Position statement addresses difficult issue: allocating scare resources in COVID-19 era
The COVID-19 pandemic has placed unprecedented pressure on societies worldwide, given the pandemic's rapid, often deadly spread. In health care, the pandemic has raised the pressing question of how society should allocate scarce resources during a crisis. This is the question experts addressed today in a new position statement published by the American Geriatrics Society (AGS) in the Journal of the American Geriatrics Society. The statement focuses primarily on whether age should be considered when making decisions to allocate scarce resources.
"A just society strives to treat all people equally, so there's something particularly unjust about characteristics beyond our control—like age—determining whether we receive care," explains Timothy W. Farrell, MD, AGSF, who led the writing group responsible for the statement. "The AGS believes we must focus on the most relevant clinical factors for each person and case when considering how to distribute resources fairly without placing arbitrary weight on age."
COVID-19 continues to impact older adults disproportionately when it comes to serious consequences, from severe illness and hospitalization to increased risk for death. Concerns about potential shortages of ventilators, hospital beds, and other supplies to address these shortages have focused attention on decision-making about who gets access to these resources.
"Unfortunately, some strategies use age as an arbitrary criterion, which disfavors older adults regardless of their function and health relative to COVID-19," said AGS President Annie Medina-Walpole, MD, AGSF. "With this statement, we hope to support hospitals, health systems, and policymakers as they develop resource allocation strategies for use in emergent situations that do not rely on age as a criterion."
After reviewing existing frameworks, recommendations, and research, an expert panel of interprofessional experts, AGS leaders and members of the AGS Ethics Committee devised seven principles aimed at helping develop strategies to allocate resources equitably when they remain in short supply:
1. Age should never be used as a means for categorically excluding someone from what is ordinarily the standard of care, nor should age "cut-offs" be used in allocation strategies.
2. When assessing comorbidities (the medical term for multiple health concerns we live with concurrently), decision-makers should carefully consider the impact of race, ethnicity, and other "social determinants," especially since these often are beyond a person's control.
3. Strategies for making allocation decisions should primarily—and equally—weigh how severe comorbidities and survival in hospital might contribute to the short-term risk for death. This means that health professionals should focus primarily on what is most within their control: Potential outcomes over the next 6 months (and not beyond, which could disproportionately impact care for older people).
4. In order to avoid bias in decision making, health professionals also should avoid criteria that might disadvantage us all as we age. These include characteristics such as:
- "Life years saved" (how many years could be added to someone's life by treatment).
- "Long-term predicted life expectancy" (the long-term view of length of life from this point in time).
5. Committees and officers tasked with triage (the technical term for organizing and prioritizing a health system's response, especially in times of crisis) also need to be chosen carefully. Ideally, these individuals not only have expertise in medical ethics and geriatrics (the healthcare specialty dedicated to our needs as we age) but also work outside "day-to-day" care so triage officers can maintain impartiality.
6. Institutions should develop resource allocation strategies that are transparent, and applied uniformly. Ideally, that means leveraging advanced planning and input from multiple disciplines, including ethics, law, medicine, and nursing. To make the work of an officer or committee transparent, institutions also should develop consistent strategies available to all for review. "Clinicians at the front lines should be applying—not selecting—emergency rationing criteria when resources are limited," the AGS position statement explained.
7. The COVID-19 pandemic highlights the critical importance of appropriate advance care planning (ACP)—the technical term for working with a health professional and anyone else you choose to document preferences for possible care situations, such as whether you'd want to be placed on a ventilator if you weren't able to breathe on your own. While engaging in these conversations early and often remains critical, they also never should be viewed as a form of rationing, nor should someone be compelled into documenting care preferences primarily because of a broader health crisis. ACP is most effective when it lives up to its name: A conversation in advance, planned with personal preferences at heart.
To help with the urgent need to put in place policies and approaches within the context of the COVID-19 pandemic, the AGS also suggested frameworks to aid health leaders and health systems. They include:
- Developing a multi-factor allocation strategy based on AGS insights;
- Establishing triage committees and identifying triage officers;
- Clearly communicating about available resources;
- Ensuring access to important treatment options (like hospice and palliative care); and
- Working to develop individual care plans for patients.
Long-term, the AGS also advocated for post-pandemic reviews of COVID-19 rationing strategies, with the goal of removing discriminatory provisions—including age-based cutoffs—which disfavor older adults.
"Health care is unlike other 'goods' or services in that it's a prerequisite for pursuing virtually every other opportunity that makes life meaningful," summarized Dr. Farrell. "Our position statement is aimed at recognizing resource allocation shouldn't be a question of 'if' but rather how we can make decisions safely and smartly, making good on our societal commitment to treat all people fairly."