State issued guidelines on rationing care, but hospitals have their own standards
A state lawmaker and disability rights group oppose standards adopted by Oregon Health & Science University
People without health insurance often use the emergency room as their provider, which drives up health care costs. (Christine Torres Hicks/OHSU)
Oregon hospitals and health care specialists are shoring up resources and adopting surge plans in preparation for an overload of Covid-19 patients. But that may not be enough to ensure everyone is treated if hospitals become overwhelmed.
On Friday, the Oregon Health Authority released guidelines to help hospital systems ration care if they run short of beds, staff or equipment. The guidelines apply to all patients – not just those infected with Covid-19.
They aim to be objective, ensuring that everyone gets a fair shot at treatment regardless of their age, disability or health care status.
So-called crisis standards of care are only used in exceptional circumstances to help overwhelmed health care providers cope.
“It is only under the circumstances that we have – like a major disaster or a broad pandemic – that the public health services start to say we need to make sure people are prepared for this contingency,” said Denise Dudzinski, chair of the Department of Bioethics and Humanities at the University of Washington. “The rest of the time we don‘t have to be prepared for it.”
Each state handles crisis care differently. Some let hospitals craft their own. Others, like Idaho, have statewide plans. Idaho activated its standards in September during the delta surge. Colorado, which also has statewide standards, activated its crisis standards of care for ambulance services on Friday.
Oregon has no uniform or mandated standards.
The 14-page tool published by the state on Friday is relatively limited: It doesn’t detail many specifics, such as what choices to make there aren’t enough ambulance services or Covid-19 treatments such as monoclonal antibody infusions or pills. Rather, it is designed to take life-and-death decisions out of the hands of individual caregivers while helping overwhelmed hospitals allocate critical care in a crisis.
“A crisis occurs when you’re so low (on resources that) you can’t always deliver the same level of health care as you would under the other circumstances,” Dudzinski said.
Oregon’s guidelines direct hospitals to create triage teams of staff, including an ethicist, not involved in a particular patient’s care to determine who gets treated if resources run short. They use a scoring system that ranks people’s health based on an assessment of their organs and other factors.
The overarching principle, the guidelines said, is to provide care first to patients likely to survive to discharge.
“The goal is to equitably allocate staff and resources during a time of crisis when you’re not going to be able to give everyone the care that they need,” said Kevin Mealy, a spokesman for the Oregon Nurses Association.
That situation could happen in Oregon by the end of January. A forecast by Oregon Health & Science University expects more than 1,600 patients to need a hospital bed when omicron cases peak.
The nurses association, a union represents about 13,000 of Oregon’s 73,000 nurses, supports Oregon’s recommendations. So does Disability Rights Oregon, which filed a federal civil rights complaint in May 2020 against the health authority’s previous guidelines, claiming they were discriminatory. In response, the health authority scrapped them.
This time the state got them right, said Emily Cooper, legal director of Disability Rights Oregon..
“We fully stand behind the tool and think it’s one of the best in the country,” Cooper told the Capital Chronicle on Monday.
The guidelines are temporary – the Oregon Health Authority plans to work with health care professionals on more detailed standards. They’re also not mandatory. The authority can’t legally enforce them, Cooper said. The agency offered them as a resource while telling hospital systems that any guidelines they adopt cannot discriminate, must ensure equity and follow Oregon law.
Hospital systems have to alert the state if they activate crisis standards of care and publish their guidelines.
Opposition to OHSU standards
The Capital Chronicle recently asked most major hospital systems in the state to provide their crisis standards of care. None has done so.
A spokesman for Veterans Affairs in Portland said the hospital system is using a VA tool that aligns with Oregon’s guidance. A spokeswoman for Asante, which runs three hospitals in southern Oregon, said the health care company doesn’t have its own.
State Sen. Sara Gelser Blouin, D-Corvallis and chair of the state Senate Interim Committee on Human Services, Mental Health and Recovery Committee, has been trying to track them down, too. Since March, 2020, she said she’s asked OHSU for its standards.
“They have not been willing to engage in conversations,” Gelser Blouin said. “I have asked multiple times for these documents and I have not been able to get them.”
Dr. John Hunter, executive vice president of OHSU, responded in a letter dated Thursday to Gelser Blouin, copying chairs of the House and Senate health care committees and the House Covid-19 committee. He said OHSU would rely on its own standards until the state released guidance.
Hunter indicated that the hospital system has used its standards five times during the pandemic.
“There have been less than six separate instances where the tool was used to determine which patient would receive the use of an extracorporeal Membrane Oxygenation (ECMO) machine when access to all available machines had been exhausted across the state and region,” Hunter wrote.
These life-support machines take over for the heart and lungs by supplying oxygen to the bloodstream and removing waste. There are few of these machines in the Northwest.
Hunter didn’t disclose what happened to the patients who couldn’t be treated.
“The OHSU scarce resources tool was developed with the understanding that there are no universally accepted answers to the questions it is designed to answer,” Hunter wrote. “A pandemic, however, is unquestionably the moment to have common scarce resource allocation standards in place.”
He acknowledged a potential for “disparate outcomes.”
“If a moment does arrive when a triage decision must be made, preparation helps ensure that the decision will be made with the greatest possible care,” Hunter wrote. “Even so, the potential for disparate outcomes remains.”
Cooper of Disability Rights Oregon assessed as problematic several aspects of OHSU’s scarce resources tool.
It directs staff to screen all patients for an advance directive, do-not-resuscitate form or another document, called POLST, that advises everyone from medics to hospital staff the extent of end-of-life care an individual wants. If patients don’t have a document, staff need to ask.
If someone doesn’t want critical care, staff should “consider transfer to comfort care/hospice,” the tool says.
Cooper said this could discriminate against people with disabilities who might be unable to express their preferences.
“There is nothing in this tool that addresses patients with disabilities who may need accommodations or support persons to make their end-of-life decisions known,” Cooper said. “In this ambiguity, this tool indicates these patients may likely be denied care and transported to hospice.”
Gelser Blouin and Cooper also object to another part of OHSU’s guidelines which direct staff in a tiebreaker situation to give priority to patients expected to live at least six months or more following discharge.
“Once you start putting a timeline on life after discharge, you’re picking and choosing based on the assumption of the value of a life as it’s measured in months or years,” Gelser Blouin said. “If you’re saying you will be excluded from care in a tie-breaker if you have terminal cancer with an expected prognosis less than six months, that is making a decision on the basis of disability because that diagnosis is a disability. It’s not an appropriate tiebreaker.”
OHSU will keep tool
Nevertheless, OHSU intends to keep its tool, a spokesman indicated in an email on Monday.
“In reviewing the OHA’s new interim guidance, we are confident that OHSU’s tool aligns with the state guidance,” said Erik Robinson, a spokesman for OHSU.
The Capital Chronicle asked other major health systems on Monday whether they would adopt the state’s guidelines. Legacy Health and Providence Health & Services responded – declining to comment. St. Charles Health System said its guidelines follow state law, including on nondiscrimination
Cooper, of Disability Rights Oregon, said having differing crisis standards of care policies among hospitals is a problem. She also said they should be transparent.
“Whatever a hospital relies on should be public and transparent and anyone would be able to view them.” Cooper said.
That may change.
An Oregon Health Authority spokeswoman told the Capital Chronicle late Monday in response that new rules were coming but provided no details. State agencies use the rule-making process to define laws. Robinson said in his statement that the guidelines are needed mostly for determining who has access to ECMO machines. Hospitals have plenty of ventilators.
Dudinski, of the University of Washington, said the current surge is likely to fill up acute care beds – not critical care units.
Omicron appears to cause less severe illness than delta. Hospital stays also appear to be shorter. But the sheer number of cases is likely to overwhelm health case systems, according to a forecast by OHSU. Every day last week broke a new record for cases. Monday’s tally soared past 18,500 cases.
“It’s not critical care with omicron that is the issue,” Dudinski said. “It’s acute care. It’s a really challenging situation.”
Crisis standards of care are not designed to address situations in which normal hospital units are overwhelmed because of a lack of staff, which is a nationwide issue.
“Now we’re in a situation where we don’t have the tools that we need,” Dudinski said.
“It’s no fault of anybody that we didn’t plan for it. We’ve never seen anything like this before.
We didn’t expect the whole world to be sick with something.”
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