Crisis Standards of Care Reviews Ordered at All RI Hospitals

Reviews of “Crisis Standards of Care” documents from all hospitals in RI have been ordered by the Department of Health (DoH), according to a statement by its director, Dr. Nicole Alexander-Scott, at the governor’s press conference on Apr 17. Such documents set out rules for rationing limited resources, such as intensive care unit (ICU) beds and ventilators, in situations where a demand surge overwhelms medical facilities.

DoH reviewed existing plans from hospitals as of Apr 13 and sent guidance containing “elements” that “must be added to each facility’s current Crisis Standards of Care plans if not already incorporated,” requiring revised plans be returned to DoH by Apr 23. Motif requested and received a copy of the instructions sent by DoH to hospitals. In the preface, DoH states that the goal is a consistent approach statewide “on this complex and uncomfortable topic.” Healthcare providers will not be allowed to trigger these plans on their own, the guidance states: “If we need to activate these Crisis Standards of Care, it must be done with the approval of the Rhode Island Department of Health and for as short a duration as possible.” The guidance was formulated “in partnership with experts in bioethics from Brown University.”

Gov. Gina Raimondo has repeatedly emphasized, most recently at her Apr 17 press conference, that under the most likely scenario predicted as of Apr 16 by mathematical models she is relying upon, developed in collaboration with Brown University, Johns Hopkins University, and the University of Washington, she expects that RI will be able to accommodate a demand surge to 2,250 beds on May 3 using capacity expanded by as much as 40% at existing hospitals. If the demand surge is larger than that, at the worst case scenario predicted by the model of 4,300 beds on Apr 27, she said that would still remain within the capability of three temporary hospital facilities at the Convention Center in Providence, the Citizen’s Bank office in Cranston, and the former Lowe’s store in Quonset (North Kingstown) set up with the assistance of the US Army Corps of Engineers, the RI National Guard, and the medical community. Only if the demand surge turns out substantially worse than the worst case scenario predicted by the model would Crisis Standard of Care plans come into play.

The DoH guidance gives broad instructions about what must be included but is much more specific about what must be avoided, requiring that hospital plans state their underlying assumptions and clarify ethical principles. For example, DoH requires that plans “should specifically recommend against using assessments of pre-existing quality-of-life, underlying life expectancy, and ‘social value’ in ranking a particular patient’s priority score for the critically scarce resource, considering these fundamentally discriminatory.” A reasonable interpretation of this provision is that DoH intends to prohibit discrimination on the basis of socio-economic class.

DoH requires that hospital plans explain that in emergencies care becomes “public-focused” rather than “patient-focused,” necessarily looking at the overall situation “to maximize population survival and allow for judicious use of the limited resources.” A key intent of these plans is to “set consistent standards for clinicians” to reinforce their scientific and medical prudence, minimizing “on-the fly decisions,” and reducing “the individual burden on providers to make what might be a series of solemn decisions.”

Where the DoH guidance is quite detailed is in mandating that front-line patient care teams report not only availability of scarce resources but also report specific decisions to limit allocation up to the hospital and state level. If local scarcity could be solved by transferring a patient to another facility, that is required.

In one of its most important provisions, the DoH guidance explicitly cautions against removing the human aspect of critical care medical practice: “The goal of being fair and objective must be balanced with the risk of relying too heavily on numerical assessments. The goal of protecting clinicians from moral distress must be balanced with the reality that simply putting their patient’s fate into the hands of others will be hard as well. The mechanism of interaction between the clinical [patient care] team and triage [patient assessment] team should be clear and should allow for appeal or reconsideration. A mechanism for oversight of the triage teams’ work should be in place. A mechanism of support or relief for the triage officer should be in place as well.”

Communications with patients and their families must not be sugar-coated: “Assessments of patient’s survival likelihood should be called that (‘survival likelihood’). Determining priority for access to the critically scarce resource is a separate step.” Again, the DoH guidance warns against discrimination: “Prioritization for access to critically scarce lifesaving resources should not depend on necessarily subjective assessments of quality of life. Social value should not be included as a criterion for prioritization unless the category of patient (e.g. healthcare worker, ‘protector of societal order’) is actually also in critically short supply.” (It’s not immediately clear what “protector of societal order” means in this context, as it could plausibly describe anyone from a police officer to the governor herself.)

Finally, the DoH guidance document provides examples of similar Crisis Standards of Care plans from Massachusetts, New York, Utah, and Washington.

It is impossible to get a sense of the practical consequences of this DoH guidance without seeing the actual plans produced from individual hospitals by the Apr 23 deadline. Different hospitals operate within different ethical frameworks, ranging from public secular institutions to those associated with the Roman Catholic faith, and they are certain to produce radically different Crisis Standard of Care plans.