Dr. Stephen Brierre,.jpg

Dr. Stephen Brierre, the head of critical care at Baton Rouge General and a professor at LSU, talks to staff in the ICU on Wednesday, August 4, 2021. 

When Dr. Stephen Brierre drafted Louisiana’s “crisis standards of care” more than a decade ago, he hoped they’d gather dust for eternity. The grim guidelines spell out how hospitals, overwhelmed during a disaster, should triage patients, outlining who should get admitted and who should be turned away.

“It’s the worst possible step,” said Brierre, the head of critical care at Baton Rouge General Medical Center. “When I was working on the guidelines, my primary thought was to never, ever, ever, ever allow this to happen.”

But as Louisiana faces its fourth wave of rapidly escalating coronavirus infections, hospitals statewide are nearing a breaking point, and the possibility that some people will be denied necessary care has become likelier than ever before. 

On Tuesday, after Louisiana shattered its previous record for COVID-19 hospitalizations, Brierre reached out to his co-author on the crisis guidelines, Dr. Michael Rolfsen, with a dire thought: “We might actually get close. We might actually do this."

Rolfsen, an internal medicine physician who teaches bioethics at LSU, agreed: “We are closer now than we have ever been in my lifetime to implementing it.”

Hospitals in Louisiana are bursting at the seams with more COVID-19 patients than ever before, and there’s no indication the latest wave will let up anytime soon. Meanwhile, nurses and respiratory therapists remain in short supply, limiting the number of beds hospitals can open.  

On Thursday, COVID-19 hospitalizations in Louisiana rose to 2,350 – the third day in a row of record-breaking numbers. Of those patients, 258 are in need of mechanical ventilation, more than at any point since the first wave.

“The point is: We are not getting better by the day. We are getting worse,” Rolfsen said. “At some point, you oversaturate the system. You don’t have the staff, the space or the supplies for more patients.”

During the first wave of the pandemic, fears that Louisiana would run out of ventilators led hospital officials to dust off the obscure 70-page document – titled "State Hospital Crisis Standard of Care Guidelines in Disasters” – that Brierre and Rolfsen helped to craft in 2009, in the wake of the swine flu outbreak. 

Early in the pandemic, the world was watching in horror as overwhelmed doctors in the north of Italy had to execute a similar plan, declining to treat some desperately ill patients in order to help those with a better chance of survival. The crisis never reached that point in Louisiana, but as the state enters its worst surge to date, officials are cracking it back open. 

The guiding philosophy of the crisis care plan is to “provide the most good for the greatest number of people” with the resources available. The document isn’t a binding one, and Rolfsen described it instead as a framework to help hospitals make ethical decisions on divvying up resources. 

“If they feel like they’re in a situation with no more beds, no more staff, no more whatever, it outlines how they should think about utilizing those scarce resources in an efficient and responsible way,” Rolfsen said.

Brierre, a pulmonary and critical-care specialist who teaches at LSU, described a “worst-case scenario” in which ventilators are no longer available and a patient lands in the ER requiring intubation.

“I have to look at the group of people on ventilators versus the person who needs the ventilator and decide who has the least chance of survival,” Brierre said. “The person with the least chance of survival, I remove their ventilator without their family’s consent and provide it to the person who came in needing a ventilator.”

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The thought of reaching that point makes Brierre sick to his stomach. 

"I'm going to build as many freakin' ICUs as I can. I'm going to grab every device I can. I'm going to repurpose drugs to make sure that never happens," Brierre said. "But it is a possibility."

The document includes three stages of triage plans: conventional, contingency and crisis. In a crisis, when hospitals are operating with too few resources, not every sick person would be a candidate for admission to intensive care units, or even the hospital’s non-ICU areas.

“Priority should be given to patients for whom treatment would most likely be lifesaving and whose functional outcome would most likely improve,” the standards say. “Such patients should be given priority over those who would likely die even with treatment and those who would likely survive without treatment.”

To decide the level of care a patient should receive, the document suggests hospitals rely on how a patient performs on a test known as a modified sequential organ failure assessment score. The test assigns points based on how a patient’s brain, heart, lungs, kidneys and liver are performing.

Rolfsen said hospitals aren’t obligated to use that test in particular, but said it's important that they rely on objective medical evidence if they’re forced to make triaging decisions. The standards advise health care workers to ignore age, race, gender, disability status and class and focus only on how sick each patient is and how likely it is that he or she will recover.

“Social worth, age and other nonmedical factors should not be used in the decision-making process,” the document says.

It’s unclear how hospitals would signal that they’ve resorted to rationing care.

The document says the change must be "formally declared by the state" through a declaration from the governor "that crisis standards of care are in operation."

Rolfsen said a more likely scenario is that individual hospitals would make the decision to enter crisis mode once if the state's medical system becomes inundated. But Robert Hart, chief medical officer at Ochsner Health System, said at a press briefing Thursday that the any decision will be coordinated with the state. 

"With crisis standards of care, it's not an individual hospital decision. We're having conversations with other hospitals across the regions as everyone continues to have their bed capacity challenge and staffing capacity challenge, but this will be something we will continue to communicate with the state on," Hart said. 

The guidelines are clear, however, that if it does come to pass, hospitals must be transparent and open with the public about their decision-making process. 

“This is a safety net that we never hope to use. Almost think of it as the president’s nuclear button,” Rolfsen said.

Staff writers Emily Woodruff and Andrea Gallo contributed to this report. 

Email Blake Paterson at bpaterson@theadvocate.com and follow him on Twitter @blakepater