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Should doctors consider vaccination status if Colorado rations are large?

When it comes to rationing health care resources, there are no more good options. The question is how to find the least bad option and save the most lives.

The Governor’s Expert Panel on Emergency Outbreak Response updates state crisis care standards on how hospitals should prioritize patients if a COVID-19 crisis worsens them impedes providing the best health care for everyone.

This process can lead to potentially thorny ethical questions: Should vaccinated patients be given priority over people who have chosen not to be vaccinated against the virus? How should the age of patients influence decisions about rationing of care?

When the standards were written at the start of the pandemic in the spring of 2020, vaccines were not yet available, science knew relatively little about the new virus, and the biggest concern was running out of ventilators.

Colorado is now more likely to run out of dialysis machines or ICU beds than ventilators; doctors know more about drugs that could help patients with COVID-19; and vaccines are widely available.

Currently, the only crisis standards in place are those that guide how to stretch hospital staff. Chief Medical Officer Dr Eric France acknowledged in late October that Colorado may need to activate rationing standards if the COVID-19 situation continues to worsen.

As of Thursday, 1,535 people were hospitalized with confirmed COVID-19, 368 more than when France made the announcement. Only 488 general beds and 81 intensive care beds remained available statewide, and projections show Colorado could exceed hospital capacity by the end of December.

Ration standards require hospitals to use a formula to assign scores to patients based on how well their organs are functioning – an indicator of their likelihood of surviving next month. Triage teams are then expected to add points based on patient age and serious chronic conditions, such as end-stage liver disease, cancer that has metastasized, or AIDS (but not HIV infection though. controlled).

The lower a patient’s score, the more likely they are to receive all the resources. Patients with higher scores may receive less intense care. Those with the lowest chances of survival may receive care focused on relieving pain and other symptoms if the system is overwhelmed.

The committee will have to meet again to vote on any revised crisis standards, which will go to Governor Jared Polis. It could then decide to authorize the use of the standards, and the final decision to put them in place would rest with France.

Should immunization status be important?

The standards state that hospitals cannot decide which patients receive resources solely based on factors such as race, disability or age.

A project the committee discussed at its last meeting didn’t mention vaccine status as a factor that shouldn’t be used in making decisions, but Claire Uebbing, vice president of healthy communities and integrity at Centura Health , asked that they add it because of concerns about “bias” among health care providers.

Dr Anuj Mehta, a pulmonary intensive care physician at Denver Health who wrote a first draft of updates to the current guidelines, noted that there was some controversy over whether vaccination status should be a factor in decisions, but said he was okay with adding it.

“Our ethical principles are to save the most lives”, not to punish irresponsible behavior, he said.

The current outbreak is largely fueled by the spread among the unvaccinated. About 82% of people currently hospitalized in Colorado with COVID-19 are not vaccinated, and the percentage is even higher among those treated in intensive care units or treated with ventilators.

Although the governor has not publicly stated that he will support the use of immunization status as a factor in care decisions, he has signaled considerable frustration with those who may be vaccinated but have chosen to do not do it.

“I have no qualms if (unvaccinated people) have a death wish, but they clog our hospitals,” Polis said at a recent press briefing.

Larry Harmsen, an Englewood resident, said he hoped Polis would push to include vaccination status in the formula for care decisions if hospitals were forced to ration.

“It may sound callous, but it’s a great way to prioritize a limited resource and further incentivize those who refuse to be vaccinated,” he said in an email. “If an unvaccinated person knew that they could be kicked out of the hospital if treated for COVID to make way for a vaccinated person (who needs hospital care for some reason), maybe they would think about it. twice before deciding not to be vaccinated. “

The frustration felt by some vaccinated people is understandable, but in medical ethics it is not acceptable to deny care to people because they may have contributed to their illness, said Matthew Wynia, director of the Center for Bioethics and Humanities at the ‘University of Colorado.

Even measures that some people might consider punitive, such as refusing a liver transplant if a person is unable to stop drinking heavily, focus on the future and on the likelihood that the surgery will save a life. he declared.

“We are not punishing people for their bad decisions,” he said.

The threat of withholding care is unlikely to motivate many unvaccinated people, as adults who have not yet been vaccinated likely do not believe COVID-19 is a serious illness, or are convinced they will not fall. not sick because they are young and healthy, says Wynia.

The only way it would be ethically acceptable to include vaccine status would be for it to be a good predictor of a person’s likelihood of survival, Wynia said.

People who have been vaccinated are at a much lower risk of developing serious complications or dying from COVID-19 overall, but if you’re trying to decide who should get a bed in an intensive care unit, the fact that a patient been vaccinated becomes less relevant: Anyone vaccinated enough who is sick enough to need an intensive care bed likely has serious health issues that make their survival far from assured, he said.

“It could mean that the unvaccinated person is more likely to benefit,” he said.

Ageism or the reflection of risk?

Janine Vanderburg, director of the anti-ageism group Change the Story, said they did not focus on the unvaccinated, although it would be infuriating if the young people who left them themselves exposed to COVID-19 were treated while that older people protecting themselves did not. t.

The biggest problem is that older people, and especially people of color, are at a disadvantage in the formula for making care decisions, she said.

“What Colorado is doing is wrong,” she said.

The current formula adds one point for patients in their 50s, with an additional point added for each decade, with a maximum of four points for anyone 80 years of age or older.

It also adds points for certain diseases:

  • A point: Chronic lung disease; genetic or autoimmune diseases affecting connective tissues (such as lupus or rheumatoid arthritis); diabetes with existing complications; moderate or severe kidney disease
  • Two points: Chronic heart failure; dementia; mild liver disease; paralysis caused by a stroke (but not paralysis present from birth or caused by an accident); current cancer
  • Four points: Moderate or severe liver disease; AIDS
  • 6 points: Cancer that has metastasized

The concern is not only that the system can discriminate, but that it cannot provide an accurate picture of people’s risk, Vanderburg said. She said advocates for the aging community would like the extra points to be removed, in order to focus on the functioning of people’s organs.

“Being 50 is no more a predictor of death in the next year than if you are younger,” she said. “This is, to me, the essence of stereotypes and discrimination.”

In the case of COVID-19, however, age can be a powerful predictor of a person’s chances of survival – perhaps even more important than measures of organ function, according to one study, Wynia said. While it is unethical to discriminate on the basis of age, if an older person is less likely to survive even in the short term, it is fair to take this into account when deciding how to save the most. lives with limited resources, he said.

“In some ways it’s very utilitarian. We want to save as many lives as possible, ”he said.

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