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Medical Providers’ Standard of Care During the COVID-19 Outbreak
As the COVID-19 pandemic rages on, government officials and hospitals throughout the country are discussing revised guidelines to ration scarce resources such as ventilators and implementing “crisis standards of care” (CSC) that may be triggered in a public health emergency. Upon initiating CSC, the focus of medical care shifts from the primary obligation of promoting the well-being of individual patients to the thoughtful use of limited resources to achieve the best possible health outcome for the population as a whole.
Medical facilities and providers have a duty to plan for providing essential services during a disaster, including how the delivery of care will transition from the conventional standards of care to a crisis surge response. The American Medical Association (AMA) has issued a medical ethics opinion on procedures that allocate scarce health care resources fairly among patients and has recommended that certain criteria be considered. The AMA recommends that resources should be allocated based on the urgency of need, the likelihood and anticipated duration of benefit, and the change in quality of life. It is not appropriate to base allocation policies on certain subjective factors such as social worth, the patient’s contribution to the illness or other non-medical characteristics. Priority should be given to those patients for whom treatment will avoid premature death or extremely poor outcomes, followed by patients who will experience the greatest change in quality of life. The AMA recommends use of an objective and transparent mechanism to determine which patients will receive the scarce resources, particularly when there are not substantial differences among patients in need. Finally, the allocation procedure must be explained to patients who are denied access to the scarce resources.
It has been reported that 36 states have worked on plans for rationing care during emergencies since Hurricane Katrina in 2005. Minnesota’s plan, for example, emphasizes that in a medical surge, “healthcare facilities must utilize an incident management system and attempt to move as rapidly as possible from a reactive stance – relying on frontline personnel utilizing job aids and applying their training – to a proactive stance – managing the event by objectives using an incident action plan.” With regard to triage decision processes and other modifications to clinical practice, medical facilities “should not allow it to fall to the individual clinician to make such decisions.” Principles that underlie triage decisions include fairness of the process, transparency in design and decision-making, consistency in application, proportionality with the scale of the emergency and degree of scarce resources, and accountability of decision-makers.