Should vaccination status and age play any roles in rationing care in Colorado?
When it comes time to ration health care resources, there are no good options left. The question is how to find the least-bad option and save the most lives.
The Governor’s Expert Emergency Epidemic Response Committee is updating the state’s crisis standards of care for how hospitals should prioritize patients if a worsening COVID-19 crisis leaves them unable to provide the best health care to everyone.
That process can lead to potentially thorny ethical questions: Should vaccinated patients be given priority over people who have chosen not to get inoculated against the virus? In what way should patients’ age play into decisions made about rationing care?
When the standards were written at the beginning of the pandemic in spring 2020, vaccines weren’t yet available, science knew relatively little about the new virus and the biggest concern was running out of ventilators.
Now Colorado is more likely to run out of dialysis machines or beds in intensive-care units than ventilators. Doctors know more about which drugs might help COVID-19 patients, and vaccines are widely available.
Currently the only crisis standards in effect are those that guide how to stretch hospital staffing.
Dr. Eric France, the state’s chief medical officer, acknowledged in late October that it’s possible Colorado could need to activate the rationing standards if the COVID19 situation continues to worsen.
As of Thursday, 1,535 people were hospitalized for confirmed COVID-19 — 368 more than were when France made that 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.
The rationing standards instruct hospitals to use a formula to assign scores to patients based on how well their organs are func
tioning — a proxy for how likely they are to survive the next month. Triage teams are then supposed to add points based on patients’ ages and severe chronic conditions, like end-stage liver disease, cancer that has metastasized or AIDS (but not a well-controlled HIV infection).
The lower a patient’s score is, the more likely they are to receive full resources. Patients with higher scores may receive lessintense care. Those with the lowest odds of survival may receive care focused on relieving pain and other symptoms if the system is overwhelmed.
The committee will need to meet again to vote on any revisions to the crisis standards, which will go to Gov. Jared Polis. He could then decide to authorize use of the standards, and the final decision to put them in place would rest with France.
Should vaccination status matter?
The standards specify that hospitals can’t decide which patients get resources based solely on factors such as race, disability or age.
A draft the committee discussed at its last meeting didn’t mention vaccination status as a factor that shouldn’t be used to make decisions, but Claire Uebbing, vice president of healthy communities and wholeness at Centura Health, asked that they add it because of concerns about “bias” among health care providers.
Dr. Anuj Mehta, a pulmonary critical care physician at Denver Health who wrote a first draft of updates to the current guidelines, noted there was some controversy about whether vaccination status should be a factor in decisions. He said he agreed with adding it.
“Our ethical principles are to save the most lives,” not to punish irresponsible behavior, he said.
The current surge is largely fueled by spread among unvaccinated people. About 82% of those currently hospitalized in Colorado with COVID-19 are unvaccinated, and the percentage is even higher among those being cared for in intensive-care units or treated with ventilators.
While the governor hasn’t said publicly that he would support using vaccination status as a factor in care decisions, he did signal considerable frustration with those who could get vaccinated but have chosen not to.
“I have no qualms if (unvaccinated people) have a death wish, but they’re clogging our hospitals,” Polis said at a recent news briefing.
Larry Harmsen, an Englewood resident, said he hopes Polis will press to include vaccination status in the formula for care decisions should hospitals be forced to ration.
“This may seem callous, but it’s an excellent 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 they may get kicked out of the hospital if they are being treated for COVID to make way for a vaccinated person (that needs hospital care for any reason), perhaps they would think twice before deciding to go unvaccinated.”
The frustration that some vaccinated people feel is understandable, but in medical ethics, it’s not acceptable to withhold care from people because they may have contributed to their illness, said Matthew Wynia, director of the University of Colorado’s Center for Bioethics and Humanities.
Even measures that some people might feel are punitive, such as withholding a liver transplant if a person is unable to stop drinking heavily, are focused on the future and how likely it is that the surgery will save a life, he said.
“We don’t punish people for their bad decisions,” he said.
The threat of denying care is unlikely to motivate many unvaccinated people, because adults who haven’t gotten the shot at this point likely don’t believe COVID19 is a serious illness, or feel confident that they won’t become ill because they’re young and healthy, Wynia said.
The only way that it would be ethically acceptable to include vaccination status would be if it was a good predictor of how likely someone is to survive, Wynia said.
Vaccinated people are at a far lower risk of developing serious complications or dying from COVID-19 overall, but if you’re trying to decide who should receive a bed in an intensivecare unit, whether a patient has had the shot becomes less relevant: any vaccinated person who is sick enough to need an ICU bed likely has severe health conditions that make their survival far from assured, he said.
“That could mean that the unvaccinated person has more likelihood of benefit,” he said.
Ageism or reflection of risk?
Janine Vanderburg, director of anti-ageism group Changing the Narrative, said the group is not focusing on the unvaccinated, although it would be galling if younger people who left them themselves exposed to COVID-19 got care while older people who protected themselves didn’t.
The bigger issue is that older people, and especially people of color, are put 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, maxing out at four points for anyone 80 or older.
It also adds points for certain illnesses:
• One point: Chronic lung disease; genetic or autoimmune conditions affecting connective tissues (like 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 since birth or caused by an accident); current cancer.
• Four points: Moderate or severe liver disease; AIDS.
• Six points: Cancer that has metastasized.
The concern is not only that the system could discriminate but that it may not provide an accurate picture of people’s risk, Vanderburg said. She said advocates for the aging community would like to see the supplemental points taken out, to put the emphasis on how well people’s organs are functioning.
“Being age 50 is no more a predictor of dying in the next year than if you’re younger,” she said. “That is, to me, the essence of stereotyping and discrimination.”
In the case of COVID-19, however, age can be a strong predictor of someone’s odds of survival — perhaps even more important than measures of organ function, according to one study, Wynia said. While it’s not ethical to discriminate on the basis of age, if an older person is less likely to survive even in the short term, it’s right to consider that 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.