With the coronavirus pandemic threatening to overwhelm medical care resources in some areas of the country, many states are facing a choice they never thought they would need to make: Who gets a ventilator?

It’s a nearly immediate matter of life or death. A person with COVID-19 who needs a ventilator can die quickly without one, and removing a ventilator from someone already on one often means they’ll die within minutes, according to a March 23 article in The New England Journal of Medicine (NEJM) titled “The Toughest Triage—Allocating Ventilators in a Pandemic.”

If and when ventilator shortages emerge in the next few weeks—a likely scenario according to several governors­—doctors will need criteria to decide who gets one and who doesn’t. Statewide criteria in New York, the current epicenter of COVID-19 in the United States, target “saving the most lives, as defined by the patient’s short-term likelihood of surviving the acute medical episode,” according to the NEJM article.

Alabama’s pandemic guidelines recommend winnowing out people with certain medical conditions from even being considered for a ventilator, no matter their current medical emergency.

The state’s existing 10-year-old recommendations would explicitly deny access to lifesaving ventilators for people with certain conditions in the event of a pandemic, according to AL.com, a website that represents several Alabama newsletters.

According to the state’s “Criteria for Mechanical Ventilator Triage Following Proclamation of Mass-Casualty Respiratory Emergency,” these conditions include metastasized cancer, AIDS, end-stage liver disease (with a MELD score of over 20), “severe mental retardation,” advanced dementia and severe burns. AL.com suggests that these conditions “could disqualify patients from being put on potentially lifesaving ventilators if a pandemic grows dire enough. And some people already on ventilators could be removed from them to make space for people impacted by the pandemic, according to the guidance.”

Metastatic, or Stage IV, cancer has spread from the original tumor site to other parts of the body. While this has the worst prognosis of any cancer stage, treatment advances in recent years have allowed some people with metastatic cancer to live for months, even years, and to manage their condition as a chronic disease, like diabetes. Additionally, new treatments, including immunotherapy, have increased the survival odds for certain metastatic cancers. For Stage IV melanoma, for instance, the five-year survival rate is now 22.5%., according to the Melanoma Research Foundation. This is much greater than it was 10 years ago, when the Alabama guidelines were first drawn up.

Because there is no shortage of ventilators at this time, the Alabama document is for guidance only.

In every state that faces a critical shortage of lifesaving equipment for COVID-19, wrenching decisions will need to be made. Reports from Italy describe physicians “weeping in the hospital hallways because of the choices they were going to have to make,” according to the NEJM. “In the weeks ahead, physicians in the United States may be asked to make decisions that they have never before had to face and for which many of them will not be prepared.”

To read the NEJM article, click here.

To read the AL.com article, click here.

To get the latest updates on the new coronavirus and cancer, click here.