Experts Optimistic Crisis Care Standards Won’t Be Activated

BOSTON (State House News Service) — Several of the leading medical experts who developed the state's controversial plan to ration access to life-saving equipment like ventilators say they believe the state's hospitals will be able to weather the surge of coronavirus infections without having to implement those protocols.

The number of patients hospitalized with COVID-19 climbed by 103 patients on Wednesday, according to the Department of Public Health, but the state's hospitals still have 56 percent capacity to accept new patients.

"A lot of the work we're doing is to prevent the crisis standards from ever having to be activated," said Dr. Michael Wagner, chief physician executive of Wellforce. "I believe we will be able to achieve that directive."

The committee of doctors, public health experts and medical ethicists that developed the crisis standards of care revised their two-week-old guidelines this week to reflect concerns voiced by state and federal lawmakers about their impact on underserved minority communities.

U.S. Rep. Joseph Kennedy III and the Black and Latino Legislative Caucus, including Boston Medical Center emergency room physician Rep. Jon Santiago, wrote to state leaders two days after the guidelines were published to warn that the standards would penalize people of color, who disproportionately struggle with underlying health conditions that make them more vulnerable to the virus.

"Once the guidelines were released there was a lot of public feedback that was super helpful and we quickly realized that we needed to make a change," said Dr. Robert Truog, director of the Center for Bioethics at Harvard Medical School.

Three doctors who sat on the panel that developed the standards presented the revisions on Thursday to the state Public Health Council.

The revised guidelines now advise hospitals to take into account a patient's chances of near-term survival over the next five years rather than trying to maximize life-years, which would have prioritized younger patients with COVID-19 and those without underlying health conditions.

Still, Truog and Dr. Emily Rubin, a critical care pulmonologist at Massachusetts General Hospital, said they're cautiously optimistic that no hospital in Massachusetts will have to make these types of decisions.

"I don't think we will need them," Truog said of the standards.

Wagner said the Crisis Standards of Care Advisory Committee was convened by Commissioner of Public Health Monica Bharel in late March to develop a set of worst-case-scenario guidelines for how to allocate resources during the pandemic should they become scare. The panel was looking to avoid a situation where patients were treated differently depending on which hospital they visited.

Truog said the initial set of guidelines took an approach adopted by several other states to prioritize the probability of a patient's long-term survival, defined as life-years saved. The new standards look only at chances of survival over the next five years, thereby reducing the impact a disability or an underlying health condition might have on someone's access to a ventilator or intensive care bed.

"We adopted what we believe to be a reasonable compromise," Truog said.

Some members of the Public Health Council, including Boston University Professor of Emergency Medicine Dr. Edward Bernstein, questioned whether the revised guidelines went far enough to prevent institutional discrimination.

"I still have real questions how we're going to protect people of color who, because of social determinants of health, have chronic diseases that were put on them and are unfair," Bernstein said.

Bernstein questioned why the state wouldn't just advise hospitals to use a lottery system as soon as a patient walks in the front door, rather than only to break a tie.

"The issue is there was fairly broad agreement that it's ethically relevant at some level to take into account duration of benefit," Rubin replied.

Truog said that the alternative would be to do nothing and rely on a first-come-first-serve system.

"This would not not only be unfortunate, but unfair. It would give priority to people with better access to health care and those who get sick earlier in the pandemic," he said.

Rubin said another key feature of the revisions is that hospitals would have to notify the Department of Public Health before they implement crisis standards of care, in case the state could locate unused equipment at another facility, and there will be reporting on the decisiona that are made to gauge their impact on different racial and ethnic groups.

Bharel told the Public Health Council that in the coming days she would be launching a health equity advisory group to help inform future decisions and their impact on underserved communities.

Last week, House Speaker Robert DeLeo and Senate President Karen Spilka said they agreed with lawmakers who had been critical of the original crisis standards of care over their impact on disadvantaged populations, and vowed action.

While the bill does not mention the standards or the issue of rationing access to care, the House Ways and Means Committee on Thursday opened voting on a bill that would create a task force to study and make policy recommendations to the Legislature to address disparities in the health care system during the pandemic for underserved or underrepresented cultural, racial, ethnic and linguistic populations and people with disabilities.

The task force, which would include the chair of the Black and Latino Legislative Caucus Rep. Frank Moran of Lawrence, would be required to file a draft report by June 1 and final recommendations by Aug. 1.

By Matt Murphy, State House News Service

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