NYU Langone tells ER doctors to 'think more critically' about who gets ventilators

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NYU Langone Health, one of the nation's top academic medical centers, told emergency-room doctors that they have "sole discretion" to place patients on ventilators and institutional backing to "withhold futile intubations."

A March 28 email from Robert Femia, who heads the New York health center's department of emergency medicine, underscored the life-or-death decisions placed on the shoulders of bedside physicians as they treat increasing numbers of coronavirus patients with a limited supply of ventilators.

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New York state guidelines, established in 2015, recommend that hospitals appoint a triage officer or committee -- someone other than the attending physician -- to decide who gets a ventilator when rationing is necessary. The guidelines say that removing the decision from the physician treating the patient avoids a conflict of interest, allows an officer or committee with access to overall ventilator availability to make the call and prevents health worker burnout and stress.

Dr. Femia said in his email, which was reviewed by The Wall Street Journal, that experts and leaders at NYU Langone were creating internal guidance on how to allocate ventilators, which are in short supply across New York City. But the emergency department couldn't afford to wait, he said.

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"In Emergency Medicine, we do not have the luxury of time, data, or committees to help with our critical triage decisions," he wrote. "Senior hospital leadership recognizes this and supports us to use our best clinical judgment."

Dr. Femia wrote that decisions about "airway management" and whether to use a ventilator or other respiratory support devices were at the sole discretion of treating physicians, but he told doctors to "think more critically about who we intubate."

"For those patients who you feel intubation will not change their ultimate clinical outcome (for example cardiac arrests, some chronic disease patients at end of life, etc) you will have support in your decision making at the department and institutional level to withhold futile intubations," he wrote, referring to the tubes attached to ventilators that are inserted in the mouths of patients and sit above the lungs.

Jim Mandler, a spokesman for NYU Langone Health, said Dr. Femia's email outlined guidance that had long been in place.

"We felt it was important to re-emphasize to our emergency medicine staff what these guidelines explicitly say, and to assure them that the decisions that they make at the bedside will be supported," he said.

Mr. Mandler added that NYU Langone was "not at the point in which these judgments need to be made within the current scope of care."

Dr. Femia's email came amid a surge in patients at NYU Langone hospitals.

NYU Langone Medical Center in Manhattan recorded 332 coronavirus patients in hospital beds on Monday, an 84% increase since Thursday, according to internal figures sent to staffers.

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Another 125 patients were in intensive care on Monday, more than double the number reported by the hospital on Thursday, according to the internal figures. At NYU Langone Hospital -- Brooklyn, intensive-care patients increased to 36 from 21 over that same period.

NYU medical-school residents also treat patients at NYC Health + Hospitals/Bellevue, the city's largest public hospital, which had 448 coronavirus patients in intensive care as of Monday, according to the figures.

Some NYU Langone doctors said they were unsettled by Dr. Femia's email.

"Asking ED physicians to make snap judgments about how well a patient will do based on little to no information is a tremendous burden to place on them," one doctor said.

"As a doctor, I don't know how to make the call," another said. The doctor said so far there was no evidence of anyone withholding care from patients. But what the email calls for "seems way too close to playing God."

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The same day doctors received the guidance from Dr. Femia, they also got a reminder not to speak to news reporters without permission from NYU Langone's Office of Communications and Marketing.

Kathy Lewis, executive vice president for communications and marketing, said in an email that NYU Langone's longstanding policy required faculty, residents and staff to forward all media inquiries to her office.

"Anyone who does not adhere to this policy, or who speaks or disseminates information to the media without explicit permission of the Office of Communications and Marketing, will be subject to disciplinary action, including termination," Ms. Lewis wrote.

Mr. Mandler, the NYU Langone spokesman, said the policy was meant to ensure that only NYU Langone officials with the most current information about coronavirus speak to reporters.

"We have a responsibility to the public at large to ensure that the information they receive from our institution is accurate," he said.