When US ICUs Are Full, Most States Ration Care by Age

By Ronnie Cohen

September 20, 2021

(Reuters Health) - As COVID-19 strains and tests the limits of hospitals and healthcare workers, how do we decide who to treat and who to turn away?

Most U.S. states have adopted pandemic preparedness plans, and, if necessary, more than half of them plan to ration access to intensive care by age or life-years, a new study finds.

Two states so far - Arizona and Idaho - have activated "crisis standards of care" as hospitals there are overwhelmed with coronavirus patients. Both states rely on age or life years in deciding how to allocate limited resources, said Dr. Daniel Sulmasy, senior author of the report in the journal Chest.

In parts of Idaho, for example, at 78 years old, President Joe Biden might not qualify for a hospital bed because of his age, Dr. Sulmasy told Reuters Health in a phone interview.

"These are horrible decisions no one would want to make," said Dr. Sulmasy, director of the Kennedy Institute of Ethics at Georgetown University in Washington, D.C. As a physician and a medical ethicist, he believes age should never be used as a criterion for rationing care.

"I would rather have decisions be made on the basis of need, first come, first served," he said. "And then a lottery would be a fair way to do it. Then we would all be equal."

For decades, ethicists studying healthcare resource allocation have held "warring philosophies" about rationing care, the study authors write. While some contend the ultimate goal should be saving the most number of lives, others prioritize attempting to calculate saving the most years of human life.

The new study examined state-approved pandemic preparedness plans with an eye toward how each incorporated the controversial question of how age and life years play into triage.

In the spring of 2020, Dr. Sulmasy and his team identified 35 published, state-endorsed pandemic preparedness plans. Most of the plans were written in 2020 in response to the novel coronavirus pandemic.

Of the 35 states with plans, 17 used age or the idea of maximizing the number of life-years expected to be saved as a prime consideration in rationing care, the study found. Seven states considered only the chances for short-term survival regardless of age.

Only one state, Arizona, had implemented its plan before the study's publication. Idaho was forced to implement its plan earlier this month, and other states could be pressed to act as they confront the latest wave of COVID-19 cases. Implementation of the plans has the potential to impact millions of people, the Chest report says.

In response to allegations that their plans discriminated against disabled and older residents, many states had to modify their plans. Alabama, for instance, initially planned to withhold ventilators from anyone diagnosed with "mental retardation," Dr. Sulmasy said. But following objections, the state lifted that restriction, he said.

He believes the fairest plans consider short-term survival as the metric by which intensive care should be rationed, if it must. The states of Alabama, California, Delaware, Iowa, Louisiana, New Mexico and Tennessee all consider only short-term survival in their preparedness plans.

Dr. Sulmasy described the Idaho protocol, which relies on total life years, as "stunning." The plan prohibits healthcare workers from performing CPR on anyone in the hospital, he said.

In addition, he said, when a patient in an Idaho hospital operating under the crisis standards has failed to improve after being in intensive care for four days, that's seen as a "failure, pull the plug."

"I can't imagine a physician really doing that, but this is what the Idaho protocol says they should do," he said. "We don't want to force these terrible choices."

SOURCE: https://bit.ly/2XtVdy7 Chest, September 7, 2021.

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