Doing the ‘Greatest Good for the Greatest Number of People’
Feature Story
By Stephanie Miceli
Last update April 20, 2020
Latest COVID-19 Conversations webinar discusses implementing crisis standards of care
By Stephanie Miceli
Nicole Lurie started her day on a conference call with New York City hospital leaders, who were afraid of running out of dialysis fluids for COVID-19 patients with kidney failure. An hour later, she spoke with a doctor on a Native American reservation — an emerging COVID-19 hot spot — who was concerned about the lack of access to tests.
“It was a reminder that crisis standards of care mean different things in different places,” said Lurie, former assistant secretary for preparedness and response (ASPR) during the Obama administration, as she kicked off the fourth COVID-19 Conversations webinar on crisis standards of care, held on April 15.
In the midst of the coronavirus pandemic, there have been a flurry of headlines about hospitals having to plan for who gets potentially lifesaving treatment — and who does not. For many hospitals, COVID-19 has quickly overwhelmed their resources — not just ICU beds, ventilators, and personal protective equipment (PPE) but also the staff needed to take care of patients.
Crisis standards of care (CSC) provide guidance on how to save the most lives possible when staff and resources are scarce, and “do the greatest good for the greatest number of people,” explained panelist John Hick, faculty emergency physician at Hennepin Healthcare in Minnesota. “If our goal is preservation of PPE, that’s a different ethics calculation than preserving the nation’s blood supply.”
The principles of CSC not only apply to COVID-19, but to any catastrophic emergency.
It is also critical that care decisions are not made on the basis of age, race, ethnicity, disability status, or ability to pay, emphasized moderator Larry Gostin, director of the O'Neill Institute for National and Global Health and Law at Georgetown University. Gostin, along with Hick, served on a National Academies committee that wrote a series of landmark reports on CSC in 2009, 2012, and 2013.
“Many of the key elements of CSC planning — equity, accountability, honesty, and proportionality to the needs of the situation — still hold true 10 years later,” said Gostin.
Protecting Providers from ‘Moral Injury’
One of the biggest misconceptions about CSC is that bedside doctors are making all the decisions about who gets what care. Usually, there is a triage team involved, said panelist Jeffrey Kahn, director and professor of bioethics and public policy at the Johns Hopkins Berman Institute of Bioethics. At Johns Hopkins, it’s a multidisciplinary team of experts in bioethics, health care quality, nursing, and the health system’s general counsel.
CSC guidelines also serve to protect providers from liability claims and “moral injury,” Kahn added. That concept is distinct from burnout and refers to a feeling of not being able to do right by a patient. “When do we decide when it’s appropriate for patients to come to Hopkins? And in what priority order? And once they’re here, in what order are beds allocated?” said Kahn, outlining the many scenarios the team discusses in their daily meetings. “We want to give clinicians specific criteria so they are not making ad hoc decisions at the bedside.”
From Hurricane Katrina to COVID-19 — What States Want
Implementing CSC requires health care systems to coordinate with their partners across the street and across state lines.
“We’re thinking about cases where we have to transfer a patient somewhere with greater capacity,” said Kahn, who is working with hospitals across Maryland. “Consistency is key — a patient shouldn’t be getting a better standard of care at one place than another.”
Rebekah Gee, head of Louisiana State University’s Health Care Services Division, reminded listeners that the state is no stranger to disaster. However, the alternate care sites that were used when hospitals reached capacity during Hurricane Katrina — such as school gymnasiums — would not be appropriate for the COVID-19 response. There are many considerations in terms of floor plans, access to bathrooms and showers, and spacing between patients.
“This is the first time in my career we had to address something for which we were not prepared — fear combined with a scarcity mentality,” said Gee. Her colleagues have found creative workarounds to get the PPE they need, including sourcing it from dental and veterinary clinics and even using 3D printing. However, the biggest challenge has been the lack of consistent guidance on distributing and disinfecting that PPE once it arrives.
“Some hospitals gave employees new masks daily. Others asked them to put the masks in paper bags and spray with disinfectant,” said Gee. “State health departments need professional societies to offer guidance on proper disinfecting of PPE.”
Federal agencies and professional societies (such as the Association of American Medical Colleges) should also offer guidance to states on deploying algorithms for prioritizing resources; and on ways to “uptrain” nurses or recent medical school graduates to deliver primary care in CSC conditions.
Preparing for a ‘Second Wave’
A recurring question from webinar attendees was: If there is a second wave of COVID-19 when social distancing measures are eased, what can the health care system do to prepare now?
Gee pointed out that in Louisiana, about 70 percent of the people who have died from COVID-19 are black — even though black people are only a third of the state’s population.
“We need health disparities data, and if implicit bias is getting in the way of decisions, that needs to be addressed now,” she said. Gee also said LSU has been turning its attention to creating materials for non-English-speaking communities, enhancing telemedicine services, and disseminating knowledge about what’s working and what’s not.
“One day, COVID-19 will be over, but we’ll have to restructure our health system, telemedicine, and the social supports we give to our vulnerable populations,” said Gostin. Public health surveillance and planning is often invisible when it works, but he hopes COVID-19 is a wake-up call that it’s vital.
“No plan, no matter how good, survives first contact with the enemy,” said Lurie. “But it sure is easier if you've thought through these circumstances before than if this is the first time you are thinking about crisis standards of care.”
Read highlights from the first, second, and third webinars
Further Reading on Crisis Standards of Care
Rapid Expert Consultation:
Consensus Study Reports:
- Crisis Standards of Care: A Toolkit for Indicators and Triggers (2013)
- Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response: Volume 1: Introduction and CSC Framework (2012)
- Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations (2009)
Workshop Summaries:
- Crisis Standards of Care: Successes and Challenges from the Past Ten Years- A Workshop (2019)
- Barriers to Integrating Crisis Standards of Care Principles into International Disaster Response Plans (2012)
- Crisis Standards of Care: Summary of a Workshop Series (2010)
NAM Perspectives discussion paper:
About
The National Academies of Sciences, Engineering, and Medicine are private, nonprofit institutions that provide expert advice on some of the most pressing challenges facing the nation and world. Our work helps shape sound policies, inform public opinion, and advance the pursuit of science, engineering, and medicine.
