Who will get access to care when there is a shortage in a crisis like COVID-19?

On Saturday, April 4, a committee advising Colorado’s Governor provided an answer. They issued Crisis Standards of Care Guidelines for hospitals during the COVID-19 Pandemic. The standards are intended to guide hospitals in making tough triage decisions when there are insufficient ICU beds, ventilators, and other resources for all the people who need them.

According to the standards, if implemented in a crisis situation, the triage process will be used for ALL patients who may require critical care resources, not just those who suffer from COVID-19.

A note before you read on: We totally understand the importance of having a set of Crisis Standards of Care. We need standards so people can be treated fairly across the state and our dedicated healthcare practitioners are spared from making individual bedside heart-rending decisions. Their jobs are demanding enough without the added burden. There is a lot in this plan to be proud of.

The best care for the most people

The stated goal of Colorado’s CSC is to “provide the best care for the most people”.

For the last two years, I’ve been traveling around the state, giving workshops and presentations, as well as writing and using social media to change the way Coloradans think, talk and act about aging and ageism. We’ve had two goals in mind:

  • Help people recognize the value that all of us bring to children, communities, workplaces, and society as we get older
  • Increase awareness of ageism and its negative effects on health, financial security, the economy and public policy decisions.

We’ve connected with partners across the state, people who believe that age-friendly policies make this a better Colorado for everyone.

When I sat down to read the standards on Monday morning, I had to read them twice. Dismay led to anger.

Ageism—defined by the World Health Organization as “stereotyping, prejudice and discrimination based on age”—is infused throughout.

In the long list of factors that will NOT be used to make triage decisions, AGE was missing:

“At no point should factors clinically and ethically irrelevant to the triage process (e.g. race, ethnicity, ability to pay, disability status, national origin, primary language, immigration status, sexual orientation, gender identity, HIV status, religion, veteran status, “VIP” status, or criminal history) be used to make triage decisions.”

This is not just an omission. Specifically, age is a basis to make choices in deciding who will get care. This is despite statements from the U.S. Office of Civil Rights that civil rights laws apply to these situations:

“Persons with disabilities, with limited English skills, and older persons should not be put at the end of the line for health care during emergencies.”

Ageism in our crisis standards of care

How will this work? Let’s dig into the details here. If these guidelines were put in place, each patient would be assessed according to a tiered system. The recommended standard call for three tiers of triage. (Triage is a process where certain criteria are used to decide the order in which people should be treated, particularly when there is a limited amount of care available.)

TIER 1

The first tier assesses two criteria and combines scores for each, with lower scores getting preference for treatment. Those criteria are:

  • How likely is someone to survive the immediate situation?
  • What comorbidities does someone have that “correlates with 1-year and 10-year survival?” This is where age now factors in two ways: If you are under 50, you are assigned a score of 0, from 50-59, a score of 1, with an additional point for each subsequent decade of life.

Under this scoring, if someone age 45 and someone age 60 arrived at the hospital, with equal chances of surviving, and there was only one ICU bed, the 45-year-old would receive it. The 45-year-old would have 0 points, and the 60-year-old would have 2.

Now we go to double jeopardy part of Tier 1. Comorbidities are essentially one or more health conditions that exist in a person at the same time, things like heart disease and diabetes. We know that as we age, we are more likely to have a chronic condition.

Additionally, this may become triple jeopardy for an older Coloradan who is a person of color. For example, health disparities data show that there are higher rates of conditions like asthma and diabetes among African-Americans. These conditions would increase comorbidities scores. People who have lived without health care for a while or who live with fewer resources in general may deal with increased health issues. This pandemic is already hitting certain communities harder.

TIER 2

Next, if Tier 1 results in a tie score, then the triage team would give preference to the following:

  • Children under age 17
  • Health Care Workers
  • First Responders

TIER 3

Here is where older Coloradans face final jeopardy. If somehow you’ve made it through the first steps and emerged with a tie score—guess what? You face the hurdle of “life years saved”. “Priority for a scarce resource can be given to a patient with more life years to be saved,” or, simply stated:

Older people, get in the back of the line for treatment.

In contrast to this built-in ageism in the crisis standards of care, here’s what the American College of Physicians (ACP) has to say about using “life years saved for triage:

“Allocation of treatments must maximize the number of patients who will recover, not the number of “life-years,” which is inherently biased against the elderly and the disabled.”

As I read these guidelines, specific examples involuntarily flashed through my mind. I thought of some of the people I’ve met since starting Changing the Narrative:

  • The Vietnam fighter pilot who after he sold his company, has been mentoring younger vets in starting businesses
  • The 60+ aged women at workshops in Logan, Mesa, Montrose and Summit counties who run all the volunteer programs
  • The leaders of different organizations in Larimer County who have all come together to create an age-friendly community
  • The quilters who are using their mad sewing skills to make masks
  • Our volunteer Change AGEnts at Changing the Narrative who have been out in the community raising awareness about ageism, and letting employers know the tremendous value that older workers can bring to teams

All of them—moved to the back of the triage line. Because of their age.

This is Colorado. We can do better than ageism in our crisis standards of care.

What do we do if we don’t use age as a factor?

The American College of Physicians recommends the following instead of using life years and age as factors:

“When, as in times of health system catastrophe, routine “first come, first served” or “sickest first” approaches are no longer appropriate, resource allocation decisions should be made based on patient need, prognosis (determined by objective scientific measures and informed clinical judgment) and effectiveness (i.e., the likelihood that the therapy will help the patient recover).”

The first part of Colorado’s Tier 1 standard is based on prognosis, and uses an objective measure.

Furthermore, renown geriatrician Louise Aronson calls for health equity and outlines a path forward in a recent online piece in the New England Journal of Medicine:

“…we can acknowledge the particular presentations, needs, and risks of elders in our protocols and planning. The Centers for Disease Control and Prevention did not create a Covid-19 Web page directed to elders until mid-March, nearly 2 months after we learned of that group’s extraordinarily high risk for critical illness and death. Most medical centers have protocols for children and adults, but nothing for elders. Basic standards of health equity demand protocols with elder-specific diagnostic, treatment, and outcome-prediction tools, addressing lower baseline and illness-related body temperatures, atypical disease presentations, and care options geared to the life stage, health status, and life expectancy of older patients.”

What can we do about ageism in standards of care?

We can use our voices. We can let our communities know about this ageism in our crisis standards of care. As people who care, we can request that our leaders join together to eliminate current discriminatory provisions from the Critical Standards of Care.

In Colorado, that would mean making the following changes to the recommended standards:

  • Including age in the list of factors that will not be used for triage decisions
  • Eliminating point scoring for age from Tier 1, as well as considering impact on people of color of some of the comorbidity scoring.
  • Eliminating the Tier 3 tiebreaker of Life Years Saved.

In so doing, we would be upholding longstanding Colorado values of justice and fairness for all, a Colorado which “continues to treat each individual with dignity and respect.”

Janine Vanderburg, Director, Changing the Narrative in Colorado
Sara Breindel, Content Manager, Changing the Narrative in Colorado