency basis. However, the longer they’re postponed, the larger the tumor will get, damaging structures around it, and the higher the chance of life-threatening metastasis.
There is a gray area: care that patients need to significantly improve their quality of life but that won’t worsen their prognosis if they must wait for it. Orthopedic procedures are a good example. Joint replacements for patients who can’t walk due to severe arthritis would greatly improve their quality of life. But even if those patients need to wait an extra 3-4 months to have an operation, their postprocedure prognosis remains good.
This category is where restrictions on nonessential care will hurt the most. These patients are often suffering while they wait for the care they need. Some can’t work until they receive treatment, leaving their financial future in jeopardy. For others, waiting for care takes an emotional toll. It’s difficult to comprehend the pain felt by patients in the throes of difficult and expensive fertility treatments that have been put on hold, or patients awaiting gender-affirming surgeries that have been canceled.
But scarcity forces difficult decisions. If the overall prognosis remains unchanged with a temporary delay, then the personal protective equipment (PPE) and personnel would be better spent in COVID-19 wards.
If delaying treatment doesn’t worsen a life-threatening or debilitating prognosis, then we consider part 2 of the framework: Does providing this care take away substantial resources that are necessary for the efforts against COVID-19? This includes physician time, PPE (masks, gloves, drapes), hospital beds, operating rooms, etc.
If no, then it can probably continue. Many of the interventions considered above would also fail this benchmark. Tommy John surgery requires substantial highly skilled physician and nurse time, lots of PPE, and valuable OR time. IVF would require significant PPE, as every patient and staff member requires such equipment for the frequent appointments. Each of these procedures also requires extensive lab support.
Preserving Resources, Preserving Patient Care
A good example of a healthcare service that would pass the resource-utilization part of the analysis—and so could be allowed to continue—is outpatient psychiatric care. Much of psychiatric care can be provided remotely. The main resource it requires is the psychiatrist’s time. At the moment, most psychiatrists have not been drafted into intensive care settings, so continuing with telepsychiatry doesn’t take resources away from COVID-19 patients.
Very early elective abortion, despite being deemed nonessential in some locales, passes as well, in that pharmaceutical abortion is not resource-intense.
The devil is in the details regarding restrictions based on resource utilization. Any in-person healthcare interaction for the foreseeable future will require masks at the very least—masks that could be sent to emergency departments and intensive care units to protect doctors and nurses.-
But there are some instances of in-person, nonessential care that use so few resources that they might be permitted to continue. An example of this type of care is Botox injection for migraines. While this procedure requires the use of masks, gloves, and physician time, it takes only about 10 minutes and is performed just once every 3 months. Moreover, one of the most common presenting complaints in emergency departments is severe migraine headache. So, if providing this treatment keeps patients out of emergency departments, the overall resource utilization may be lowered by administering Botox in the outpatient setting.
The framework presented here doesn’t definitively determine which healthcare services should continue during the COVID-19 pandemic and which should be temporarily suspended, nor does it permit politics to shape what is restricted or restored.
What it does do is discard unhelpful labels such as “essential” or “necessary” and provide a structure for how to think through care decisions in a way that promotes what healthcare institutions are trying to achieve through care rationing.
Restoring medical services ought to be guided by the redeployment of resources that put the least strain on the system while making the biggest difference to those at most risk for death or disability. As the pandemic runs its course, this framework can be used to assess which services should be reinstated as the resource landscape changes. No physician wants to ration care, but if it’s done in a thoughtful, consistent, objective way, it can help ensure that as many patients as possible receive the care they absolutely need while still getting the care they might want.
Arthur L. Caplan, PhD, is director of the Division of Medical Ethics at New York University Langone Medical Center and School of Medicine. He is the author or editor of 35 books and 750 peer-reviewed articles as well as a frequent commentator in the media on bioethical issues.
Shailin A. Thomas is enrolled in a joint MD/JD program between New York University Grossman School of Medicine and Harvard Law School.
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