Researchers from Rush University and the University of Chicago investigated how many U.S. states have guidelines for allocating the use of ventilators during equipment shortages, such has occurred during the COVID-19 pandemic.

“Individual physicians, ethicists, medical societies, and US states have published multiple recommendations regarding how to allocate ventilators in a public health emergency and are largely in consensus that ventilators should be allocated to do the greatest good for the greatest number of people,” the authors wrote.

“However, it is currently unknown how many US states have translated these ethical standards into practical guidelines for how ventilator support should be allocated during a public health emergency. It is also unknown how the existing guidelines compare with one another regarding challenging questions, such as the method to rank patients in order of priority; whether it is acceptable to use age, chronic medical conditions, or estimates of remaining life-expectancy in priority scores; and whether it is ethical or legal to withdraw ventilatory therapy from one patient to provide it to another.”

As of May 10, 2020, 26 states had publicly available ventilator guidelines, and 14 states had pediatric guidelines. Use of the Sequential Organ Failure Assessment score in the initial rank of adult patients was recommended in 15 state guidelines (58%), and assessment of limited life expectancy from underlying conditions or comorbidities was included in 6 state guidelines (23%). Priority was recommended for specific groups in the initial evaluation of patients in 6 states (23%) (ie, Illinois, Maryland, Massachusetts, Michigan, Pennsylvania, and Utah). Many states recommended exclusion criteria in adult (11 of 26 states [42%]) and pediatric (10 of 14 states [71%]) ventilator allocation. Withdrawal of mechanical ventilation from a patient to give to another if a shortage occurs was discussed in 22 of 26 adult guidelines (85%) and 9 of 14 pediatric guidelines (64%).

These findings suggest that although allocation guidelines for mechanical ventilatory support are essential in a public health emergency, only 26 US states provided public guidance on how this allocation should occur. Guidelines among states, including adjacent states, varied significantly and could cause inequity in the allocation of mechanical ventilatory support during a public health emergency, such as the coronavirus disease 2019 pandemic.