Responding to requests from health care leaders, Massachusetts public health officials have released guidelines for how hospitals can navigate “tragically difficult decisions,” such as rationing ventilators and intensive care beds as the COVID-19 pandemic rages on.
The state Department of Public Health guidance, “Crisis Standards of Care,” which is by no means a mandate, was created by health care and ethics experts from across the commonwealth, Ann Scales, a department spokesperson, told Boston.com.
“These are not conversations that anybody ever wants to have,” Gov. Charlie Baker said during a press conference Wednesday. “But over the past few weeks we’ve heard from many in the health care community on the need to issue recommendations on how to equitably and ethically allocate health care resources across the system.”
The 34-page document suggests hospitals and medical facilities use a “priority scoring” system, if at capacity, for determining which patients receive critical care resources. The framework is based around saving the most lives, and saving the most life years, giving preference to healthier patients who are more likely to survive a serious illness.
Health care workers and those “who perform tasks that are vital to the public health response” also receive preference under the system, and, should a score tie arise, younger patients are prioritized, according to the document.
The guidance explicitly states factors that professionals should not consider include race, disability, gender, sexual orientation, gender identity, ethnicity, socioeconomic status, homelessness, ability to pay, immigration status, incarceration status, and perceived social worth, among others.
“There is a great sense of urgency,” Dr. Robert Truog, director of the Center for Bioethics at Harvard Medical School and a pediatric intensivist who helped craft the guidance, told The Boston Globe. “We realize this all needs to be in place soon. It’s very important to have current guidelines that provide very concrete advice to hospitals about how to allocate these resources.”
The state guidelines closely follow with a proposal last month at the University of Pittsburgh, which has been adopted by several states, according to Baker.
“The guidelines just released are as thoughtful as any that any state has yet produced, because they built from so much important work that other states had done before us,” Dr. Lachlan Forrow, director of ethics and palliative care at Beth Israel Deaconess Medical Center and a member of the advisory committee that worked on the Massachusetts guidelines, told WBUR.
The recommendations underscore the need to keep the public’s trust by rolling out uniform critical care allocation protocols across the state.
Baker stressed that the document contains only recommendations and that the actions outlined are not mandatory.
“But we have a moral obligation to ensure there are transparent and ethical guidelines available to our medical professionals if they have to make these excruciating decisions,” he said.
The guidance comes as Massachusetts and states across the country brace for an anticipated surge in COVID-19 patients. Baker said Wednesday Massachusetts appears to still be on the rising slope and that a peak in cases could come sometime between April 10 and 20.
Officials expect the guidelines would only be used “in true disaster situations,” he added.
“Of course we’re doing everything in our power to prevent these situations from occurring in the first place,” Baker said.
Here are some key takeaways:
The decision makers
Decisions over who receives critical care would not be made by doctors and nurses caring for patients in question, according to the guidelines. Instead, a group of triage officers at each hospital would assign each patient a priority score based on an eight-point system, which would determine equipment allocation.
“The separation of the triage role from the clinical role is intended to enhance objectivity, avoid conflicts of commitments, and minimize moral distress,” the document says.
A review and oversight committee would handle reassessments, appeals, and disputes.
The decision process
Patients would receive priority scores to determine their likelihood of surviving with intensive care, and scores would be given based on factors such as existing comorbid conditions that can limit life expectancy.
“Patients who are more likely to survive with intensive care are prioritized over patients who are less likely to survive with intensive care,” the guidance says. “Patients who do not have serious comorbid illness are given priority over those who have illnesses that limit their life expectancy.”
Priority would be given to patients with lower scores, and pregnant patients and first responders would also receive priority scores. Patients would be assigned to priority groups based on their scores.
Reassessments and appeals
The triage team and hospital leaders should make reassessments on equipment allocation at least twice a day under the recommendations.
“There may be situations in which the hospital determines that it will offer critical resources to a certain priority group on a given day, and then there are not enough critical care resources for all patients within that priority group to receive them,” the guidelines say. “In such a case, the raw priority scores will determine the priority order for patients in the same priority group (the lower the score, the higher the priority). In some circumstances, it may be ethically permissible to conserve scarce critical care resources during times of high demand to assure that the resources are available to those with the best prognoses.”
Reassessments would be made through re-calculating priority scores and “consulting with the treating clinical team regarding the patient’s clinical trajectory,” officials say.
Patients who are no longer prioritized for critical care should receive intensive symptom management care and psychological support, according to the guidance.
Acknowledging the need for an appeals process, the document says because initial triage decisions have to be made quickly, the only appeals that hospitals would entertain to those decisions are claims based on the idea that “an error was made by the triage officer in the calculation of the priority score.” The score would then be re-calculated.
Patients may also appeal a decision to remove him or her from “scarce resources,” such as ventilators. The review and oversight committee would oversee the process and render a final decision.
Truog told WBUR the main focus of the guidelines DPH has issued to the public is to “increase the capacity of medical care so that everyone is able to get what they need.”
“But if, and when, that capacity is exceeded, the public should know that we are not flying by the seat of our pants — we have a plan that has been carefully developed by clinicians, ethicists, and members of the public, and that is designed to be as fair, equitable, and non-discriminatory as possible,” he said.
Read the full guidelines.