Rationing Scarce Resources: The Potential Impact of COVID-19 on Patients with Chronic Kidney Disease
Authors: Jeffrey Silberzweig, T. Alp Ikizler, Holly Kramer, Paul M. Palevsky, Joseph Vassalotti, Alan S. Kliger
Journal: Journal of the American Society of Nephrology (2020)

During the coronavirus disease 2019 (COVID-19) pandemic, the first surge of infected patients hospitalized between March and May 2020 threatened to overwhelm hospitals' capacity and existing resources.1 Preventive measures successfully reduced the severity of the crisis but as of June 23, 2020, the United States had suffered 120,674 deaths among 2,332,755 patients with COVID-19: a case fatality rate of 5.2% based on tests positive for severe acute respiratory syndrome coronavirus 2. In the state of New York, the diagnosis of new cases decreased from a peak of 10,824 on April 9 to 644 on June 21.2 At the height of the pandemic, the dramatic increase in the need for ventilators to support the respiratory needs of patients with COVID-19 led to discussions of potential rationing or sharing of this equipment. Although clinicians in several states turned to published guidelines14–45 which prioritized increasing the supply of ventilators rather than rationing these limited resources, serious discussions were held about how ventilator resources would be rationed if patient need exceeded available supply. Fortunately, ventilators were obtained from federal stockpiles and new manufacturers, averting a crisis requiring rationing. Nonetheless, this experience laid bare the need to consider a fair and rational approach to rationing if ever such a crisis occurs in the COVID-19 pandemic, or other similar pandemic situations. As supplies dwindled, hospitals and state policymakers turned to crisis-management policies—many of which were drafted in the pre–COVID-19 era—to determine how best to manage potential shortages.5 Numerous criteria can direct allocation of scarce life-sustaining resources including fair-chance systems (either "first come, first served" or a lottery system), and criteria based on estimates of short- and long-term survival, age, and value to others. These criteria are not mutually exclusive and may be combined to develop a priority system.6 For example, the state of Maryland published a set of guidelines in 2017 outlining "a multi-principled approach… that strives to save the most lives, preserve the most years, prioritize evidence-based decisions, and show compassion to non-recipients."4 They used focus groups to engage the public in this discussion. More recently, Emanuel et al.7 published recommendations guiding who gets health resources during the COVID-19 pandemic: "maximizing benefits, treating equally, promoting and rewarding instrumental value and giving priority to the worst off." During the COVID-19 pandemic, they recommend maximizing benefits; prioritizing health workers; not allocating on a first-come, first-served basis; responsiveness to evidence; recognizing research participation; and applying the same principles to all. These types of nuanced approaches are preferable to other proposals that categorically exempt certain populations from receiving care. For example, in 2010, the state of Alabama published its guidelines as an Annex to ESF 8 of the State of Alabama Emergency Operations Plan3 that "outlines a ventilator triage protocol intended for use only during a mass casualty event." The guidelines suggest that if all efforts to obtain ventilators are exhausted, clinicians should consult a list of exclusion criteria to guide decision making. The guidance goes on to state that in the event of a mass casualty respiratory emergency, patients with end stage organ failure, including anyone on or requiring dialysis, would not receive ventilator treatment. Fortunately, in response to concerns raised by patient advocates, the Office of Civil Rights of the US Department of Health and Human Services resolved a compliance review after the state removed ventilator rationing guidelines that allegedly discriminated on the basis of disability and age.8 As clinicians in the field of nephrology, we understand all too well the challenges of triaging patients and allocating scarce resources.9 In 1962, as described in Shana Alexander's grim article in Life magazine, "They Decide Who Lives, Who Dies", lack of funding required rationing of hemodialysis and the Seattle Artificial Kidney Center charged a committee of physicians, nurses, and community and civic leaders with developing an allocation system. The committee based its decisions primarily on a subjective assessment of "social worth," an assessment of the individual's anticipated contribution to society. As applied, these criteria favored employed white men over other groups. Recently, Gauray Jain10 wrote a letter to the editor of Mayo Clinic Proceedings stating "CKD/ESRD should not be a blanket exclusionary condition in the provision of critical care services, including ventilator support." We agree. To avoid the mistakes of arbitrary or social-worth criteria to decide who will live and who will die in the COVID-19 era, we urge policymakers, hospital leaders, and physicians to consider the following recommendations. All published guidelines on the allocation of scarce healthcare resources state that any rationing should not occur until we exhaust all efforts to increase the availability of the limited resources and adapt existing devices to serve as many individuals as possible.Innovation is required to increase the availability of the limited resources by adapting other devices or creating new ones. The need for innovation in the present circumstance includes efforts to increase ventilator and acute dialysis capacity. Although we are used to a surfeit of resources, our society needs to recognize and prepare for contingencies if resources are not available at the time they are needed.In that case, efforts—like those undertaken in Maryland—should include public focus groups to help put medical and ethical guidance into a more universal perspective. The process must be transparent and the resulting guidance must be shared publicly. As guidelines are developed, they must refrain from excluding whole classes of individuals because of specific diagnoses. Should these contingencies emerge, a more balanced approach like that proposed by White et al.11 is warranted. The use of standardized assessment tools like Sequential Organ Failure Assessment score can provide the basis for objective decisions about allocation of scarce resources without arbitrarily excluding individuals with ESKD irrespective of age and comorbidities.12 Finally, when this crisis is behind us, the leaders of medicine, ethics, and public policy must come together to review lessons learned from the current situation. In addition to establishing collaborative efforts to scale up availability of critical care equipment in the face of increased demand, more equitable approaches to allocate scarce resources need to be developed. We must aim to ensure consensus to apply equitable allocation guidelines in advance of future crises.13 Moving forward, data collection, registries, and targeted clinical investigation are required to more precisely characterize the interaction between chronic kidney failure treated with dialysis or kidney transplant on COVID-19 severity and therapies. Disclosures P. Palevsky is President-elect of the National Kidney Foundation. All remaining authors have nothing to disclose. Funding None.