Two years ago, a panel of Washington hospital and health-care officials traveled the state asking residents to consider a nightmare scenario: If the state was hit with a pandemic that swamped the health-care system, how should we prioritize who should be treated and live, and who should be left to die?
In a series of seven public hearings, officials asked residents on both sides of the Cascades what should and shouldn’t be considered when deciding who should benefit from limited medical or emergency resources — such as ventilators, drugs or personal protective equipment — and who should be given comfort only, during their last hours.
There were debates about ethics and “social utility,” and “rich discussions” before generally concluding that, if necessary, the old should be sacrificed for the young and that health-care workers should be among the first people saved, according to a 2019 state Department of Health (DOH) report summarizing the findings.
The information gathered from those eerily prescient hearings is now informing draft crisis standards of care (CSC) guidelines being prepared should that nightmare scenario become reality, and a flood of sick and dying COVID-19 patients overwhelm the state’s ability to care for them.
“Our current data do not suggest that we will need to use CSC,” wrote state health officer Dr. Kathy Lofy in a joint statement Thursday with Dr. Vicki Sakata, an emergency room physician and chief medical adviser to the Northwest Health Care Response Network, which is spearheading those preparations. “We continue to hope for the best and prepare for the worst.”
It could be close.
“Many of the indicators would point to the fact that we are in a better situations than a couple of weeks ago,” when discussions about CSC began in earnest, the statement said. “However, we continue to plan for a significant surge in COVID patients. We do not know exactly how strained our health care system might be at the peak of activity.”
The doctors pointed to modeling the University of Washington’s Institute of Health Metrics and Evaluation provided to the DOH on Thursday predicting the state could be 26 intensive-care beds short at the height of the surge. “But the need could be much higher or lower,” the statement said.
In the event need outstrips the system’s capacity, even if only for a few days, the crisis standards of care guidelines are intended to provide an ethical, fair and consistent method to help providers prioritize who gets care when there aren’t enough resources for every patient, according to the 2019 report on the public hearings.
In 2009, the Institute of Medicine (now part of the National Academies of Science, Engineering and Medicine) suggested states establishe guidelines for providing care during extreme crises such as hurricanes, earthquakes or pandemics. The DOH recognized “that determining how to provide care in crisis situations can involve difficult ethical questions about who receives care and when” and embraced an Institute of Medicine suggestion to reach out to communities to ensure those guidelines reflect their “ethical values and priorities.”
So in March and April of 2018, the DOH’s Center for Public Affairs and the state Office of Emergency Preparedness and Response, with the help of a private facilitator, sponsored meetings in seven Washington communities — Bellingham, Yakima, Wenatchee, Spokane, Vancouver, Tumwater and Aberdeen — and led 136 residents in an extensive series of what-if exercises, surveys, prioritization and discussions focused on four substantive questions:
- What criteria should be used to allocate scarce medical and lifesaving resources when there are not enough for all the patients in need?
- Which options for allocating these resources should not be considered at all — taken “off the table?”
- What unique factors in their community or region, if any, need to be considered in issuing crisis standards of care guidance, including such things as distances patients might have to drive or specific cultural characteristics?
- How should the state explain crisis standards of care to the public, and when should that information be given?
Participants were also asked how their attitudes and perspective on crisis standards of care changed as a result of the meetings.
In addition to the residents, the meetings were attended by health-care, public-health and emergency management officials from the areas where the meetings were held to provide relevant information and expertise during the daylong exercises.
Although the report did not identify civilian participants at the meetings, it did include demographic information: , two-thirds of the participants were women, 70% were white and 66% were between the ages of 30 and 59. Just over half indicated they had at least a bachelor’s degree and another 24% said they had attended some college.
Participants in each of the meetings were presented with a scenario that involved a deadly influenza pandemic and presented with a group of fictitious sick patients from a variety of backgrounds and ages, all needing immediate care. They were asked to decide who would get care first, knowing that some or all of the others will die, and explain why.
Another exercise involved ranking 25 statements regarding who should receive medical priority along a continuum from “most fair” to “most unfair.”
The upshot is that the groups as a whole endorsed three “predominant perspectives” on implementing crisis standards of care: the care for health care providers, first-responders and vulnerable populations should be prioritized. Otherwise, the state should adopt a “utilitarian approach” to care, giving it to people who would benefit the most.
Debate about this, however, was robust, the report says.
“Across meetings, participants routinely grappled with the question of which social functions should be prioritized, if any, and how to measure one’s degree of ‘social utility’ for the purpose of allocating care,” the report says. “A subset of participants believed assessing social utility and using that as a criterion for medical care prioritization would be complicated, subjective and potentially discriminatory.”
While wanting to protect “vulnerable populations,” such as the aged, pregnant women and people with physical or emotional infirmities, there also was a desire to protect the most “life years,” and the young — and children in particular — were prioritized across the board.
“Participants commonly believed age was an acceptable criterion on which to base crisis care decisions and tended to favor prioritization of infants and young children,” the report said. However, at every meeting it was “regularly noted that deference for youth reflects a Western (specifically American) bias that should be checked,” particularly when dealing with cultures that value respect for elders.
What the group generally rejected were “chance-based” prioritization processes, such as using a lottery to determine who would get care, or allocating scarce critical care on a “first-come, first-serve” basis.
Participants were divided on whether health care providers should be able to reallocate lifesaving resources, taking them from one patient to give to another, but agreed that if doctors were given that power “there should be clear guidelines” on when and how it can occur.
One unanimous finding was that the DOH must be transparent. The public must be aware beforehand that crisis standards of care are going to be imposed, and that communication with the public, patients and their families is “a critical component of developing and maintaining public support.”
Information and data from the public hearings has since been synthesized into the Washington State Crisis Standards of Care Guidance Framework, which provides a consistent structure for state and local government and health-care organizations to implement crisis standards of care. It lays out an ethical structure of seven principles under which all crisis standard of care decisions must be made: fairness, duty to care, duty to steward resources, transparency, consistency, proportionality and accountability.
The framework was activated when it become clear in mid-March that surging COVID-19 cases might exceed the ability to care for them.
“The health care system is committed to maximizing the use of scarce resources to save the greatest number of lives during a crisis,” the guidelines state. “Consistent implementation of this plan across the state allows for the most effective use of resources.”
Once activated, the framework lays out the roles and responsibilities of everyone involved, from the governor to local hospitals. The overarching goal is to conserve critical resources in order to provide them to the people most likely to survive.
Sakata has said that crisis standards of care begin with the sorts of things that Washington has already implemented — social isolation, encouraging hand washing and hygiene, and closing business — all of which are intended to slow the spread of the virus so hospitals can handle the load over time.
At the hospital level, decisions on where to allocate scarce resources such as ventilators — required to treat COVID-19 patients who suffer from Acute Respiratory Distress Syndrome — will be made by a “triage team,” consisting of senior clinicians and medical ethicists, said Dr. Lofy, the DOH medical officer.
“They will be blinded to all personal data and there will be an oversight review process to review their decisions,” she said.
Moreover, the DOH has provided local health and hospital officials a packet of suggested critical-care materials, including trauma “score cards” with which clinicians can quickly assess the survivability of mass-casualty or crisis victims.
While all of this has given state health officials a view of what they might have to do in the coming weeks, the officials cannot be sure whether they will actually have to make such life and death decisions. As a result, Lofy said she has not issued the final crisis standards of care protocols. The DOH says it will do so publicly only if, in the coming days, it becomes clear that the number of critically ill COVID-19 victims has outstripped the system’s ability to treat them.
“We will communicate these plans to the public when the time is right,” Lofy said. “If we communicate about CSC now, people will think that we will be using it soon.”