There could be a shortage of lifesaving equipment in New Jersey. Who decides who gets it?

New Jersey is predicting a surge in the number of patients who will need critical care by mid-April, state Health Commissioner Judith Persichilli said Friday. And there is a chance there won't be enough lifesaving equipment to address everyone's needs. 

New Jersey asked for 2,500 ventilators from the federal government. It has received four, according to a March 27 letter from New Jersey's congressional delegation to the president. 

Who will decide which patients receive a ventilator or other lifesaving equipment if New Jersey runs out of available units?

New Jersey is creating an advisory committee to weigh these bioethical questions. It will meet early this week, with input from the Medical Society of New Jersey and retired state epidemiologist Eddy Bresnitz, Persichilli announced Thursday.

"Perhaps the most difficult question to answer and be responsive to, and that is the one: 'What happens if we don’t have enough ventilators to take care of the patients that we have?' " Persichilli said. "That is, I would have to say, one of the more difficult issues that we will be discussing."

New Jersey's hospitals currently have 2,000 critical care beds and need to double that number to meet a surge in coronavirus patients, Persichilli said. Each bed should have a ventilator, a machine that helps move air into the lungs, so the state asked the federal government for an additional 2,300 from the nation's stockpile.

"We believe we’ll be fine handling the critical care surge," Persichilli said. "Three of our CEOs from the largest [hospital] systems are prepared for that. And that hopefully will be in a couple of weeks, so we can deal with it and see how all of our plans are working, which we believe they will be fine.

"Ventilators are another story," she said. "We believe right now we have enough ventilators. If a surge results in more individuals needing ventilators than our projections, we certainly need to get ventilators in our reserve. We will push that. That's what we need."

New Jersey's U.S. senators and members of Congress wrote that the state has received only a fraction of help from the federal government compared with what officials have requested. Here is what New Jersey received and what it requested:

• N95 respirators: 169,155 received. 4.5 million requested.
• Face/surgical masks: 402,959 received. 864,000 requested.
• Face shields: 76,731 received. 1.3 million requested.
• Surgical gowns: 62,560 received. 1.4 million requested.
• Coveralls: 320 received. 864,000 requested.
• Gloves: 222,755 received. 2.2 million requested.
• Ventilators: 4 received. 2,500 requested.

Gov. Phil Murphy said Friday that there is no evidence any company is making ventilators in New Jersey, and that the state is looking to buy them. They cost about $20,000 a piece, Murphy said. 

The state surveyed all ambulatory surgery centers, stopped all elective procedures as of March 27 at 5 p.m. and called on all businesses, non-hospital health care facilities and colleges to tell the state how many ventilators, respirators and anesthesia ventilators they have by that same time. Anesthesia ventilators can easily be converted to respirators, and New Jersey has more than 1,000 such machines, Persichilli said. They should submit that information to covid19.nj.gov/ppereport. 

"But I do want to make sure that everyone understands that we are doing everything possible to make sure that we do not get into that situation," Persichilli said, referring to having to choose which patient lives or dies.

But in case this resource allocation and other measures are not enough, New Jersey has to be prepared. 

Inspiration from New York guidelines

The Medical Society of New Jersey's committee on biomedical ethics met on March 19 and submitted recommendations about what the state would do in case of a shortage of lifesaving equipment. The committee has been around 30 to 40 years and has close to 40 members, including clergy, physicians, social workers, lawyers and nurses, said CEO Larry Downs. 

"We are hopeful that the stay-at-home orders, social distancing policies and discipline to comply with that should not cause these policies to ever be put into place," Downs prefaced. "We’re doing this in an abundance of caution to be prepared in the event that we do have an overwhelming of our health care system. We don’t think that’s imminent, but it's much better to have a thoughtful process set out before you get into the throes of an emergency."

Downs said that when the final plans are decided, they should be shared with the public, but he could not go into specifics about what the committee gave state health officials.

He said they considered triage criteria for resources and patients, legal protections for health care providers to make these difficult decisions and support for health care workers who are under moral or emotional distress. He also noted there should be consistency throughout the region, and people shouldn't be getting different levels of care just based on where they are in the state. 

'If you think too much, you cry':NJ nurses try to stay positive at heart of coronavirus crisis

See the list:NJ coronavirus cases listed by town for Bergen and Passaic counties

The committee sought inspiration from the New York State Task Force's 272-page guidelines for ventilator usage updated in 2015 to prepare for an influenza epidemic. The framework aims to "balance the goal of saving the most lives with important societal values, such as protecting vulnerable populations," the New York State Department of Health announced when it released the plan. 

According to New York's guidelines, a "triage officer or committee" will decide who receives or will continue to receive ventilator therapy. The person who decides will not be patients' attending physicians, in order to prevent a conflict of interest. 

Patients "who have the highest likelihood of survival with ventilator therapy" are prioritized. The decision-making process should never consider factors like "race, ethnicity, sexual orientation, socioeconomic status, advanced age, perceived quality of life, ability to pay, role in the community, or other subjective criteria." The task force weighed and rejected approaches like first-come-first-served or a lottery as being too subjective and not able to save the most lives. 

An older patient's age should not be a triage factor, as "there are many instances where an older person could have a better clinical outlook than a younger person," the report said. But if two patients have the same likelihood of survival, young age (17 years or younger) can be used as a "tiebreaker" in limited cases because of a "strong societal preference for saving children."

Story continues below gallery

What is the process for deciding who gets a ventilator? New York's guidelines say patients without a medical condition "that will result in immediate or near-immediate mortality even with aggressive ventilator" are eligible.

Then, people are prioritized if they have a "moderate risk of mortality" and for which a ventilator "would most likely be lifesaving."

Patients are assessed 48 hours and 120 hours after receiving a ventilator to see whether they should continue with the treatment. 

It is unclear how many of New York's guidelines the Medical Society of New Jersey recommended to the state, and what the state will include in its guidelines. 

NorthJersey.com reached out to hospitals in North Jersey and asked about what policies, if any, they had in place in case they ran out of health care equipment. Most did not respond to requests for comment.

“We are working with Level I Trauma-Designated hospitals, which are coordinating efforts to organize our state health care resources, as we prepare for the anticipated surge of COVID-19 patients,” said Donnalee Corrieri at Bergen New Bridge Medical Center.

How other states decide, cope

In Michigan, a draft letter was leaked from the Henry Ford Health System that the hospital wrote as part of its emergency response planning, in case it runs out of ventilators or intensive care unit beds. 

In the draft letter, addressed to its patients, families and community: “Patients who have the best chance of getting better are our first priority. Patients will be evaluated for the best plan for care, and dying patients will be provided comfort care.” 

Conditions that could make patients ineligible for critical care include “severe heart, lung, kidney or liver failure; terminal cancer; or severe trauma or burns," the letter says. 

Pennsylvania is drafting "crisis standard of care" guidelines that have not been made public. But the Philadelphia Inquirer spoke with a physician who saw the draft, who said it doesn't include hard and fast rules based on age or preexisting conditions.  

“It’s a combination of how critically ill a patient is and determining how long and whether they would benefit from ventilator treatment and prognosis over the short, medium or long term,” Arvind Venkat, an emergency physician at Allegheny General Hospital in Pittsburgh, told the Inquirer. 

A March 23 article in the New England Journal of Medicine said removing a patient from a ventilator or ICU bed to give it to others is justifiable and patients should be made aware that it could happen. 

"Undoubtedly, withdrawing ventilators or ICU support from patients who arrived earlier to save those with better prognosis will be extremely psychologically traumatic for clinicians — and some clinicians might refuse to do so," the journal said. "However, many guidelines agree that the decision to withdraw a scarce resource to save others is not an act of killing and does not require the patient’s consent. We agree with these guidelines that it is the ethical thing to do."

The journal also recommended that COVID-19 treatment should go first to front-line health care workers and others taking care of ill patients. 

"These workers should be given priority not because they are somehow more worthy, but because of their instrumental value: They are essential to pandemic response," the journal said. 

New York Presbyterian Hospital began "ventilator sharing," or setting up two patients instead of one on a ventilator, a practice that has been used in crisis situations but may never have been tried before in the United States as a longer-term plan, according to The New York Times. 

A group of medical associations released a joint statement Thursday that said ventilators should not be shared with multiple patients because it cannot be done safely with current equipment. 

"Even in ideal circumstances, ventilating a single patient with acute respiratory distress syndrome and non-homogenous lung disease is difficult and is associated with a 40%‐60% mortality rate," said the Society of Critical Care Medicine, American Association for Respiratory Care, American Society of Anesthesiologists, Anesthesia Patient Safety Foundation, American Association of Critical‐Care Nurses, and American College of Chest Physicians. "It is better to purpose the ventilator to the patient most likely to benefit than fail to prevent, or even cause, the demise of multiple patients."

Ashley Balcerzak is a reporter in the New Jersey Statehouse. For unlimited access to her work covering New Jersey’s legislature and political power structure, please subscribe or activate your digital account today.

Email: balcerzaka@northjersey.com Twitter: @abalcerzak