Timothy Farrell, MD, AGSF, on Resource Allocation and Age-Related Considerations During the Pandemic

In May 2020, the American Geriatrics Society (AGS) issued a position statement on age-related considerations and strategies for resource allocation during the COVID-19 pandemic. The AGS’s recommendations include:

• Age should not be used to categorically exclude individuals from standard-of-care therapeutic interventions, nor should specific age-based cutoffs be used in terms of allocating resources.
• Health disparities impacted by social factors such as culture, ethnicity, socioeconomic status, and related factors should be considered when assessing comorbidities.
• The primary allocation method in emergency situations during which resources are scarce and rationing is required warrant multi-factor resource allocation strategies that equally consider in-hospital survival and severe comorbidities that contribute to short-term (< 6 month) mortality.
• Criteria including “life-years saved” and “long-term predicted life expectancy” should not be used when forming resource allocation strategies, as these criteria disadvantage older adults.
• Triage committees and triage officers, ideally with expertise in ethics, geriatrics, and palliative care, who have no direct clinical role in caring for patients being considered for allocation of limited resources should be aware of available resources at their institution. These committees should be available to clinicians when decisions related to rationing must be made. Clinicians at the front lines should be applying—not selecting—emergency rationing criteria when resources are limited.
• Health care institutions should develop transparent, consistent, and uniformly-applied resource allocation strategies with multidisciplinary input. These strategies should be reviewed often as new information emerges in order to avoid disparities or biases.
• Advanced care planning plays an important role in making ethical health care decisions based on each patient’s goals, values, and preferences, but should not be viewed as a rationing method. It is important that advanced care planning is done well in advance of a time of crisis, and efforts to increase meaningful advance care planning should be an area of focus going forward.

Infectious Diseases Consultant discussed the position statement further with Timothy Farrell, MD, AGSF, associate professor of medicine and adjunct associate professor of family medicine at the University of Utah School of Medicine in Salt Lake City, Utah.

ID CON: In the position statement, you and your colleagues note that older adults are disproportionately affected by COVID-19, and that a number of strategies for resource allocation have used age as a criterion. Could you elaborate on this and any ethical issues this could pose?

Dr Farrell: The genesis of the position statement was the circulation of statements in the media and elsewhere suggesting that older adults should be kept in isolation during the pandemic so that others can get on with their lives. I looked into this more and found that certain countries such as Italy, under very dire circumstances, actually had rationing and resource allocation strategies with age cutoffs. In the United States, there are some resource allocation strategies that also use older age to determine whether a patient receives health care resources, such as ventilators. To my colleagues and me, this approach seemed inherently unjust.

Some of the major ethical issues involved include what framework is being applied in resource allocation strategies. Utilitarian frameworks, which aim for the greatest good for the greatest number, often include the concept of maximum life-years saved. The “fair innings” argument prioritizes younger patients because they have not gone through as many stages of life as have older patients. Both justifications for withholding health care resources from older adults are ethically problematic. It is very difficult to accurately prognosticate life expectancy beyond a short-term timeframe among older patients. It is also difficult to say which stage of life is more valuable than other stages. From a legal standpoint, age cutoffs violate antidiscrimination laws.

One of the key points we make in the AGS position statement is that resource allocation strategies cannot use a one-size-fits-all approach because there is quite a wide spectrum of older adults.  As a result, it is ethically problematic to base decisions on age or functional impairment.

ID CON: Could you discuss the clinical factors that the AGS says should be considered instead of age for each patient with COVID-19?

Dr Farrell: It is extremely important to consider that, in any pandemic, illnesses such as heart failure, diabetes, and cancer are still present. Any ethical resource allocation strategy should treat patients the same whether or not they have COVID-19. The AGS advocates for inclusion of multi-principle frameworks that include measures of short-term survival in any resource allocation strategy. For example, models such as the Sequential Organ Failure Assessment (SOFA) score take into account clinical factors that predict in-hospital mortality.

Resource allocation strategies should also weigh comorbidities that contribute to short-term mortality. When considering comorbidities, it is important to avoid discriminating against patients who have been disadvantaged in some way. Unfortunately, some resource allocation strategies disadvantage underrepresented patient populations. For example, a patient with hypertension who has had greater access to primary care over the years and did not develop clinical sequelae of hypertension would likely fare better in comorbidity scores than another patient with untreated hypertension who later developed a stroke due to inadequate access to care.

ID CON: What is the significance of establishing triage committees in the event that emergency rationing must occur, and what are some important considerations for establishing these committees?

Dr Farrell: Triage committees are a key component of any resource allocation strategy. The idea behind triage committees is to provide central guidance at an institutional level that removes the moral distress of making rationing decisions from front-line healthcare workers. With the implementation of a triage committee, the front-line clinician simply has to apply whichever decision the triage committee makes when rationing is needed. Ideally, the triage committee members would have backgrounds in ethics, geriatrics, and palliative care. As such, these committees should have multidisciplinary representation.

Triage committees also allow for ongoing review of the resource allocation strategies that have been implemented. Because information related to COVID-19 is changing so rapidly, it is vital to have a triage committee that is able to incorporate new information to ensure that resource allocation strategies are fair to all patients, and to avoid unnecessary rationing.

Transparency is also important in situations where rationing is necessary. This can build confidence among the public and members of the hospital system that the decision-making process is fair.

ID CON: What are the key takeaways that you want to leave with health care practitioners, especially those who are on the front lines of combatting this pandemic?

Dr Farrell: Douglas White, MD, MAS, a bioethicist who developed one of the most widely used resource allocation models, recently told CNN “…the only thing worse than developing a clear allocation framework is not developing one, because then decisions made during a crisis will be biased and arbitrary.” It is not acceptable to use an ad hoc approach when rationing becomes necessary, and the AGS position statement clearly states that hospitals and health systems should develop or adopt an ethical resource allocation strategy if they do not already have one. These resource allocation strategies should incorporate the principles outlined in the AGS position statement. My co-authors and I also addressed the importance of conducting a post-pandemic review of the resource allocation strategies that were implemented, which presents an opportunity to remove any unjust provisions such as age cutoffs.

Finally, we emphasized the importance of advance care planning. Advance care planning should be done by both primary care physicians and specialists. When done well, it will identify patients who do not want to receive aggressive care if they are affected by COVID-19 or another illness. It is important to note, however, that advance care planning is not rationing and that patients should not even be subtly pressured to engage in this process. Advance directives must reflect patients’ preferences, as this demonstrates respect for their autonomy. It is important to ensure that resources are directed towards patients who want them, and not inadvertently to patients who do not want or would not have wanted these resources.

—Christina Vogt

Reference:
Farrell TW, Ferrante LE, Brown T, et al. AGS position statement: Resource allocation strategies and age-related considerations in the COVID-19 era and beyond. J Am Geriatr Soc. Published online May 6, 2020. doi:10.1111/jgs.16537