Overwhelmed hospitals in California are rapidly inching towards the abyss of rationing care.
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On Jan. 4, 2021, an LA Times headline read “Ambulance crews told not to transport patients who have little chance of survival”.
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The same article included a directive from the L.A. County Emergency Medical Services Agency to withhold oxygen from patients with 02 sats of 90% or higher.
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Two days later, the L.A. Times reported that Methodist Hospital in Arcadia, CA notified the California Department of Public Health that it would implement crisis care guidelines.
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“If a patient becomes extremely ill and very unlikely to survive their illness (even with life-saving treatment), then certain resources currently limited in availability, such as ICU care or a ventilator, may be allocated to another patient who is more likely to survive,” read the county hospital's message.
Bodies are being stored in hastily ordered refrigerated trucks and morgues are turning away families. Patients are being cared for in hallways and tents.
We’re all exhaustingly familiar with surge/contingency state by now, but the next tier, crisis care, takes us to the far and extreme end of the spectrum. Moving to a crisis standard of care is not optional, it is forced (IOM 2009). It’s when all other options have been exhausted.
Crisis Standards of Care
Crisis Standards of Care typically apply to the battlefield. It conjures up movie scenes of doctors and nurses stepping over the bodies of those likely to die to treat only those less likely to die. Once unthinkable in healthcare, the hows and whys of it are now being planned.
Warning
We were warned to prepare for this scenario decades ago.
“Therefore, the United States must continue to plan for a catastrophic public health event that will cause grave injury, disease, or death to potentially thousands or tens or hundreds of thousands in a city, region, or entire nation.” (IOM, 2009 pg 17). These words, written in 2009, sound almost prophetic when read today.
Hospitals and states are required to formulate Crisis Standards of Care Guidelines to activate during a catastrophe. Once a facility, a county, or even an entire state declares they are operating under Crisis Standards of Care, rationing is in effect. It should be formally announced that the facility is operating under Crisis Standards of Care due to specific circumstances to protect nurses and for public transparency.
According to the Institute of Medicine (IOM), Crisis Standards of Care are guidelines developed beforehand to help decision-makers allocate limited resources in a disaster. They provide a framework for decision-making when a hospital or system is so overwhelmed that it cannot provide the best care.
Decision-makers under extreme stress need guidelines when information and situations are rapidly changing or otherwise, a first-come, first-serve prevails. Without guidelines, front-line workers have to make life and death and supply decisions at point of need. Chaos ensues.
Doctors could argue about which patients gets a ventilator, or dialysis, or ECMO. Nurses would have to decide who gets what medications and treatments first or not at all. Nursing assistants could compete to get blood pressure machines or oxygen tanks.
Crisis Standards of Care aka Rationing
It will be called resource allocation by hospitals, and it means rationing.
Who Gets Care?
Under Crisis Standards of Care, choices will be made to save the most lives, even if those choices are not in the best interests of individual patients.
A triage officer is appointed and a team convened, ensuring no one person has to play God. The team could include doctors, nurses, spiritual care providers, and ethicists. Committee members will not include the patient’s nurse or doctor.
There are different ways to make such highly sensitive, ethical decisions. What are some criteria being considered?
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Should age be a determinant? Preference given to a young person who has a full life ahead over a 70 yr old? But some 70 and even 80 yr olds still contribute a great deal, for example, Dr. Fauci, who is 80 yrs old, fit, and works 18 hr days.
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What about people with disabilities? Some people with disabilities are afraid they won’t make the cut to the front of the line. Should someone with a higher baseline functional status be given preference over someone in a wheelchair, or someone with schizophrenia?
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Should likelihood of survival be the main decider? There are patients who have been on ventilators more than 30 days, more than 40 days. Currently if you are on a ventilator, the ventilator is yours until you improve or die. Under Crisis Standards of Care, it could be re-assigned after a period of time or if there’s no improvement.
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Should those with chronic conditions and co-morbidities be given a lower priority? But won’t that discriminate against people of color, who have chronic conditions due to socioeconomic status and lack of access to healthcare?
These are tough questions. Should patients during admission be asked if they would forgo being placed on a ventilator if there is a shortage?
California guidelines state that a person's age, race, sex, disability status, religion and ability to pay legally cannot be an explicit factor in making the decisions and proposes sequential organ failure assessment (SOFA) scoring.
SOFA Scoring
Some hospitals are already measuring SOFA scores.
Scores measure oxygen levels, jaundice, kidney function and responsiveness. All things being equal, if 2 patients qualify for an ICU bed, it can go to the younger patient. Some patients who have been in ICU a very long time and are not improving based on condition scores may get removed or moved to a non-ICU bed.
Is your hospital moving toward crisis mode? What are you seeing and what are your thoughts?
Best wishes,
Nurse Beth
Author, "First-Year Nurse" the ultimate insider's guide to helping new nurses succeed while avoiding first-year pitfalls.
References
Berlinger, N., & WM, P. T. Ethical framework for health care institutions & guidelines for institutional ethics services responding to the coronavirus pandemic: Managing uncertainty, safeguarding communities, guiding practice. (2020, March 16). https://www.thehastingscenter.org/ethicalframeworkcovid19/ Retrieved 2021,Jan. 4.
Committee on Crisis Standards of Care: A Toolkit for Indicators and Triggers; Board on Health Sciences Policy; Institute of Medicine; Hanfling D, Hick JL, Stroud C, editors. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington (DC): National Academies Press (US); 2013 Sep 27. 3, Toolkit Part 1: Introduction. Available from: https://www.ncbi.nlm.nih.gov/books/NBK202382/ Accessed 2021 Jan 4.
IOM. Crisis standards of care: A systems framework for catastrophic disaster response. Washington, DC: The National Academies Press; 2012. http://www.nap.edu/catalog.php?record_id=13351. Accessed 2021 Jan 4.
Hanfling, D., Hick, J. L., & Stroud, C. (2013). Toolkit Part 2: Public Health. In Crisis Standards of Care: A Toolkit for Indicators and Triggers. National Academies Press (US).
IOM (Institute of Medicine). Guidance for establishing crisis standards of care for use in disaster situations: A letter report. Washington, DC: The National Academies Press; 2009. http://www.nap.edu/catalog.php?record_id=12749.
Wigglesworth, A., Rong-Gong, L., Karlamangla, S, Money, L.(2021, Jan 4). Ambulance crews told not to transport patients who have little chance of survival. LA Times. Retrieved 2021, Jan 4
JBMmom, MSN, NP
4 Articles; 2,537 Posts
We currently have a heartbreaking little lady in our ICU. Ninety years old, resident of a long-term care facility, end stage dementia. Has been non-verbal for years and she didn't speak or understand English when she was still speaking. It took three people to hold her down to insert the central line so we could run three pressors. We got her through the night on BiPAP 88-91% oxygen, but didn't even take her off to do mouth care. My hope was that the intensivist could talk with the family and make her a DNR/DNI or CMO before she needed intubation. Nope, came back the next night and guess who's on a vent, tied to the bed, sedated and miserable. Family insists that everything be done.
Education in the general public about end of life issues is so lacking. If people saw what we were doing to patients they would probably accuse of us abuse, but here we are honoring the family's wishes to "do everything". I really don't want to do CPR on one more COVID patient just to break their ribs and have them die anyway.
These are the mornings I drive away from work feeling a moral crisis knowing that what my job requires is so at odds with what I feel to be the right thing to do as a human being.