Covid-19: We need to be open about rationing ventilators

Why aren’t we being more explicit about the ever changing problems around ventilators?1234 The Italians warned us.5 The New England Journal of Medicine said that volunteers should “shoulder the burden” of explicit rationing.6 The National Institute for Health and Care Excellence continues to develop its response.7

I don’t claim to have definitive “answers,” but, decades ago, I led the first explicit rationing of health services in England. Maybe some of the lessons I learnt would be helpful8:

• Keep learning from the evidence about direct and indirect costs and benefits.9101112 We’ll need to collect and share more of this as we go along. But an up-to-date explicitly evidence based policy is much easier for patients, families, and clinicians to accept.

• We must be clear about what will be done instead of any rationed intervention. Good quality supportive and palliative care must be immediately available.

• Explain the policy clearly—to patients, families, communities, clinicians, and the press. We haven’t much time but must have some (fast) involvement.

• Protect the clinicians making frontline decisions. Proper buy-in to an up-to-date evidence-based policy will make this easier—both now and to reduce later regrets.

• NEJM suggests that a specific volunteer group make disputed decisions. These volunteers must be protected too: the group I led explicitly looked after each other.

• Include lay people in decision making. My group was hesitant about this, but we quickly found lay people worth more than their weight in gold. I recommend finding, paying, and supporting the right lay people.

• Handling the media (social and other) right helps with the messaging. Get it wrong and the problems will continue through the inevitable inquiry.