The Best Time to Address Crisis Standards of Care Issues Is Now
Although the late winter wave of COVID-19 in the United States seems to have crested, the emergence of variant strains and ongoing questions about immunity and vulnerability leave open the real possibility of additional waves later this year. Meanwhile, there is a growing humanitarian crisis befalling South Asia – in particular, the tragedy unfolding in India, where the health care system has essentially collapsed and many victims of COVID-19 are unable to receive any level of care whatsoever. These current events should make clear how important it is to prepare for future waves of the virus, as the fight against COVID-19 is not over. We must promote vaccination at every turn, support efforts to share clinical and operational lessons learned in order to make improvements based on this past year’s experiences, and ready our health care system and communities for the potential for further surges in demand for care.
The prospect of once again facing decisions about whether to transition to crisis standards of care (CSC) calls for action now, while a relative lull in cases allows stakeholders to plan thoughtfully for such decisions. This is especially important in light of painful lessons the pandemic has taught about the need for clarity and consistency across institutions and jurisdictions about invoking CSC and the disproportionate impact COVID-19 has had on historically minoritized and marginalized populations. Going forward, addressing equity must be recognized as a vital consideration for refining and deploying CSC. The challenge of CSC that are not sensitive to issues of equity can be compounded when they are put into practice through processes that similarly fail to embed considerations of equity.
As a concept, CSC were originally designed to involve declarations from the state government when invoked. Unfortunately, in jurisdictions where these declarations occurred during the pandemic, CSC was not needed in many cases. On the other hand, in many jurisdictions where health care providers were making difficult triage decisions, there was no formal recognition of the application of CSC. Further, “declarations” were difficult because only certain aspects of the response qualified as CSC (e.g., the supply of personal protective equipment), while others were not. The actions of the state should be tied to the necessary actions of clinicians (e.g., liability protections for certain actions, statewide clinical guidance). The role of the state increases as the clinical situation becomes dire. However, political considerations may preclude appropriate acknowledgement of challenging conditions. The expectations in each state should be clearly understood and agreed to by health care leaders and policy makers. Going forward, the following actions would support a more efficient response:
- Ensuring that health care facilities in a given area have common indicators and agreed-on thresholds for what is considered “crisis” –in terms of both staffing and decisions being made.
- Creating messages for health care providers and the public to communicate effectively about what to expect from the health care system when crisis thresholds are reached.
- Ensuring that strategies are in place to “load-balance” patients and resources regionally to avoid triage decisions, particularly decisions that are likely to lead to adverse and inequitable outcomes.
- Briefing local officials on response plans and providing situational updates, thereby encouraging recognition of crisis situations “on the ground” as well as official support for the response.
Providers have significant concerns about their liability protections under CSC. Protections vary significantly by state. Although the “reasonable provider” standard does provide some overall protection, the following actions would provide greater clarity and security:
- Understanding what protections are provided by the state and federal laws.
- Ensuring that legal counsel in health care facilities/systems understands the importance of developing policy for CSC resource allocation decisions, rather than leaving decisions to providers. Legal counsel should be prepared to defend the system and provider decisions.
The concept of “triage teams” was designed to support decision making when the outcome of a decision may be grave (e.g., ventilator allocation). This construct proved too narrow due for the breadth and novelty of the decisions faced by providers during the COVID-19 pandemic, which were often ad hoc and difficult. Going forward, the following strategies would improve care and decision making:
- Ensuring that any provider facing a novel/uncomfortable allocation decision has a designated point of contact to obtain immediate expert advice (e.g., an intensivist on call) and a channel to raise the issue to an incident management team.
- Employing a standardized assessment of the goals of care with the patient and family at the time of hospitalization and reconsidering for the continuation of therapies when the patient’s condition changes.
- Ensuring the availability of palliative care providers to support providers as well as family and patient needs and to facilitate more complicated decision making; and encouraging best practices of palliative care to enhance the comfort of all patients and ensure that care is consistent with patient wishes.
- Developing facility/system policy to support common allocation decisions (e.g., strategies adopted house-wide to stretch dialysis or oxygen resources) whenever possible.
- Emphasizing that staff should not be taking upon themselves decisions to restrict resources (e.g., withholding mechanical ventilation due to personal interpretation of resource scarcity or impending scarcity).
Among the biggest challenges for health care systems throughout COVID-19 has been having too few staff with appropriate training to meet the needs of incoming patients, particularly for emergency and critical care. Going forward, the following actions would help ameliorate the effects of this shortage:
- Providing health care staff with support, respite, information about behavioral health resources, and monitoring/check-ins for adverse personal impacts.
- Assessing intent of staff in the next 6-12 months to retire, re-train, or cut back hours to avoid potential dramatic impact on staffing after COVID-19.
- Educating staff about plans during any future surge (e.g., plans for expanding space or staff, triggers, and expectations for how staff will be deployed).
- Ensuring that staff have access to education (proactive and just-in-time) as well as onboarding and mentoring for non-traditional positions.
- Developing regional plans for surge staffing that avoid direct competition among facilities and systems for contract and other staff, and ensuring that communities plan support needs for hospital staffing prior to the staffing of community-based alternate care sites.
Hospitals and health care providers have responded with great skill to the burdens of COVID-19. Whatever challenges lie ahead, a partnership between clinical and administrative staff, including legal counsel, is necessary in order to ensure the development of channels to share information and develop policies that will mitigate the consequences of resource shortages and moral distress that accompanies rationing decisions. Further, hospitals are not islands – connection between and across jurisdictions and regions is needed to load-balance patients and resources in the interest of fairness and equity – both key goals of CSC.
The best time to address these issues is now, while they are top of mind. Failure to capitalize on this opportunity means the continuation of a fractured system that could do much more to protect both patients and providers in times of crisis.
Representatives from the signatory organizations are available for comment. Please contact Dana Korsen at firstname.lastname@example.org to be connected.
- Previous Joint Statement
- 1-page Overviews
- National Academies of Sciences, Engineering, and Medicine
- Institute of Medicine (now National Academy of Medicine)
- Technical Resources, Assistance Center, and Information Exchange (TRACIE), Office of the Assistant Secretary for Preparedness and Response, U.S. Department of Health and Human Services
- Robert Wood Johnson Foundation
- Oregon Health Authority