Saint Joseph’s Bioethicists Play Leading Role in Pandemic Response

As the nation faces a rising number of patients diagnosed with COVID-19, it’s become increasingly evident that one concern may outweigh all others — there may not be enough ventilators and life-saving drugs to supply everyone in need with them.

Patients who need ventilators must be sedated so they can be intubated and then need specific drugs once the breathing tube is connected to the ventilator. All levels of government, alongside private sector companies, are trying to come up with ways to rapidly produce the volume of equipment and drugs required to meet the demand. But without a clear resolution, health systems are faced with making tough choices about how to distribute and ration scarce resources.

Many hospitals and healthcare systems in Greater Philadelphia are looking to experts at Saint Joseph’s Institute of Clinical Bioethics (ICB) for help in making those decisions. The team at ICB, including Peter Clark, S.J., Ph.D. ‘75, professor of medical ethics and director of the ICB; Aloysius S. Ochasi, S.T.L., Ph.D., ‘11 (M.S.), ICB’s assistant director of academics and consultation; and Post-Doctoral Fellow Bege Dauda, Ph.D., has been working closely with the institute’s 17 affiliated hospitals, which include providers in Pennsylvania, Maryland and Delaware, along with Caritas Baby Hospital in Palestine, to provide 24/7 consultations and to address broader ethical issues that have come up due to the spread of COVID-19.

According to Clark, each provider is charged with developing its own protocols and procedures for care, but also must take into consideration any policies being developed by individual states.

“The problem is that the health systems are coming up with policies on allocations of services, but so is the state,” says Clark. “We have to adhere to the state guidelines, but those guidelines can only be looked at if the states’ governors activate them,” which has not yet been the case in the three states where ICB-affiliated providers are located.

At each hospital, triage teams have been tasked with making the tough decisions about rationing care, should the need arise. The teams consist of one critical care physician, one critical care nurse and one respiratory therapist. By moving the decision from the bedside physician to the triage team, the burden — and pressure — is lifted from the doctors dealing directly with patients, Clark says.

“Triage is based on a very clinical, complex scoring system called a SOFA score — Sequential Organ Failure Assessment,” says Clark. “These scores are based purely on symptoms and comorbidities [the presence of other conditions in addition to the patient’s primary condition], all in an attempt to make these decisions as objective as possible across the board.”

Enabling neutral triage teams to determine who gets a ventilator or certain drugs ensures the decision is made without knowing a patient’s financial situation, social status and whether or not they have health insurance, among other factors, Ochasi explains.

“Ultimately, we hope and pray that these triage teams will never have to be used, that we will be able to have enough supplies to treat all patients,” Ochasi says. “But it is better for us to have something in place ahead of time that is objective and can be applied across the board, instead of having physicians make these difficult decisions on the fly.”

Transparency in the triage process is essential in ensuring that all members of the community know exactly what standards are being put into place, Clark and Ochasi say, before they find themselves or a loved one in the triage process.

Triage teams have not been activated yet, Clark and Ochasi say, as local hospitals have not had to ration equipment and supplies. The federal government recently implemented the Defense Production Act to expedite the production of ventilators, as well as other critical supplies, in hopes of eliminating the need for these difficult decisions.

If the triage teams are needed, they will be ready, says Clark. Teams are already running through practice cases to make sure SOFA scores are calculated correctly and to identify any possible flaws in the system.

“As Catholic teachings tell us, each human life has inherently equal moral worth,” says Clark. “These systems and protocols help us to ensure that decisions are made based upon that ideology.”