Additional Equity Interventions in Revised Pandemic Policy to Allocate Scarce Critical Care Resources

The model hospital policy for allocating scarce critical care resources during the pandemic (originally distributed in March 2020) has been updated to include several modifications that strengthen the equity focus of the policy. Authored by Douglas White, MD, MAS and Bernard Lo, MD, the revised policy, “Allocation of Scarce Critical Care Resources during a Public Health Emergency,” includes allocation criteria based on the two ethical goals of saving lives and promoting equitable access to the scarce resources. The critical care resources vulnerable to scarcity during a public health emergency may include ventilators, ICU staffing and beds, physician and/or nurse knowledge, and oxygen, among others.

The updated policy is freely available to download as PDF or editable Word versions.

For more detail on the ethics and rationale for the policy, see Dr. White’s Feb. 2021 paper “Mitigating Inequities and Saving Lives with ICU Triage during the COVID-19 Pandemic” in the American Journal of Respiratory and Critical Care Medicine.

“We know that disadvantaged people are bearing the greatest burden, so we’ve taken action to prevent and reduce inequitable outcomes,” said Dr. White, professor of Critical Care Medicine and director of the Program for Ethics and Decision Making at the Department of Critical Care Medicine.

Recent scientific evidence has shown that (a) minority populations are far more likely to be infected, hospitalized and die of COVID-19 than White populations, and (b) people from economically disadvantaged communities are disproportionately impacted by the pandemic.

Dr. White explained that the initial policy, launched in the early days of the pandemic, contained several strategies to promote equitable allocation, including disallowing consideration of long-term life expectancy, perceived quality of life or social worth, categorical exclusion of any patient groups, and giving heightened priority to the frontline essential workers.

“It soon became clear from the epidemiological data about COVID outcomes that Black, Latinx and Indigenous people were disproportionately impacted by severe COVID-19 infections, and that we needed to do more to ensure that triage guidelines address these inequities. We added a correction factor to ensure that individuals from disadvantaged communities were not unfairly disadvantaged in the triage process. We also revised our approach to considering duration of benefit as a criterion, so that patients who are expected to live at least a year are all treated equally in this regard, rather than giving higher priority to patients expected to live at least five years.”

What are the allocation criteria in the revised framework?

A. Ethical goals

  1. Saving lives
  2. Promoting equitable access to scarce resources

B. Critical care patient priority score

Based on a multi-principle allocation framework (1-8 scale; lower scores indicate higher priority for critical care), the scoring criteria include efficiency-focused and equity-focused considerations.

Efficiency-focused considerations:

  1. Likelihood of surviving to hospital discharge, assessed with an objective risk predictor (e.g., the LAPS2 score)
  2. Near-term prognosis, assessed as the presence of end-stage illness such that the patient is expected to die within a year even if they survived the acute critical illness

Equity-focused considerations: 

  1. Disallowing consideration of long-term life expectancy, perceived quality of life or social worth, rejecting categorical exclusion of any patient groups
  2. Heightened priority to frontline essential workers
  3. A correction factor to lessen the extent to which severe structural inequities disadvantage already-disadvantaged patients in triage
  4. Heightened priority to the young, who are the worst off in the sense that if they die, they will have had the least opportunity to live through life’s stages

About Dr. Douglas White, MD, MAS

Dr. White is the UPMC Endowed Chair for Ethics in Critical Care Medicine and professor of Critical Care Medicine, Medicine, and Clinical and Translational Science in the Department of Critical Care Medicine at the University of Pittsburgh. Professor White is director of the CRISMA Program on Ethics and Decision Making in Critical Illness. He and his colleagues conduct scholarly work to understand and improve how medical decision are made for critically ill patients, many of whom are unable to made decisions for themselves.

References

  1. White DB, Lo B. Mitigating Inequities and Saving Lives with ICU Triage during the COVID-19 Pandemic. Am J Resp Crit Care Med. 2021 Feb 1;203(3):287-295. doi: 10.1164/rccm.202010-3809CP. PMID: 33522881.
  2. Mello MM, Persad G, White DB. Respecting Disability Rights - Toward Improved Crisis Standards of Care. N Engl J Med. 2020 Jul 30;383(5):e26. doi: 10.1056/NEJMp2011997. Epub 2020 May 19. PMID: 32427433.
  3. White DB, Bernard Lo. Promoting Equity with a Multi-principle Framework to Allocate Scarce ICU Resources. Journal of Medical Ethics. J Med Ethics June 7, 2021 online ahead of print;  http://dx.doi.org/10.1136/medethics-2021-107456
  4. Auriemma CL, Molinero AM, Houtrow AJ, Persad G, White DB, Halpern SD. Eliminating Categorical Exclusion Criteria in Crisis Standards of Care Frameworks. Am J Bioeth. 2020 Jul;20(7):28-36. doi: 10.1080/15265161.2020.1764141. Epub 2020 May 18. PMID: 32420822; PMCID: PMC7387214.
  5. White DB, Lo B. A Framework for Rationing Ventilators and Critical Care Beds During the COVID-19 Pandemic. JAMA. 2020 May 12;323(18):1773-1774. doi: 10.1001/jama.2020.5046. PMID: 32219367.
  6. Sonmez T, Pathak P, Unver U, Persad G, Truog RD, White DB. Categorized Priority Systems: A New Tool for Fairly Allocating Scarce Medical Resources in the Face of Profound Social Inequities. Chest. 2020 Dec 26:S0012-3692(20)35502-1. doi: 10.1016/j.chest.2020.12.019. Epub ahead of print. PMID: 33373597.
  7. Antiel RM, Curlin FA, Persad G, White DB, Zhang C, Glickman A, Emanuel EJ, Lantos JD. Should Pediatric Patients Be Prioritized When Rationing Life-Saving Treatments During COVID-19 Pandemic. Pediatrics. Pediatrics. 2020 Sep;146(3):e2020012542. doi: 10.1542/peds.2020-012542. Epub 2020 Jul 9. PMID: 32647066.
  8. Julia S. C. Chelen, Douglas B. White, Stephanie Zaza, Amanda N. Perry, Deborah S. Feifer, Maia L. Crawford, and Amber E. Barnato. US Ventilator Allocation and Patient Triage Policies in Anticipation of the COVID-19 Surge. Health Security. June 9, 2021 online ahead of print; https://doi.org/10.1089/hs.2020.0166
  9. Cohen IG, Crespo AM, White DB. Potential Legal Liability for Withdrawing or Withholding Ventilators During COVID-19: Assessing the Risks and Identifying Needed Reforms. JAMA. 2020 May 19;323(19):1901-1902. doi: 10.1001/jama.2020.5442. PMID: 32236491.
  10. Daugherty Biddison EL, Gwon H, Schoch-Spana M, Cavalier R, White DB, Dawson T, Terry PB, London AJ, Regenberg A, Faden R,  Toner ES. The community speaks: understanding ethical values in allocation of scarce lifesaving resources during disasters. Annals of the American Thoracic Society 2014;11:777-83.