The National Academy of Medicine and nine other national organizations call for key actions to be taken in order to do the most good possible for the largest number of people with limited resources.
The crisis is now: governors, health departments, hospitals, and other health care sector partners must take immediate action to save lives and fairly allocate limited resources. Hospitals across most of the United States are experiencing alarmingly high surges in COVID-19 patients, and many intensive care units across the country are already over capacity and many more will be so in the coming weeks. In response, hospitals are canceling admissions and non-emergency procedures, identifying ways to augment staff, transferring patients outside their local jurisdictions, and even establishing and operating alternate care sites. Many of the hardest-hit hospitals are those that serve Black, Brown, Asian, and tribal communities, threatening to exacerbate existing inequities in care quality and outcomes.
We have reached a point in the crisis at which critical decisions must be made in order to do the most good possible for the largest number of people with limited resources. These decisions effectively signal a shift from conventional to crisis standards of care (CSC). This means making unprecedented and agonizing decisions about how resources are used, stretching many resources well beyond conventional limits. Every action possible should be taken now to mitigate the need to operate under crisis conditions. Failure to act will inevitably mean more lives lost, lasting damage to our fragile health care system, and deepened scars of health inequity.
We recommend the following key actions be taken now:
- Governors
- Work with the health departments and hospitals in their state to prepare appropriate draft emergency declarations that identify resources that are in limited supply, as well as consider appropriate legal and regulatory relief for actions that might have to be taken by health care providers to address the unprecedented demand for health care services.
- Work with health departments and hospitals to ensure equitable resource allocation in CSC conditions, with special attention to outcomes for people of color, people with disabilities, and people with low income. This includes collecting, analyzing, and reporting on data disaggregated by race, ethnicity, disability, neighborhood, and other sociodemographic characteristics.
- Work with health departments to monitor the impact on health care facilities and support distribution of resources and patients to enhance fairness and avoid inequity.
- Frequently communicate with patients, families, and providers with full transparency. Messages should reflect the current situation, with updates and details of recommended actions, when appropriate.
- State Health Departments
- Work with health care coalitions to coordinate health system response across their regions in order to assist with patient “load balancing” and harmonizing strategies, as much as possible, for patient distribution and care.
- Work with health care facility and system leaders to prioritize situational awareness, reporting on data points related to the supply of key resources and their impact on demand for service.
- Work with federal and state regulators and stakeholders, including people with disabilities, to develop statewide CSC plans in compliance with applicable civil rights law.
- Hospitals/Health Care Systems
- Socialize existing CSC plans with health care personnel and take steps to make the plans operational, including determining how staffing shortages will be addressed and what resources clinicians can draw upon for difficult triage or allocation decisions. Whenever possible, these decisions should be made according to best available evidence, consistent with crisis standards guidance, and supported by an incident management team, rather than left to bedside providers.
- In the absence of a CSC plan, convene an interdisciplinary team to immediately draft a plan (see the resource list at the conclusion of this letter). Plans should be focused on describing the incremental changes to the way health care – particularly critical care – will be delivered. They should define how staffing accommodations will be implemented to cover the demand for services as fairly as possible. Plans should define the role of an incident command team, how the facility should interact with the rest of the health care system in its region, and the clinical and resource support that is available to clinicians who have to make decisions that fall outside their usual practice standards.
- Provide instruction related to applicable civil rights law in the adoption and implementation of CSC plans including prohibitions on unlawful stereotyping.
- Make resource allocation decisions based on individualized assessments of each patient, using the best available objective medical evidence concerning likelihood of death prior to or imminently after hospital discharge, including clinical factors relevant and available to such determinations, which may include age under limited circumstances.
- However, such assessments should NOT use categorical exclusion criteria on the basis of disability or age; judgments as to long-term life expectancy; evaluations of the relative worth of life, including through quality of life judgments, and should NOT deprioritize persons on the basis of disability or age because they may consume more treatment resources or require auxiliary aids or supports.
- Plan for how to engage families and palliative care departments in end-of-life discussions and, crucially, ensure that end-of-life wishes are documented, including desire for multi-organ failure support and prolonged mechanical ventilation. Avoid steering or pressuring patients to agree to the withdrawal or withholding of life-sustaining care.
We call on governors, health departments, hospitals and other health care sector partners to act immediately to be prepared to implement crisis standards of care. Governors should be prepared to support the transition of care under crisis conditions. They will be required to implement specific actions and facilitate communications strategies that empower their administrations to address the unprecedented demand in surge for healthcare services, and recognize that the standard of care will necessarily change under current circumstances. These include legal protections for health care workers practicing in crisis situations and the use of statewide mechanisms to share information with patients, families, and providers alike. States must also be prepared to assist in the distribution of patients and resources. Health departments, along with health care coalitions, should be coordinating care across jurisdictions, and hospitals should be working closely with their clinicians to not only adjust processes and procedures to maximize capacity, but also implement processes to make fair and ethical decisions if these adjustments fail and there is not enough of an essential resource.
Government, public health agencies, and the public should be doing everything possible to curb the spread of the virus and flatten the curve to protect the health care system from functional collapse. But, increasingly, many hospitals are being forced into crisis conditions, particularly related to staffing. Health care, public health, and state/local governments all have a duty to prepare so that the death toll is as small as possible and clinicians are not forced to make agonizing decisions in a vacuum without guidance, training, or a considered process. Failure to do so will lead to unnecessary loss of life for COVID and non-COVID patients alike, exacerbate poorer outcomes for people of color, and cause profound moral injury to health care workers forced to make agonizing decisions for which they are not prepared.
SIGNATORIES:
Representatives from the signatory organizations are available for comment. Please contact Dana Korsen at dkorsen@nas.edu to be connected.
ADDITIONAL RESOURCES
- 1-page Overviews
- National Academies of Sciences, Engineering, and Medicine
- Institute of Medicine (now National Academy of Medicine)
- Chest
- 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
