A panel of advisers on Monday issued recommendations for new crisis treatment standards, advising doctors and hospitals on how they should decide which patients with COVID-19 get lifesaving care and which do not.
The report from a National Academies of Sciences committee offers a framework for treating patients during the COVID-19 crisis that shifts from saving individual patients to a focus on saving the most individuals possible.
It was issued at the request of US Assistant Secretary for Health Admiral Brett Giroir and US Assistant Secretary of Preparedness and Response Robert Kadlec.
The new Crisis Standards of Care guidelines come as the US faces the prospect of rationing ventilators and other essential equipment to cope with a surge of severely ill patients infected with the new respiratory virus that is projected to kill between 100,000 and 200,000 people in the US.
In the report, the panel says that in spite of efforts to forestall the virus, it expects “a growing number of hospitals will face medical needs that outpace the existing supply of ventilators, protective equipment and other essentials, as well as the rate that enhanced supply can be produced, acquired and put into place. These circumstances will require a shift to Crisis Standards of Care.”
The panel says there is “an imminent need to prepare for difficult decisions about allocating limited resources, triaging patients to receive life-saving care and minimizing the negative impacts of delivering care under crisis conditions.”
First issued in 2009, Crisis Standards of Care were used sporadically to help doctors respond to hurricanes Katrina and Sandy, and doctors were preparing to use them in the 2009 H1N1 flu pandemic, but never did, experts said.
They characterized the government’s request for an updated report — tailored to the COVID-19 pandemic — as both sobering and responsible.
“It’s important that we have these ahead of time so that doctors don’t have to decide these things on the fly,” said Amesh Adalja, an infectious disease specialist and senior scholar at the John Hopkins University Center for Health Security.
“This is serious business,” said William Schaffner, an infectious disease expert at Vanderbilt University Medical Center. “If it’s not done, no one gets good care.”
According to the National Academies, the standards shift the focus from what is best for the individual to what can help save the most lives, especially when equipment, staffing and materials are in short supply.
They do not dictate which choices should be made, but provide a framework for making them.
They also protect physicians from malpractice lawsuits, said Lawrence Gostin, an expert in global health law at Georgetown University, who helped write the original guidelines in 2009.
Gostin said individual states were responsible for setting malpractice standards, but in a pandemic, the hope is that the federal government would implement the standards nationally, which would then be passed along to states and then to local hospitals.
Gostin said the fact that US officials requested the report signals “an urgency in trying to prepare hospitals for acute shortages, which will have implications for deciding who can live and who can die.”
Under normal standards of care, doctors in the US have a duty to provide the highest-quality treatment available.
“If someone is in respiratory arrest and the standard of care is a ventilator and there aren’t enough, doctors can be sued,” Gostin said.
Alta Charo, a bioethicist at the University of Wisconsin, said shifting to crisis standards allowed states or healthcare providers to relax or change certain rules, such as using medical devices in ways they were not originally approved for, if they offer a “better-than-nothing option.”
A key principle is that doctors never withhold care solely because of age, disability, race or gender.
“These are critical life or death decisions. Doctors and hospitals shouldn’t be making them themselves,” Gostin said.
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