Hospitals consider universal do-not-resuscitate orders for coronavirus patients

https://www.washingtonpost.com/health/2020/03/25/coronavirus-patients-do-not-resucitate/?utm_campaign=wp_post_most&utm_medium=email&utm_source=newsletter&wpisrc=nl_most

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Worry that ‘all hands’ responses may expose doctors and nurses to infection prompts debate about prioritizing the survival of the many over the one.

Hospitals on the front lines of the pandemic are engaged in a heated private debate over a calculation few have encountered in their lifetimes — how to weigh the “save at all costs” approach to resuscitating a dying patient against the real danger of exposing doctors and nurses to the contagion of coronavirus.

The conversations are driven by the realization that the risk to staff amid dwindling stores of protective equipment — such as masks, gowns and gloves — may be too great to justify the conventional response when a patient “codes,” and their heart or breathing stops.

Northwestern Memorial Hospital in Chicago has been discussing a do-not-resuscitate policy for infected patients, regardless of the wishes of the patient or their family members — a wrenching decision to prioritize the lives of the many over the one.

Richard Wunderink, one of Northwestern’s intensive-care medical directors, said hospital administrators would have to ask Illinois Gov. J.B. Pritzker for help in clarifying state law and whether it permits the policy shift.

“It’s a major concern for everyone,” he said. “This is something about which we have had lots of communication with families, and I think they are very aware of the grave circumstances.”

Officials at George Washington University Hospital in the District say they have had similar conversations, but for now will continue to resuscitate covid-19 patients using modified procedures, such as putting plastic sheeting over the patient to create a barrier. The University of Washington Medical Center in Seattle, one of the country’s major hot spots for infections, is dealing with the problem by severely limiting the number of responders to a contagious patient in cardiac or respiratory arrest.

Several large hospital systems — Atrium Health in the Carolinas, Geisinger in Pennsylvania and regional Kaiser Permanente networks — are looking at guidelines that would allow doctors to override the wishes of the coronavirus patient or family members on a case-by-case basis due to the risk to doctors and nurses, or a shortage of protective equipment, say ethicists and doctors involved in those conversations. But they would stop short of imposing a do-not-resuscitate order on every coronavirus patient. The companies declined to comment.

Lewis Kaplan, president of the Society of Critical Care Medicine and a University of Pennsylvania surgeon, described how colleagues at different institutions are sharing draft policies to address their changed reality.

“We are now on crisis footing,” he said. “What you take as first-come, first-served, no-holds-barred, everything-that-is-available-should-be-applied medicine is not where we are. We are now facing some difficult choices in how we apply medical resources — including staff.”

The new protocols are part of a larger rationing of lifesaving procedures and equipment — including ventilators — that is quickly becoming a reality here as in other parts of the world battling the virus. The concerns are not just about health-care workers getting sick but also about them potentially carrying the virus to other patients in the hospital.

R. Alta Charo, a University of Wisconsin-Madison bioethicist, said that while the idea of withholding treatments may be unsettling, especially in a country as wealthy as ours, it is pragmatic. “It doesn’t help anybody if our doctors and nurses are felled by this virus and not able to care for us,” she said. “The code process is one that puts them at an enhanced risk.”

Wunderink said all of the most critically ill patients in the 12 days since they had their first coronavirus case have experienced steady declines rather than a sudden crash. That allowed medical staff to talk with families about the risk to workers and how having to put on protective gear delays a response and decreases the chance of saving someone’s life.

A consequence of those conversations, he said, is that many family members are making the difficult choice to sign do-not-resuscitate orders.

Code blue

Health-care providers are bound by oath — and in some states, by law — to do everything they can within the bounds of modern technology to save a patient’s life, absent an order, such as a DNR, to do otherwise. But as cases mount amid a national shortage of personal protective equipment, or PPE, hospitals are beginning to implement emergency measures that will either minimize, modify or completely stop the use of certain procedures on patients with covid-19.

Some of the most anxiety-provoking minutes in a health-care worker’s day involve participating in procedures that send virus-laced droplets from a patient’s airways all over the room.

These include endoscopies, bronchoscopies and other procedures in which tubes or cameras are sent down the throat and are routine in ICUs to look for bleeds or examine the inside of the lungs.

Changing or eliminating those protocols is likely to decrease some patients’ chances for survival. But hospital administrators and doctors say the measures are necessary to save the most lives.

The most extreme of these situations is when a patient, in hospital lingo, “codes.”

When a code blue alarm is activated, it signals that a patient has gone into cardiopulmonary arrest and typically all available personnel — usually somewhere around eight but sometimes as many as 30 people — rush into the room to begin live-saving procedures without which the person would almost certainly perish.

“It’s extremely dangerous in terms of infection risk because it involves multiple bodily fluids,” explained one ICU physician in the Midwest, who did not want her name used because she was not authorized to speak by her hospital.

Fred Wyese, an ICU nurse in Muskegon, Mich., describes it like a storm:

A team of nurses and doctors, trading off every two minutes, begin the chest compressions that are part of cardiopulmonary resuscitation or CPR. Someone punctures the neck and arms to access blood vessels to put in new intravenous lines. Someone else grabs a “crash cart” stocked with a variety of lifesaving medications and equipment ranging from epinephrine injectors to a defibrillator to restart the heart.

As soon as possible, a breathing tube will be placed down the throat and the person will be hooked up to a mechanical ventilator. Even in the best of times, a patient who is coding presents an ethical maze; there’s often no clear cut answer for when there’s still hope and when it’s too late.

In the process, heaps of protective equipment is used — often many dozens of gloves, gowns, masks, and more.

Bruno Petinaux, chief medical officer at George Washington University Hospital, said the hospital has had a lot of discussion about how — and whether — to resuscitate covid-19 patients who are coding.

“From a safety perspective you can make the argument that the safest thing is to do nothing,” he said. “I don’t believe that is necessarily the right approach. So we have decided not to go in that direction. What we are doing is what can be done safely.”

However, he said, the decision comes down to a hospital’s resources and “every hospital has to assess and evaluate for themselves.” It’s still early in the outbreak in the Washington area, and GW still has sufficient equipment and manpower. Petinaux said he cannot rule out a change in protocol if things get worse.

GW’s procedure for responding to coronavirus patients who are coding includes using a machine called a Lucas device, which looks like a bumper, to deliver chest compressions. But the hospital has only two. If the Lucas devices are not readily accessible, doctors and nurses have been told to drape plastic sheeting — the 7-mil kind available at Home Depot or Lowe’s — over the patient’s body to minimize the spread of droplets and then proceed with chest compressions. Because the patient would presumably be on a ventilator, there is no risk of suffocation.

In Washington state which had the nation’s first covid-19 cases, UW Medicine’s chief medical officer, Tim Dellit, said the decision to send in fewer doctors and nurses to help a coding patient is about “minimizing use of PPE as we go into the surge.” He said the hospital is monitoring health-care workers’ health closely. So far, the percentage of infections among those tested is less than in the general population, which, he hopes, means their precautions are working.

‘It is a nightmare’

Bioethicist Scott Halpern at the University of Pennsylvania is the author of one widely circulated model guideline being considered by many hospitals. In an interview, he said a blanket stop to resuscitations for infected patients is too “draconian” and may end up sacrificing a young person who is otherwise in good health. However, health-care workers and limited protective equipment cannot be ignored.

“If we risk their well-being in service of one patient, we detract from the care of future patients, which is unfair,” he said.

Halpern’s document calls for two physicians, the one directly taking care of a patient and one who is not, to sign off on do-not-resuscitate orders. They must document the reason for the decision, and the family must be informed but does not have to agree.

Wyese, the Michigan ICU nurse, said his own hospital has been thinking about these issues for years but still is unprepared.

“They made us do all kinds of mandatory education and fittings and made it sound like they are prepared,” he said. “But when it hits the fan, they don’t have the supplies so the plans they had in place aren’t working.”

Over the weekend, Wyese said, a suspected covid-19 patient was rushed in and put into a negative pressure room to prevent the virus spread. In normal times, a nurse in full hazmat-type gear would sit with the patient to care for him, but there was little equipment to spare. So Wyese had to monitor him from the outside. Before he walked inside, he said, he would have to put on a face shield, N95 mask, and other equipment and slather antibacterial foam on his bald head as the hospital did not have any more head coverings. Only one powered air-purifying respirator or PAPR was available for the room and others nearby that could be used when performing an invasive procedure — but it was 150 feet away.

While he said his hospital’s policy still called for a full response to patients whose heart or breathing stopped, he worried any efforts would be challenging, if not futile.

“By the time you get all gowned up and double-gloved the patient is going to be dead,” he said. “We are going to be coding dead people. It is a nightmare.”

 

 

 

 

Bill Gates says we can’t restart the economy soon and simply “ignore that pile of bodies over in the corner”

https://www.vox.com/recode/2020/3/24/21192638/coronavirus-bill-gates-trump-reopen-business?fbclid=IwAR3j7XzP_Mf3i9VhZwzYk2jTesqLjr9SAtmb4B-xLy0KXaeyZ2zK4lUWjdU

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Bill Gates rebuked proposals, floated over the last two days by leaders like Donald Trump, to reopen the global economy despite the Covid-19 coronavirus outbreak, saying that this approach would be “very irresponsible.”

Gates did not mention Trump by name, but the American president has said that he may decide to relax some of the country’s “social distancing” in order to jumpstart the country’s shut-down economy. Gates, the country’s leading philanthropist, has been among the most active tech leaders in using his resources to try and contain the virus.

“There really is no middle ground, and it’s very tough to say to people, ‘Hey, keep going to restaurants, go buy new houses, ignore that pile of bodies over in the corner. We want you to keep spending because there’s maybe a politician who thinks GDP growth is all that counts,’” Gates said in an interview with TED Tuesday. “It’s very irresponsible for somebody to suggest that we can have the best of both worlds.”

Trump has suggested that this middle ground would indeed be possible — by letting some healthy people return to work, for instance, while keeping more vulnerable workers in their homes. Experts have said that drastic and widespread social distancing is required to keep the pandemic from spreading further. Trump has said he would make a decision at the end of the month but has said that he believes the “cure” could be worse than the “problem itself.”

Asked what he would do if he were president, Gates returned to his concerns about reopening the economy.

“The economic effect of this is really dramatic. Nothing like this has ever happened to the economy in our lifetimes,” Gates said. “But bringing the economy back … that’s more of a reversible thing than bringing people back to life. So we’re going to take the pain in the economic dimension — huge pain — in order to minimize the pain in the diseases-and-death dimension.”

The Bill and Melinda Gates Foundation has put up $100 million for programs to fund testing and science around the pandemic, and he has begun using his public profile, too, to shape the coronavirus conversation. This month, Gates himself resigned from the board of Microsoft, which he founded, and is now effectively a full-time philanthropist — and the country’s most famous one.

And Gates has tried to cast himself as an optimist. He has said that the social distancing measures might need to last as little as six weeks, but said that “we have no choice,” despite the economic impacts.

“It’s disastrous for the economy,” Gates said. But “the sooner you do it in a tough way, the sooner you can undo it and go back to normal.”

 

 

 

Administration Considers Reopening Economy, Over Health Experts’ Objections

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The president is questioning whether stay-at-home orders have gone too far. But relaxing them could significantly increase the death toll from the coronavirus, health officials warn.

As the United States entered Week 2 of trying to contain the spread of the coronavirus by shuttering large swaths of the economy, President Trump, Wall Street executives and many conservative economists began questioning whether the government had gone too far and should instead lift restrictions that are already inflicting deep pain on workers and businesses.

Consensus continues to grow among government leaders and health officials that the best way to defeat the virus is to order nonessential businesses to close and residents to confine themselves at home. Britain, after initially resisting such measures, essentially locked down its economy on Monday, as did the governors of Virginia, Michigan and Oregon. More than 100 million Americans will soon be subject to stay-at-home orders.

Relaxing those restrictions could significantly increase the death toll from the virus, public health officials warn. Many economists say there is no positive trade-off — resuming normal activity prematurely would only strain hospitals and result in even more deaths, while exacerbating a recession that has most likely already arrived.

The economic shutdown is causing damage that is only beginning to appear in official data. Morgan Stanley researchers said on Monday that they now expected the economy to shrink by an annualized rate of 30 percent in the second quarter of this year, and the unemployment rate to jump to nearly 13 percent. Both would be records, in modern economic statistics.

Officials have said the federal government’s initial 15-day period for social distancing is vital to slowing the spread of the virus, which has already infected more than 40,000 people in the United States. But Mr. Trump and a chorus of conservative voices have begun to suggest that the shock to the economy could hurt the country more than deaths from the virus.

On Monday, Mr. Trump said his administration would reassess whether to keep the economy shuttered after the initial 15-day period ends next Monday, saying it could extend another week and that certain parts of the country could reopen sooner than others, depending on the extent of infections.

“Our country wasn’t built to be shut down,” Mr. Trump said during a briefing at the White House. “America will, again, and soon, be open for business. Very soon. A lot sooner than three or four months that somebody was suggesting. Lot sooner. We cannot let the cure be worse than the problem itself.”

Similar views are emanating from parts of corporate America, where companies are struggling with a shutdown that has emptied hotels, airplanes, malls and restaurants and sent the stock market tumbling so fast that automatic circuit breakers to halt trading have been tripped repeatedly. Stocks have collapsed about 34 percent since the coronavirus spread globally — the steepest plunge in decades — erasing three years of gains under Mr. Trump.

Lloyd Blankfein, the former chief executive of Goldman Sachs, wrote on Twitter that “crushing the economy” had downsides and suggested that “within a very few weeks let those with a lower risk to the disease return to work.”

Even Gov. Andrew M. Cuomo of New York, whose state has emerged as the epicenter of the outbreak in the United States, has begun publicly floating the notion that, at some point, states will need to restart economic activity and debating how that should unfold.

“You can’t stop the economy forever,” Mr. Cuomo said in a news conference on Monday. “So we have to start to think about does everyone stay out of work? Should young people go back to work sooner? Can we test for those who had the virus, resolved, and are now immune and can they start to go back to work?”

Any push to loosen the new limits on commerce and movement would contradict the consensus advice of public health officials, risking a surge in infections and deaths from the virus. Many economists warn that abruptly reopening the economy could backfire, overwhelming an already stressed health care system, sowing uncertainty among consumers, and ultimately dealing deeper, longer-lasting damage to growth.

The recent rise of cases in Hong Kong, after there had been an easing of the spread of the virus, is something of an object lesson about how ending strict measures too soon can have dangerous consequences. Yet places like China, which took the idea of lockdown to the extreme, have managed to flatten the curve.

“You can’t call off the best weapon we have, which is social isolation, even out of economic desperation, unless you’re willing to be responsible for a mountain of deaths,” said Arthur Caplan, a professor of bioethics at NYU Langone Medical Center. “Thirty days makes more sense than 15 days. Can’t we try to put people’s lives first for at least a month?”

For the last four days, some White House officials, including those working for Vice President Mike Pence, who leads the coronavirus task force, have been raising questions about when the government should start easing restrictions.

Among the options being discussed are narrowing restrictions on economic activity to target specific age groups or locations, as well as increasing the numbers of people who can be together in groups, said one official, who cautioned that the discussions were preliminary.

Health officials inside the administration have mostly opposed that idea, including Dr. Anthony S. Fauci, an infectious diseases expert and a member of the White House coronavirus task force, who has said in interviews that he believes it will be “at least” several more weeks until people can start going about their lives in a more normal fashion.

Dr. Deborah L. Birx, the White House coronavirus response coordinator, said the United States had learned from other countries like China and South Korea, which were able to control the spread of the virus through strict measures and widespread testing.

“Those were eight- to 10-week curves,” she said on Monday, adding that “each state and each hot spot in the United States is going to be its own curve because the seeds came in at different times.”

Dr. Birx added that the response “has to be very tailored geographically and it may have to be tailored by age group, really understanding who’s at the greatest risk and understanding how to protect them.”

Other advisers, including members of Mr. Trump’s economic team, have said repeatedly in recent months that the virus does not itself pose an extraordinary threat to Americans’ lives or the economy, likening it to a common flu season. Some advisers believe the White House overreacted to criticism of Mr. Trump’s muted actions to deal with the emerging pandemic and gave health experts too large a sway in policymaking.

On Monday, Mr. Trump echoed those concerns, saying that things like the flu or car accidents posed as much of a threat to Americans as the coronavirus and that the response to those was far less draconian.

“We have a very active flu season, more active than most. It’s looking like it’s heading to 50,000 or more deaths,” he said, adding: “That’s a lot. And you look at automobile accidents, which are far greater than any numbers we’re talking about. That doesn’t mean we’re going to tell everybody no more driving of cars. So we have to do things to get our country open.”

Mr. Trump has watched as a record economic expansion and booming stock market that served as the basis of his re-election campaign evaporated in a matter of weeks. The president became engaged with the discussion on Sunday evening, after watching television reports and hearing from various business officials and outside advisers who were agitating for an end to the shutdown.

Casey Mulligan, a University of Chicago professor who served as chief economist for Mr. Trump’s Council of Economic Advisers, said on Monday that efforts to shut down economic activity to slow the virus would be more damaging than doing nothing at all. He suggested a middle ground, one that weighs the costs and benefits of saving additional lives.

“It’s a little bit like, when you discover sex can be dangerous, you don’t come out and say, there should be no more sex,” Mr. Mulligan said. “You should give people guidance on how to have sex less dangerously.”

Many other economists say the restrictions in activity now are helping the economy in the long run, by beginning to suppress the infection rate.

“The idea that there’s a trade-off between health and economics right now is likely badly mistaken,” said Jason Furman of Harvard University, a former chairman of the Council of Economic Advisers under President Barack Obama. “The thing damaging our economy is a virus. Everyone who is trying to stop that virus is working to limit the damage it does to our economy and help our eventual rebound. The choice may well be taking pretty extreme steps now or taking very extreme steps later.”

Mr. Furman and other economists have pushed Mr. Trump and Congress to ease the economic pain by offering trillions of dollars in government assistance to affected workers and businesses. As lawmakers tried to negotiate an agreement on such a bill Monday, an influential business lobbying group, the U.S. Chamber of Commerce, said it supported restrictions on the economy to slow the virus.

“Our view is, when it comes to how you contain the virus, you do everything the public health professionals say to contain the virus,” said Neil Bradley, the chamber’s executive vice president and chief policy officer.

The president’s suggestion that the response may be an overreaction plays into doubts already held by some Americans suffering the economic consequences. Among the self-quarantined, some have questioned the purpose of isolating themselves if the virus is already circulating widely. Students sent home from college have wondered whether they are more likely to infect higher-risk older adults at home.

Dan Patrick, Texas’ lieutenant governor, said Monday on Fox News that he was in the “high-risk pool” but would be willing to risk his life to preserve the country for his children and grandchildren.

“We are going to be in a total collapse, recession, depression, collapse in our society,” said Mr. Patrick, who turns 70 next week. “If this goes on another several months, there won’t be any jobs to come back to for many people.”

But public health officials stress that there would be consequences to ending the measures too quickly. In a tweet on Monday morning, Thomas P. Bossert, the former homeland security adviser who for weeks has been vocal about the need for the U.S. government to take stricter measures, said: “Sadly, the numbers now suggest the U.S. is poised to take the lead in #coronavirus cases. It’s reasonable to plan for the US to top the list of countries with the most cases in approximately 1 week. This does NOT make social intervention futile. It makes it imperative!”

Mr. Trump’s interest in potentially easing some of the restrictions met with pushback from one of his close allies, Senator Lindsey Graham, Republican of South Carolina, who himself self-quarantined after a potential exposure. “President Trump’s best decision was stopping travel from China early on,” Mr. Graham tweeted on Monday. “I hope we will not undercut that decision by suggesting we back off aggressive containment policies within the United States.”

Health officials remain largely united in defense of sustaining the restrictions.

“There is a way to think through how and when to start reopening our economy and society, and it’s important to get this right,” said Dr. Thomas R. Frieden, a former director of the Centers for Disease Control and Prevention.

Dr. Tom Inglesby, the director of the Center for Health Security at the Johns Hopkins Bloomberg School of Public Health, pointed to the experience of countries like Italy, which did not institute aggressive measures to stop the spread of the virus and saw infection rates and deaths soar as a result.

The United States will need “a couple weeks” to see positive effects from its measures, Dr. Inglesby said, and abandoning them would mean “patients will get sick in extraordinary numbers all over the country, far beyond what the U.S. health care system will bear.”

 

 

 

 

COVID-19 threatens to overwhelm hospitals. They’re weighing how best to ration care.

https://www.healthcaredive.com/news/covid-19-threatens-to-overwhelm-hospitals-theyre-weighing-how-best-to-rat/574489/

The coronavirus outbreak is forcing the U.S., a nation largely unaccustomed to scarcity, to have tough conversations about how to allocate limited medical resources as hospitals warn its only a matter of time before they’re inundated with COVID-19 patients.

Across the country, hospital officials are discussing ethical dilemmas and attempting to draft policies about rationing care when patients needing ventilators and other resources dwarf the supply, several hospital ethicists told Healthcare Dive. In addition to issues of mortality, questions also are being raised about whether medical workers can opt out of treating patients with COVID-19, particularly if they don’t have the right personal protective equipment.

“They are having these conversations at the policy level,” Kelly Dineen, director of the health law program at Creighton University and a member of COVID-19 Ethics Advisory Committee at the University of Nebraska Medical Center​, told Healthcare Dive.

Ethical dilemmas are usually tackled by a hospital’s ethics committee, which, in an ideal scenario, encompasses a variety of workers from across the hospital, including clinicians, ethicists and social workers. 

No federal mandate exists requiring hospitals to have such committees. However, many do to meet accreditation standards that require facilities to have some sort of mechanism for ethics conflicts and decision making. Many choose to meet that standard by having an ethics committee, though not all do, according to one expert.

Hospitals are at risk of not having the capacity to care for a surge of COVID-19 patients if an outbreak similar to Wuhan or Italy occurs here. New York Gov. Andrew Cuomo has pleaded with the federal government to allow the Army Corps of Engineers to build back-up facilities as the COVID-19 rapidly spreads through areas of the hard-hit state. Similarly, California Gov. Gavin Newsom has requested a Navy hospital ship and two mobile hospitals to address a surge in patients.

Federal officials are urging Americans to do their part by retreating to their homes to socially distance themselves from others in an effort to hamper the disease’s reach. CMS also last week urged hospitals to put off non-essential elective surgeries to prepare for an onslaught of cases. Years of culling hospital beds in a shift to outpatient care has the nation’s facilities short of meeting expected demand under some prediction models.

The concern about scarce resources is not unfounded. Italy’s healthcare system has been pushed to the brink and many see parallels in terms of the trajectory of the spread. Overwhelmed with sick patients, Italy’s society of anesthesiology and intensive care published recommendations on how to prioritize patients and not just serve the first in the door.

China, the first country to report cases of the disease, feverishly began building hospitals to meet demand.

And the U.S. has far fewer hospital beds per 1,000 residents than China or Italy.

It’s important facilities across the country start having conversations about allocating resources now before clinicians are pushed to their limits, ethicists said.

“Any time you have that kind of pressure and load … it’s going to be hard to also be thinking about all of the ethical implications and what that means in a way that might otherwise not be so hard,” Dineen said.

The struggle will be effectively communicating those policies throughout a system or hospital, Erica Salter, associate professor and program director of the doctorate program for healthcare ethics at St. Louis University, told Healthcare Dive.

“It’s wise to anticipate failures of communication and protect against those,” Salter said.

Ultimately, those policies will vary by institution, though ethicists said it’s important to be proactive rather than reactive. And hospitals should also be prepared to be held to account for decisions that are made, Dineen said.

Patients and their loved ones will want to know there was a process and that it was fair, not arbitrary. 

“There’s no reason we can’t be prepared with a process, even if we don’t necessarily have a better answer,” she said.

Still, despite the most well-intentioned plans it will always be the doctor’s call, Arthur Caplan, head of the division of medical ethics at NYU School of Medicine, told Healthcare Dive.  

“You’re going to see variation in what is decided floor to floor, doctor to doctor, hospital to hospital,” Caplan said.

Still, some hospitals are hesitant to issue overly broad guidance because of the liabilities that might come later. However, depending on the state, emergency orders issued during a pandemic may help shield providers or systems from liability as standard of care decisions were made during a unique situation.

And, though Americans may struggle to talk about the end of life and mortality, the medical profession is used to tough conversations about scarce resources.

For example, when dialysis machines were first developed, the technology was not widely available for everyone with end-stage kidney failure. A decision had to be made about which patients were granted access to the lifesaving treatment and which ones were not. It’s a conversation that continues today for those needing transplants.

“The principles guiding these decisions are not new,” Salter said. “We’ve been dealing with issues of scarce resources for many decades.”