Another lesson from the pandemic: Crisis standards of care are needed everywhere

As COVID-19 cases fall nationally, a reprieve makes for a good time to revisit the shared need for crisis standards of care. 

The latest surge of COVID-19, brought on by the delta variant, renewed the need for hospitals in several states to invoke crisis standards of care due to patients overwhelming their facilities and resources. 

Reading about hospitals in Idaho, Alaska and other states implementing these protocols instantly brought me back to our experience here in New York City in the spring of 2020. Although we never reached the point to activate crisis standards, we came very close. 

I can recall our hospital beds filling up and a daily race to stay ahead of the surge — opening new beds and creating pop-up ICUs to meet the tsunami of cases. Those days were the most stressful I have ever experienced in healthcare. There is no worse feeling than the fear we would not be able to meet the needs of the patients at our doors. 

As we contemplated what would happen if we did run out of resources, we were confronted with the fact that our state did not have defined Crisis Standards of Care to help guide decisions about triaging care. We were not prepared for the moment. 

That's the case in many states in our country. Articles on this topic list 29 states that have some form of crisis standards of care. The rest, including my state of New York, do not. 

What does the lack of clear standards mean for patients, providers and hospitals? It puts everyone in a terrible spot. The absence of standards forces everyone to scramble. It makes already difficult conversations and decisions even harder. In fact, it can make them excruciating. There is no base to stand on, and crises like the pandemic are not times to improvise. The result is further trauma for all involved. I am aware of stories from doctors, for example, who are still traumatized by the position that a lack of standards placed them in.

I would imagine that these decisions being made by providers and organizations in Idaho and Alaska right now remain very painful. But at least they have a set of guidelines to stand on that are objective and promulgated to all.   

We are learning many hard lessons from this pandemic. One is that we need a national conversation about crisis standards of care. They must be in place for every community. It is hard to create these now — during the crisis. But another crisis will come, and we can never find ourselves this unprepared again.

What elements should be included in this conversation? To begin with, conversations about crisis standards of care will be difficult and complex. One reason we don't have standards in every state is because these conversations are about rationing care and making determinations that literally impact life or death for patients. This difficult topic is easy to avoid or kick down the road. Before COVID-19, the prospect of needing them may have seemed remote. We need to overcome that denial. We cannot find ourselves here again.

Crisis standards of care will need to be based on objective criteria. For example, many sets of standards use a SOFA (Sequential Organ Failure Assessment) score, or criteria similar to it. These scores are intended to help clinicians prioritize care for patients based on likelihood of survival if limited life- sustaining treatment is provided to them. During this pandemic, there has been a lot of discussion about criteria like this, especially with regard to equity. We have to assure that any standards do not discriminate against vulnerable patient populations.

It's easy to imagine how difficult it is to develop crisis standards of care because we are providing guidance for some of the hardest decisions a care team will ever make. But avoiding the conversations is not acceptable and has surely hurt patients and providers during this pandemic.  

I also want to make sure we listen to the voices of clinicians from across our country on this issue. They have lived through the trauma of a pandemic that taxed them to their core. They had to initially deal with an illness about which we knew very little and had limited resources to address. They have lived through wave after wave of infections in their communities. Not having clear crisis standards to work from when they are on the front line making extremely difficult decisions has only added to the trauma. We owe it to these heroes to have their backs and address this issue.

Sadly, it also needs to be said the implementation of crisis standards of care could largely be avoided if more people are vaccinated. This pandemic will come to an end. But history shows there will be another in the future. And as we regain room to breathe and reflect, we need to overcome our denial and address this once and for all. 

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