| Today's Feature Clarified Trash
Pick-up Regulations.
The City Council heard the
first reading of an ordinance that will modify
the rules for storing and disposing of trash and
garbage during its meeting last Tuesday evening.
Most of the changes are due to the new automated
system that is scheduled to go into effect
October 1.
The ordinance provides that all
city residents "shall be provided by the
city or its contractor, sufficient and adequate
containers for the storage of all solid waste
...and shall maintain such solid waste containers
at all time in good repair." It also
requires that no other containers except the
provided poly-carts can be used to store solid
waste.
"Solid waste containers
which are not approved may be collected together
with their contents and disposed of by the
collectors," the proposed ordinance reads.
Containers are to be stored so
as to not be seen from the street behind the
front line of a residence, except that
"Containers may be placed at the curb side
after 5:00 p.m. the day before the regularly
scheduled pickup day but no later than 6:30 a.m.
the pickup day. Containers shall be removed from
the curb by 7 p.m. on the pickup day."
Flu Nightmare:
In Severe Pandemic, Officials Ponder
Disconnecting Ventilators From Some Patients
by Sheri Fink, ProPublica
With scant public input, state
and federal officials are pushing ahead with
plans that -- during a severe flu outbreak --
would deny use of scarce ventilators by some
patients to assure they would be available for
patients judged to benefit the most from them.
The plans have been drawn up to
give doctors specific guidelines for extreme
circumstances, and they include procedures under
which patients who weren’t improving would
be removed from life support with or without
permission of their families.
The plans are designed to go
into effect if the U.S. were struck by a severe
flu pandemic comparable to the 1918 outbreak that
killed an estimated 50 million people worldwide.
State and federal health officials have concluded
that such a pandemic would sicken far more people
needing ventilators than could be treated by the
available supplies.
Many of the draft guidelines,
including those drawn up by the Veterans Health
Administration, are based in part on a draft plan
New York officials posted on a state Web site two
years ago and subsequently published in an
academic journal. The New York protocol, which is
still being finalized, also calls for hospitals
to withhold ventilators from patients with
serious chronic conditions such as kidney
failure, cancers that have spread and have a poor
prognosis, or "severe, irreversible
neurological" conditions that are likely to
be deadly.
New York officials are studying
possible legal grounds under which the governor
could suspend a state law that bars doctors from
removing patients from life support without the
express consent of the patient or his or her
authorized health agent.
State and federal officials
involved with drafting the plans say they have
been disquieted by this summer’s uproar over
whether Medicare should pay for end-of-life
consultations with families. They acknowledged
that the measures under discussion go far beyond
anything the public understands about how
hospitals might handle a severe pandemic.
By every indication, state and
federal officials expect to weather this
year’s flu season without having to ration
ventilators. That assumes that the H1N1 virus
will not mutate into a more serious killer, that
the vaccines against it and the other seasonal
flus will continue to prove effective, and that
any dramatic surges in the number of patients in
need of ventilators will occur in different parts
of the U.S. at different times.
In recent months, New York
officials have met three times with physicians,
respiratory therapists and administrators to
rehearse how their plan might play out in
hospitals in a severe epidemic. In one of those
"tabletop exercises," participants
suggested that the names of triage officers
charged with making life and death choices among
patients at each hospital should be kept secret.
The secrecy would be needed, participants said in
interviews, to avoid pressure and blame from
colleagues caring for patients who were selected
to be taken off life support.
When they posted their plan on
the Web in coordination with a video conference
in 2007, New York officials promised to solicit
public input. Since then, they have consulted
with medical and legal professionals and other
experts, but few members of the general public,
and the plan has remained unchanged. They
declined to make the comments they have gathered
immediately available for review, and those
comments are not published on the Health
Department’s Web site.
In the initial proposal,
officials called public review "an important
component in fulfilling the ethical obligation to
promote transparency and just guidelines."
The academic publication of the
plan envisaged the use of focus groups to solicit
comment from "a range of community members,
including parents, older adults, people with
disabilities, and communities of color."
Those have not been held.
Beth Roxland, the current
executive director of the New York State Task
Force on Life and the Law, said the ethicists
included in the state’s planning process
focused largely on vulnerable populations.
"Even if we didn’t have direct input
from vulnerable populations," she said,
"their interests have been well accounted
for." Roxland said that public comment
solicited when the ventilator plan was posted on
the Health Department Web site was
"sparse."
Dr. Guthrie Birkhead, Deputy
Commissioner of the Office of Public Health for
New York state, said he wondered whether it was
possible to get the public to accept the plans.
"In the absence of an extreme emergency, I
don’t know. How do you even engage them to
explain it to them?"
Even so, other states, hospital
systems and the Veterans Health
Administration—which has 153 medical centers
across all states -- have drafted protocols that
are based in part on New York’s plan. The
inclusion and exclusion criteria for access to
ventilators, however, are different. For example,
under the current drafts, a patient on dialysis
would be considered for a ventilator in a VA
hospital in New York during a severe pandemic,
but not in another New York hospital that
followed the state’s plan, which excludes
dialysis patients. The VA’s exclusion
criteria are looser because the patient
population it is charged with serving is
typically older and sicker than in other acute
care hospitals. Different states, reflecting
different values, have also established different
criteria for who gets access to lifesaving
resources.
The Institute of Medicine, an
independent national advisory body, is expected
to release a report on Thursday morning, at the
request of the U.S. Department of Health and
Human Services, that will recommend broad
guidelines to help guide planners crafting
altered standards of care in emergencies. At an
open meeting held to inform the report on Sept.
1, participants described successful public
exercises related to allocating scarce resources
in Utah and in a Centers for Disease Control and
Prevention study conducted in Seattle.
Questions about how hospitals
would handle massive demand for life support
equipment arose when New York state health
department officials ran exercises based on a
scenarios involving H5N1 influenza.
"They kept running out of
ventilators," said Dr. Tia Powell, director
of the Montefiore-Einstein Center for Bioethics
and former executive director of the New York
State Task Force on Life and the Law, which was
asked to address the problem. "They
immediately recognized this is the worst thing
we’ve ever imagined. What on earth are we
going to do?"
Officials calculated that
18,000 additional New Yorkers would require
ventilators in the peak week of a flu outbreak as
deadly as the 1918 pandemic. Only a thousand
machines would be available, the officials
estimated. The state’s acute care hospitals
in 2005 had about 6,000 ventilators, 85 percent
of which were normally in use. A moderately
severe pandemic would have resulted in a
shortfall of 1,256 ventilators, health officials
found.
In 2006, New York planners
convened a group of experts in disaster medicine,
bioethics and public policy to come up with a
response. After months of discussion, the group
produced the system for allocating ventilators.
They first recommended a number of ways that
hospitals could stretch supply, for example by
cancelling all elective surgeries during a severe
pandemic. The state has also since purchased and
stockpiled 1,700 Pulmonetic Systems LTV 1200
ventilators (Cardinal Health Inc., NYSE) --
enough to deal with a moderate pandemic but not
one of 1918 scale.
Officials realized those two
measures alone would not be enough to meet demand
in a worst-case scenario. Ventilators were
costly, required highly trained operators, and
used oxygen, which could be limited in a
disaster.
The group then drew up plans
for rationing of ventilators. The goal,
participants said, was to save as many lives as
possible while adhering to an ethical framework.
This represented a departure from the usual
medical standard of care, which focuses on doing
everything possible to save each individual life.
Setting out guidelines in advance of a crisis was
a way to avoid putting exhausted, stressed
front-line health professionals in the position
of having to come up with criteria for making
excruciating life and death decisions in the
midst of a crisis, as many New Orleans health
professionals had to do after Hurricane Katrina
[2].
The group based its plans, in
part, on a 2006 protocol developed by health
officials in Ontario, Canada, which relied on
quantitative assessments of organ function to
decide which patients would have preference for
an intensive care unit bed. The tool, known as
the Sequential Organ Failure Assessment (SOFA)
score, is not designed to predict survival, and
not validated for use in children, but the
experts adopted it in light of the lack of an
appropriate alternative triage system.
This summer, New York officials
brought the state’s plan to groups from
several New York hospitals for the tabletop
exercises. They met behind closed doors to assess
how hospitals might implement the proposed
measures if the H1N1 pandemic turned unexpectedly
severe this fall. In the fictional scenario,
paramedics were ordered not to place breathing
tubes into patients until physicians "can
assess whether they meet the criteria to be
placed on a ventilator.’’
Problems were immediately
apparent. Dr. Kenneth Prager, a professor of
medicine and director of clinical ethics at
Columbia University Medical Center, was concerned
about the lack of awareness of the plan among the
larger public and the majority of the medical
community. Societal input "is totally
absent," he said and called for more
outreach to the public. "Maybe society will
say: ‘We don’t agree with your plan.
You may think it’s ethically OK; we
don’t.’ "
The protocol, he said, would
also place a great burden on clinicians charged
with selecting which patients would be removed
from life support. Physicians were concerned
doctors involved in the legitimate and painful
selection processes might be inappropriately
construed as "death squads." "We
facetiously dubbed them the ‘death
squad’ or the ‘guys in the back
room,’ " Prager said. He envisioned
family members breaking down and screaming when
they found out their loved ones would be
disconnected from ventilators. "It really is
a nightmare."
Even so, he felt that the plan
– and its effort to save the greatest number
of patients – was ethically appropriate.
"If we don’t use triage, people will
die who would have otherwise been saved," he
said, because a number of ventilators are
"being used to prolong the dying process of
patients with virtually no chance of
surviving."
Doctors at the exercises feared
that they would be sued by angry patients if they
followed the draft guidelines. "There’s
absolutely no legal backing for physicians,"
said Lauren Ferrante, a medical resident at
Columbia University Medical Center.
"Who’s to say we’re not going to
get sued for malpractice?"
New York officials said they
were currently working out legal options for
implementing the plans, such as gubernatorial
emergency declarations or emergency legislation.
"You can take something
today that’s not necessarily active and
overnight flip the switch and make it into
something that has those teeth in it," said
Dr. Powell, who served on the committee that
drafted the plan.
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