Who is given preference if there’s a shortage of ventilators? Who is not?

Since the early days of the novel coronavirus pandemic, hospitals have been scrambling to update documents that describe how they would allocate scarce resources. Citing the sensitive nature of their life-or-death deliberations, many hospitals have declined to talk on the record about their plans.

Now, a paper published in the Annals of Internal Medicine gives the first broad look at some of those rationing documents.

The analysis examines 29 plans primarily from large academic medical centers in urban areas in 18 states and the District. The plans diverge significantly on multiple issues.

Ten of the plans give preference for scarce ventilators to health-care workers, citing a reciprocal moral responsibility because the medical professionals voluntarily put themselves in harm’s way and/or because they are critical to the pandemic response.

Half of the policies use age as a criterion for rationing ventilators, but only two had explicit age cutoffs. Four plans go in the opposite direction, prohibiting decisions based on age.

Seventeen policies prohibit using criteria such as ability to pay, race and citizenship to determine who gains access to ventilators.

Seven of the plans allow doctors to write do-not-resuscitate orders for patients even if it goes against the wishes of their families. The rest do not address this issue.

Thomas A. Bledsoe, a physician at Brown University and chair of the Ethics Committee for Rhode Island Hospital, wrote in a commentary accompanying the study that the variation among policies is problematic, because it may result in injustice.

He said approaches that “advocate disadvantaging older adults, disabled persons, or other groups on the basis of diagnosis, perceived social worth, or predicted life expectancy send a message to all patients that some lives are valued more than others.” He also objected to universal do-not-resuscitate orders and the use of social worth and “life-years” — a measure of a person’s life expectancy — as criteria for resource allocation. Such measures, he said, conflict with fairness principles.

“Pitting generation against generation, patient groups against each other, patients against physicians, or physicians against institutions is harmful. We are all in the same boat. When things get tough — especially when things get tough — we must all row in the same direction,” Bledsoe wrote.