Directing Doctors to Treat Others With COVID-19 First

Not since the Spanish flu pandemic of 1918 has this country contemplated the unthinkable: rationing vital medical resources on a wide scale. Since the first confirmed case of COVID-19 in the U.S. in January, the pandemic has raised fears that some hospitals might hold back ventilators and other coronavirus health care from the old and provide it to younger patients.

Referring to the growing number of possible triage situations, Dr. Andrea Kittrell, a Lynchburg, Va. otolaryngologist (ear, nose and throat specialist) says: "I have white knuckles, I mean it’s coming."  She has been in private practice for over 20 years and is chair of the medical ethics committee at her regional hospital system.

One night last March, when Kittrell had trouble sleeping, she had an idea.

“I started contemplating mortality, thinking about some of my patients over the course of my career who I would ask, ‘How are you?’ And they'd say, ‘You know, I'm fantastic. If God took me today, that would be fine with me.’ Or ‘I’ve had a good life,’” she said. “’So I started wondering: if there are people who would need to be treated for COVID at a hospital that faced a shortage of medical resources, who would be ready to accept death? Maybe those patients would want other people to have their chance to live.”

Then a light bulb went off for Kittrell. Why not a COVID-19-specific advance directive to supplement other advance directives that tell health care providers your wishes regarding life-saving treatments and procedures?

So, she formed a nonprofit, built a website and in April 2020, her Save Other Souls (SOS) advance directive was born.

It lets people (regardless of age or racial or ethnic background) sign instructions in advance of any potential COVID-19 hospitalization that read as follows: “It is my wish and direction that any health care providers and others involved in my care DIRECT RESOURCES TO OTHERS THAN TO ME AS SET FORTH BELOW.

In other words, give my seat in the lifeboat to someone else.

But it’s more complicated than that.

Below the line to direct care to others is this statement and three checkboxes:

“In the event of shortages, I am willing to receive compassionate palliative care instead of one or more of the following (check all that apply):

• Critical medical equipment (ventilator, ECMO, etc.)
• Medication (other than palliative)
• Critical Care services in a hospital setting

Kittrell has received some voluntary data and email addresses from people who have recently downloaded the SOS directive. So far, all are women over 60. Since the directive is anonymous, there’s no record of exactly how many people have signed one.

One person who did is Winnona Merritt, an organic gardener in High Point N.C. who turns 83 later this month.

She says she’s in really good health. But as a member of the Bahai faith, Merritt believes “people are created as altruists and to be a servant of humanity.” That’s why, when filling out the SOS advance directive, Merritt checked all three boxes.

If she needs hospitalization for COVID-19, her directive says, she’ll be willing to forego medical equipment, medication (other than palliative) and critical care services.

Checking all the boxes makes sense to Dr. Matthew Wynia, director of the Center for Bioethics and Humanities at the University of Colorado. He was among the team a decade ago that reviewed guidance for clinicians and hospital administrators on how to allocate limited medical resources during H1N1 (the swine flu) and future pandemics.

Wynia knows there are altruistic people like Merritt who might willingly give up their spot in line for coronavirus care because some of them have contacted him and said so.

But Wynia has concerns about the SOS directive itself.

He asks: “Can you manage this process through a website? A check box is particularly worrisome. If you say, ‘I would want critical medical equipment but don’t want a medication,’ that doesn’t make sense. You can’t be on a ventilator without sedation and pain relief.”

Before signing the SOS directive, Wynia advises, “it’s critical to have a thorough conversation with someone who might actually be there at the time difficult decisions need to be made.”

In response, Kittrell says: “The SOS directive, like all advance directives, is a very personal document which should be thoughtful and carefully considered prior to signing. But, she adds, unlike a Do Not Resuscitate order, “the SOS directive is not a medical order and would serve as guidance in the triage process, not as refusal of care.”

When Kittrell came up with the SOS advance directive idea, she turned to Dr. Michael Gillette, a bioethicist contracted with her hospital group.

“We are used to talking about how we manage a [health care] situation where demand outpaces supply. What's new here is that we're even contemplating, under the COVID pandemic scenario, taking resources away from one person or give them to someone else,” Gillette said. “A very [immuno] compromised forty-year-old would get a lower priority because of their likelihood of survival than a healthier older person.”

The SOS directive, Gillette said, “might actually be more interesting to people who are very healthy and chosen to receive the [COVID-19 health] resource but want to give up that spot in order to help someone else.”

I asked Kittrell if she would be willing to sign her own SOS advance directive. She said: “At this stage in her life, I want my kids to have a mommy.” In other words: not right now.

But Kittrell didn’t rule it out at a different stage in her life.

And what kind of person does Kittrell anticipate would be willing to sign the SOS advance directive?

“I'm thinking about the person who is selfless and is not thinking of themselves as much as they're thinking of others,” she said. “And the person who would run into the burning building at his own risk or dive into the water for the chance of saving someone else.”

So, Kittrell added, it wouldn’t depend on their age or sex or race. “It's just that zeal for contributing to the survival of others,” she said.

Someone like Winnona Merritt.

“I’m working on a compilation of the Bahai writings in agriculture. I want to stick around to see this book published. But it doesn’t stop me from signing the SOS advance directive,” she said. “If I can help doctors struggling in an emergency situation to decide who to help, I want to let them off the hook.”