By Rebecca Mansour – 27 Mar 2020

A draft letter by one of southeast Michigan’s major hospital systems was leaked online Thursday revealing the hospital’s policy to prioritize care for “patients who have the best chance of getting better” in the event of a shortage due to the coronavirus pandemic.

The letter was drafted by officials at the Henry Ford Health System and is addressed to “our patients, families and community.” It outlines the criteria for which patients will be eligible for care if the hospital reaches capacity and is forced to ration limited resources. “Patients who have the best chance of getting better are our first priority. Patients will be evaluated for the best plan of care and dying patients will be provided comfort care.”

The letter explains the policy in the event of a shortage of ICU beds and ventilators: “If you (or a family member) becomes ill and your medical doctor believes that you need extra care in an Intensive Care Unit (ICU) or Mechanical Ventilation (breathing machine) you will be assessed for eligibility based only on your specific condition.”

Some of the conditions that may make a person ineligible are listed as “severe heart, lung, kidney or liver failure; Terminal cancers; Severe trauma or burns.”

A statement issued Thursday night by Dr. Adnan Munkarah, executive vice president and chief clinical officer of Henry Ford Health System, confirmed the authenticity of the draft letter, but stressed that it reflects a “worst case scenario.”

“With a pandemic of this nature, health systems must be prepared for a worst case scenario,” Munkarah said. “Gathering the collective wisdom from across our industry, we carefully crafted our policy to provide critical guidance to healthcare workers for making difficult patient care decisions during an unprecedented emergency.”

He added, “These guidelines are deeply patient focused, intended to be honoring to patients and families. We shared our policy with our colleagues across Michigan to help others develop similar, compassionate approaches. It is our hope we never have to apply them and we will always do everything we can to care for our patients, utilizing every resource we have to make that happen.”

The draft letter was leaked online Thursday when Nicholas Bagley, a University of Michigan law professor, tweeted out an image of the letter on what appeared to be official hospital letterhead.

The full contents of the letter was printed by the Detroit Free Press (emphasis in original):

To our patients, families and community:

Please know that we care deeply about you and your family’s health and are doing our best to protect and serve you and our community. We currently have a public health emergency that is making our supply of some medical resources hard to find. Because of shortages, we will need to be careful with resources. Patients who have the best chance of getting better are our first priority. Patients will be evaluated for the best plan of care and dying patients will be provided comfort care.

What this means for you and your family:

1. Alert staff during triage of any current medical conditions or if you have a Do Not Resuscitate (DNR)/Do Not Attempt Resuscitation (DNAR) or other important medical information.

2. If you (or a family member) becomes ill and your medical doctor believes that you need extra care in an Intensive Care Unit (ICU) or Mechanical Ventilation (breathing machine) you will be assessed for eligibility based only on your specific condition.

3. Some patients will be extremely sick and very unlikely to survive their illness even with critical treatment. Treating these patients would take away resources for patients who might survive.

4. Patients who are not eligible for ICU or ventilator care will receive treatment for pain control and comfort measures. Some conditions that are likely to may [sic] make you not eligible include:

• severe heart, lung, kidney or liver failure
• Terminal cancers
• Severe trauma or burns

5. Patients who have ventilator or ICU care withdrawn will receive pain control and comfort measures.

6. Patients who are treated with a ventilator or ICU care may have these treatments stopped if they do not improve over time. If they do not improve this means that the patient has a poor chance of surviving the illness — even if the care was continued. This decision will be based on medical condition and likelihood of getting better. It will not be based on other reasons such as race, gender, health insurance status, ability to pay for care, sexual orientation, employment status or immigration status. All patients are evaluated for survival using the same measures.

7. If the treatment team has determined that you or your family members does not meet criteria to receive critical care or that ICU treatments will be stopped, talk to your doctor. Your doctor can ask for a review by a team of medical experts (a Clinical Review Committee evaluation.)

Michigan has become an emerging hot spot for the coronavirus pandemic in the United States. The state’s top health official, Dr. Joneigh Khaldun, said hospitals in southeast Michigan are “at or near capacity.”

The Henry Ford Health System is one of the major hospital providers in the Metro Detroit area, along with the William Beaumont Health System. Both providers have said they were caring for more than 1,000 COVID-19 patients at their 13 hospitals. Due to the sudden surge, operating rooms were being converted into intensive care units, and clinics had been turned into rooms for patients needing other medical care.

On Wednesday, Beaumont Health said its hospitals were swamped with 650 patients who had tested positive for the COVID-19 virus and more than 200 with tests pending. It said it would transfer more people to its hospital in Wayne County and get help from other health care providers.

“The number of patients coming to our emergency rooms continues to grow rapidly,” Beaumont CEO John Fox said.

Fox told the Detroit Free Press on Wednesday that the pandemic is proving to be healthcare providers’ “worst nightmare,” noting that Beaumont is admitting 100 new coronavirus patients per day, at that time.

“What we all need to remember is that we got our first patient two weeks ago. So this is coming on hard and fast. This is definitely a biological tsunami,” he said.

“In my lifetime, we’ve never had a pandemic like this,” Fox said.

“Across our system, we are facing limitations and nearing capacity with our staffing, personal protective equipment, and mechanical ventilators,” said Beaumont’s chief operating officer Carolyn Wilson.

“The numbers are changing and increasing even in two-hour intervals,” said Bob Riney, the chief operating officer at Henry Ford, whose flagship hospital is in the city of Detroit.

Dr. Betty Chu, the chief clinical officer and chief quality officer at Henry Ford, predicted an “upcoming surge.” Chu noted that the hospital was already reallocating resources because the Henry Ford hospitals in West Bloomfield and Detroit have reached capacity due to COVID-19 patients.

“Today our capacity is quite full at those two hospitals — West Bloomfield and Henry Ford Hospital in Detroit,” Chu said Wednesday. “We fortunately have the luxury right now of having additional capacity at some of our other campuses.”

On Wednesday, Mary Macdonald, an Oakland County ER nurse, posted a viral video on Instagram detailing the harrowing conditions at southeast Michigan hospitals where medical staff are combating shortages of essential supplies and equipment to care for this surge of coronavirus patients.

“It’s getting to the point now that it’s going to be just like Italy,” Macdonald said. “From 10:00 PM last night to this morning, we intubated two of my patients within a half-hour. And upwards of 10 patients were put on ventilators. My patient took the last ventilator available in the hospital,” she said.

“Normally, if a patient was to pass away, it would be because we tried everything that we could, we did everything that we could, we had all the resources and all the people that we needed to help save this patient’s life, and it was just their time. And now we aren’t giving the patient the time to choose whether it’s their time or not. We’re choosing for them,” she said.

Macdonald also noted that the hospital is short of even basic supplies.

“Resources are very slim. We have no medications to keep these patients even ventilated, let alone ventilators,” she said, adding that they are out of medications like propofol to keep people sedated when they are intubated. She said they are even running out of Tylenol.

“There are no masks. There are no gowns. They’re running low on gloves because everyone has panicked and stockpiled this, so that medical staff doesn’t have it,” she said and then showed the disposable N95 mask she was required to stow in a brown paper bag after every workday to be reused for the rest of the year.

Macdonald urged her fellow Michiganders to take the social distancing instructions seriously in order to protect themselves and their neighbors from spreading the virus, otherwise the overwhelmed hospital system won’t be able to care for all the sick.

“We don’t have any ventilators to put these patients on,” Macdonald stressed. “So, we’re going to start making life or death decisions in regards to people’s care. So you’re going to come in and you’re going to get tagged whether you [are] deem[ed] necessary to even get intubated or are you being sent home to die. This is truly scary, and nobody is taking it seriously.”

Khaldun, the chief medical office for Michigan’s Department of Health and Human Services, said the state is “probably a few weeks out” from hitting a peak in coronavirus cases. Michigan reported nearly 2,900 cases by Thursday and 60 deaths, both an increase of Wednesday’s statewide numbers.

Wayne County, home to Detroit, accounted for nearly half of the cases. Dr. Deborah Birx, the White House coronavirus response coordinator, called Wayne a “hot spot” nationally and said she was concerned the county was “having a more rapid increase.”

Southeast Michigan, like New York City, is a hub for international travel. As the capital of the world’s auto industry, Metro Detroit has daily direct flights to and from major cities in Europe and Asia.

Although the virus is hitting the entire metro area hard, the city of Detroit is uniquely vulnerable to the pandemic. Despite its dramatic economic rebound in recent years after its municipal bankruptcy in 2013, the city is still one of the poorest in the nation, with a poverty rate three times higher than the national average, and the city’s population suffers in greater numbers from underlining conditions like diabetes and heart disease.

“Part of what we’re seeing in Detroit is that there’s such a high number of individuals who have those underlying conditions, who have diabetes and the heart disease, who may have obesity,” Khaldun explained.

On Tuesday, Marlowe Stoudamire, 43, one of the young entrepreneurs involved in rebuilding the city, died from complications from COVID-19. According to health officials at Henry Ford Health System, Stoudamire had “no known underlying health conditions or recent travel.”

The city of Detroit’s police force has also been hit especially hard by the coronavirus pandemic, as 331 Detroit officers and 70 civilian police employees have been quarantined since the outbreak, and two members of the force have died this week due to COVID-19.

The Associated Press contributed to this report.