NKF: Patients with ESKD may be getting low priority if ventilators need to be rationed
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The National Kidney Foundation is investigating decisions by some health systems to use state emergency preparedness policies to create protocols that place patients on dialysis who are diagnosed with COVID-19 toward the bottom of the list of priorities for ventilators if these machines become in short supply.
In a letter sent to the CEOs of the American Hospital Association, the Federation of American Hospitals and America’s Essential Hospitals, NKF President Holly Mattix- Kramer, MD, MPH, and CEO Kevin Longino said in a letter that the foundation was “deeply troubled by news reports that some health systems and state governments are considering crisis management policies that would deprive certain patients – including patients with end-stage renal disease – of life-saving interventions for COVID-19, including ventilation.”
“The National Kidney Foundation understands that these are extreme circumstances but cannot support a policy that would arbitrarily deny someone treatment due to their pre-existing health condition or disability,” they wrote in the letter. “ ... as health systems find themselves without adequate supplies, we encourage you to adapt decision-making protocols that treat each patient as an individual and determine treatment plans that reflect each patient’s unique medical circumstances. Unilateral guidance should never outweigh sound, medical judgment.”
The polices would apply in cases in which ventilators were in short supply and had to be rationed, but Kramer said each patient case should be evaluated individually.
“As a nephrologist who treats end-stage renal disease patients, I can tell you that each patient is different and medical judgment, instead of arbitrary hospital or health system guidelines, should be used when determining who gets access to a life-saving ventilator and other COVID-19 treatments,” Mattix-Kramer said in a separate statement. “Thanks to the miracles of dialysis and transplant, end-stage renal disease is not a terminal condition and should not be treated as such.”
“While we appreciate that these draft policies attempt to set parameters to help health care providers make unimaginable, heartbreaking choices, a one-size-fits-all category that denies care to all patients with ESRD is short-sighted, arbitrary and discriminatory,” Longino said in the statement. “It could deny care to entire categories of individuals who might recover from COVID-19 and go on to live long, productive lives.”
In Tennessee, Ashish Soni, MD, president and CEO of Nashville-based Nephrology Associates P.C., a 31-member physician practice group, sent a letter to hospitals, providers and health care systems in the state, noting, “It concerns us that conversations are being had to totally exclude those with end-stage kidney disease (ESRD) and dialysis dependency from the same critical care their fellow Tennessee citizens would be offered and that the decision would be based only on a patient’s diagnosis and not the entirety of the individual patients’ clinical picture ... We strongly propose that each decision to treat, or not to treat a patient, be individualized and discussed with the medical team including the patient, and not be made as part of a general decision tree.”
Fresenius Medical Care, through its global medical office, and DaVita Inc. also responded to the issue, citing concerns that patients with kidney disease who have the novel coronavirus may be denied access to needed care.
“People with advanced kidney disease come in varied degrees of health and functional status, but they all want to be productive and active members of their families and communities, and we are doing everything in our power to support their desire for individual choices on the level of care they receive,” Franklin Maddux, MD, global chief medical officer for Fresenius, said in a release. “We want to avoid population-based decisions on care that may not be in the best interests of the individual person.”
The company’s global medical advisory on apportioning care, released on April 9, called on “all authorities to recognize the need to make critical equipment, supplies, facilities and care delivery available to patients with advanced kidney diseases that need lifesaving therapy at all times, including during this COVID-19 disease pandemic.”
Jeffrey Giullian, MD, the DaVita Kidney Care chief medical officer, said in a statement that states and health systems should “refrain from instituting policies that restrict care for ESKD patients with COVID-19 who need critical care interventions to survive.”
“We appreciate the incredible strain many hospitals and their care teams are under because of COVID-19, and we deeply appreciate their heroic work,” Giullian said in the statement. “We’re working hard to help keep dialysis patients treating safely in our centers and out of the hospital to reduce the burden on the system. That said, when our patients need acute care due to COVID-19, they deserve the same access to life-saving treatment as everyone else.” – by Mark E. Neumann