The emergence of a new infectious disease that rapidly spreads around the world, like Covid-19, makes disaster planning experts move into overdrive. Lessons learned over the last decade can help cope with the spread of the novel coronavirus.
In the spring of 2009, a new type of flu virus, called H1N1, was detected in the United States. It spread across the U.S and to other countries. The Centers for Disease Control and Prevention has estimated that, in the U.S. alone, between April 2009 and April 2010 H1N1 sickened more than 60 million people, caused 275,000 hospitalizations, and killed more than 12,000 people.
In the midst of a summer lull in H1N1 cases, the Institute of Medicine (now the National Academy of Medicine) convened a committee to come up with guidance for clinicians and hospital administrators who might need to make difficult choices during this — and future — overwhelming pandemics.
Choices like these: If there aren’t enough masks or ventilation machines available, what is an ethically defensible way to allocate them? Might it be ethically acceptable to remove one patient from a ventilator so another could use it? Should clinicians who are forced to make such choices be legally protected? And who should get priority access to vaccines if they become available?
The panel, which one of us (J.H.) had the honor to be on and the other (M.W.) served as a reviewer for, had little time to deliberate, since its task was to produce a report in less than six weeks. Yet the influence of that report, Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations, has been extraordinary. More than 36 states and many localities and health systems have since worked on crisis standards of care (CSC) plans, based on that report and later ones from the National Academies, the CDC, and the World Health Organization.
And though the H1N1 pandemic turned out not to be catastrophic in terms of lives lost, the ethical principles the panel laid out (see the summary below) were widely recognized as important, and crisis standards of care plans have been used since in high-profile events like responding to the earthquake in Haiti in 2010 as well as lesser-known incidents, like the loss of power at a hospital.
With this legacy in mind, the National Academies convened many of those involved in developing the 2009 report for a two-day workshop in November 2019 to commemorate 10 years of planning for crisis standards of care, to consider lessons learned, and to determine where these standards should go next. At the time, we had no idea that the next potential pandemic had already been sparked.
In late November, the SARS-CoV-2 virus was almost certainly already being transmitted. The first case was diagnosed in Wuhan, China, on Dec. 1. Since then, more than 100,000 people have been diagnosed with Covid-19, the disease caused by this novel coronavirus. It seems likely that millions of people around the world will be infected by it.
So far, about 2% of people with diagnosed Covid-19 have died, and between 5% and 10% have required intensive care. But if even a small fraction of a very large number of infected people might benefit from critical care resources like mechanical ventilation or extra-corporeal membrane oxygenation to help them breathe, difficult triage decisions could be required.
A discussion paper release last week by the National Academies, on which we are co-authors, summarizes a set of strategies to help mitigate the impact of shortages of medical resources that might arise as a result of the Covid-19 epidemic.
For ethical preparedness, three issues deserve urgent attention to assure that any triage decisions that must be made during this crisis will be ethically defensible.
Good ethics begin with good facts
The 2009 report indicated that organizations had an ethical duty to plan for catastrophic disasters, which later legal precedent supported. It is unfair, inefficient, and potentially cruel, so the thinking went, to leave clinicians to make ad hoc rationing choices during an epidemic without good guidance, support, and protection. Given that, a major purpose of crisis standards of care protocols is to support clinicians and planners across a spectrum of care, including extreme cases in which clinicians could be forced to choose who lives and who dies.
Guidance for clinical triage should optimize survival across a population by translating the best available evidence into reliable algorithms that can be used at the point of care. The ethical justification generally given for withholding or removing potentially lifesaving care from one person or group without their consent and giving it to another is that the latter person or group has a significantly better chance at long-term survival.
Yet the 2009 National Academies report recognized that triage decision aids of the time were primitive, simplistic, and mostly untested for use in disasters. Today, clinical triage guidance specific to Covid-19 is urgently needed. Real-time clinical data should be used to develop an accurate, predictive model for death due to this disease. We need to know who is most likely to survive if they are given a full-court press and who is most likely to die regardless of treatment.
Good data on likely survival is not the only criterion for making ethically defensible triage decisions, but it is a critical starting point.
Practice ‘extreme surge’ scenarios
Hospitals and public health agencies in the U.S. should be practicing scarcity scenarios related to Covid-19. Although many states have formal crisis standards of care plans, few hospitals have practiced implementing them. And though most clinicians are familiar with the concept of triage, few have ever had to implement it.
That’s a problem because resource allocation challenges occur frequently in hospitals and health systems, albeit often on a small scale. When a hospital faces a shortage of a medication for which no adequate substitute exists, for example, how do clinicians decide who gets the medication? Who should be involved in making the decision? And what criteria should be used? For many organizations, such common occurrences reflect lost opportunities to intentionally practice using crisis standards of care principles.
With the potential for Covid-19 creating scarcity scenarios, clinicians and administrators should practice ways to avoid the need for making tragic choices by developing, using, and refining contingency plans — calling in staff, conserving and substituting medications, transferring patients, employing alternative ventilation methods like continuous positive airway pressure or bilevel positive airway pressure devices, reusing or adapting existing supplies, and so on.
The main reason to do careful crisis standards of care planning is not to get comfortable making tragic triage decisions, it’s to figure out how to avoid needing to make them.
Teach scarcity thinking across clinical training
If the Covid-19 epidemic does require tragic triage choices, in China or elsewhere, it won’t be the last time such actions are needed. Educators should begin to teach “scarcity thinking” in medical schools, residencies, and other training situations, with a focus on practical guidance for contingency planning and a deep understanding of the ethical principles of implementing crisis standards of care.
The ethical principle of proportionality, a key focus of the original CSC construct, should be especially emphasized. Proportionality calls for restricting care no more than is absolutely required by the situation and continually re-balancing restrictions against the evolving supply/demand situation. It makes adequate situational awareness a critical component of ethical resource allocation.
The Covid-19 outbreak reaffirms that the ethical principles of crisis standards of care are as valuable now as they were in 2009. But a lot has changed since then. To ethically implement these standards of care, clinicians must have excellent clinical guidance, training, opportunities for practice, and situational awareness. Because scarcity situations will continue to arise, all clinicians must understand triage principles and processes for decision-making so they, and the public, can be confident they are prepared to make ethically and medically defensible decisions in very difficult situations.
Matthew K. Wynia, M.D., is professor of medicine and public health and director of the Center for Bioethics and Humanities at the University of Colorado Anschutz Medical Campus. John L. Hick, M.D., is a professor of emergency medicine at the University of Minnesota and an emergency medicine physician at Hennepin Healthcare
Ethical principles to guide development and implementation of crisis standards of care
(Adapted from the 2009 Institute of Medicine’s Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report.)
Fairness: Standards of care protocols must be recognized as fair by all affected parties.
Duty to care: Even during disasters, health care professionals’ primary duty is to patients in need of medical care, including when providing care entails some risk to the clinician.
Duty to steward resources: Health care professionals must balance the duty to care for each individual patient with a duty to steward limited communal resources. The level of scarcity in a disaster exacerbates this tension, making it essential to establish ethical processes for making triage decisions.
Transparency: Ethically sound decisions reflect technical expertise but also reflect values. Public engagement in establishing protocols is critical. If that is not possible, leaders must rely on clear, honest, real-time communication with communities and after-the-fact review.
Consistency: Treating like groups alike, and avoiding invidious discrimination is an important way to promote fairness and foster public trust.
Proportionality: Limitations on services provided should be necessary and commensurate with the scale of the disaster.
Accountability: All decision-makers should be accountable for a reasonable level of situational awareness and for incorporating evidence into decision-making, including revising decisions as new data emerge.