Bioethics Forum Essay
After the Surge: Prioritizing the Backlog of Delayed Hospital Procedures
The rewards of social distancing are beginning to accrue in former hotspots such as Seattle, the New York metropolitan area, and the San Francisco Bay Area, where the number of new Covid-19 cases requiring hospitalization is declining. Assuming the rewards hold in the face of pressures to reopen the economy, hospitals will now face challenges of reopening their own nonpandemic services for patients whose elective surgeries and other procedures were postponed. Which patients should get priority?
Anticipated shortages of ICU beds and ventilators, as well as hospital beds in general, forced a significant re-orientation in the allocation of resources from a conventional individual patient-focused duty of care to a more community-focused duty of care aimed at saving as many lives as possible. In a sense, this is a shift from procedural justice—striving to treat everyone as equal (a goal if not a reality in all cases)—to a focus on outcomes-–striving to save as many lives as possible. As part of triage, myriad elective and other procedures were postponed to reserve resources for Covid patients, in accordance with recommendations from the Centers for Disease Control and Prevention and professional organizations such as the American College of Surgeons. Even many needed interventions that were time-sensitive were postponed, such as surgeries to remove cancerous tumors before they metastasized.
As we transition back to scheduling nonpandemic interventions, we will return to procedural justice—striving to treat everyone equally. But, given the backlog, we will have to take other factors into account, including the severity of need, risk of progression, and continued risk of Covid-19 infection. But even these factors raise justice-related issues. Should surgery for a hernia that is at risk of getting worse be prioritized over surgery for lower-back pain that is unlikely to further progress—even if the back surgery was scheduled weeks before the hernia operation? Patients who were scheduled for surgery earliest will feel entitled to priority. Their priority, however, might be undermined not only by consideration of outcomes, but also the renewed emphasis on procedural justice.
In normal circumstances, “first-come, first-served” is widely recognized as biased toward those with better insurance and access to health care services, since they are able to schedule medical appointments earlier in the progression of their condition than people with poor insurance and access, who often delay seeing a primary health provider. Thus, a first-come, first-served policy can exacerbate existing unjust disadvantages by prioritizing those with the best insurance and access over those with the most need.
Scheduling decisions could be further complicated by the need to distribute limited available slots among a variety of specialties, including oncology, orthopedics, cardiology, and urology. Within each of these, there will be a range of cases with different levels of risk from delay–risks such as progression of disease, debilitation, disability, and pain. Tools to measure the potential benefits from surgery and risk of harm from delay will need to be evaluated clinically to determine if they are suitable for prioritizing surgeries during a time of scarcity. These tools include the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Surgical Risk Calculator and the GRACE risk score for acute coronary events.
In addition, severity of need will have to be balanced against the risk of non-Covid patients becoming infected with the coronavirus in the hospital. Hospitals have long been recognized as incubators of disease. This problem is magnified when a crisis such as a pandemic overwhelms a hospital’s capacity to practice normal infection control. In addition, well-documented shortages of PPE exacerbate risk among health workers and patients, and the possible infectiousness of people who are asymptomatic or have mild symptoms unrecognized as signs of Covid mean that it will likely be impossible to guarantee full protection against hospital-based exposure in the initial stages of reopening nonpandemic services. For patients with comorbidities that increase the risk of mortality from Covid-19, the further heightened risks of infection from hospitalization for an intervention will need to be balanced against the risk of disease progression if intervention is further delayed.
Finally, one of the defining features of a pandemic surge (as opposed to a surge in need for care from catastrophic events such as earthquakes, hurricanes, or terrorist bombs) is its sustained nature. Especially for diseases like the novel coronavirus, where the potential for re-infection and/or limitations of immunity are unknown, the potential for second or third “waves” is significant. We must carefully weigh these factors as we determine how many postponed procedures to reschedule and when.
Jana M. Craig, PhD, is the regional director, Ethics Department, at Kaiser Permanente, Northern California. Mark P. Aulisio, PhD, is the Susan E. Watson Professor and Chair, Department of Bioethics, Case Western Reserve University School of Medicine. Thomas May, PhD, is the Floyd and Judy Rogers Endowed Professor at Washington State University.