The Massachusetts Department of Public Health (DPH) released on Tuesday its guidance to the state’s doctors and hospital staff on how to determine who gets crucial coronavirus care should the system be overwhelmed by cases. The state’s guidance details how to determine a “priority score” for each patient based on both the individual’s likelihood of recovering and potential length of life.
In its “Crisis Standards of Care” for the COVID-19 pandemic issued Tuesday, Massachusetts’ DPH attempts to address potential questions that may arise on account of the virus, including if the system is overwhelmed due to an influx of cases, potentially requiring some degree of rationing of care and equipment. In such a situation, the state’s health officials say medical professionals should attempt to preserve the most life possible, taking into account how likely patients will recover and how long those patients are likely to live if they do.
The guidelines present the concept of a “priority score” for patients to help determine who to give critical care, including ICU beds and potentially life-saving medical equipment like ventilators, should it need to be rationed.
“The guidance, which is not mandatory, asks hospitals to assign patients a score that gives preference to healthier patients who have a greater chance of surviving their illness, and living longer overall,” the Boston Globe explains. “It gives additional preference to medical personnel who are vital to treating others, and to women further along in pregnancy. In the event of tie scores, younger patients are given priority.”
The guidelines specifically state that medical professionals should not consider several factors, among them: “race, disability, gender, sexual orientation, gender identity, ethnicity, ability to pay, socioeconomic status, perceived social worth, perceived quality of life, immigration status, incarceration status, homelessness or past or future use of resources.”
What should play into decisions should care need to be rationed is survival likelihood as well as longevity:
[T]he allocation framework operationalizes the broad public health goal by giving priority to patients who are most likely to survive to hospital discharge and beyond with appropriate treatment with critical care resources. The allocation framework described in this document differs in two important ways from other allocation frameworks. First, it does not categorically exclude any patients who, in usual circumstances, would be eligible for critical care resources. All patients are treated as eligible to receive critical care resources and receive a priority assignment based on illness severity. Second, the allocation framework goes beyond attempting to maximize the number of patients who survive to hospital discharge, because this is a narrow conception of maximizing benefit to the population. Instead, the allocation framework also attempts to maximize the number of life-years saved.
The guidelines provide less specific scoring criteria for patients under 18, stating that “scoring systems that are meaningful for adult critical care patients do not apply to pediatric patients or newborns,” and recommending that “experienced pediatric intensivists and neonatologists serving as Triage Officers should exercise clinical judgment in assigning priority scores for children.” But the guidelines get very specific with officials’ recommended “priority scoring” approach for adult patients (18 and over). Below is an excerpt from the section:
Priority Scoring for Adult Patients (18 and over)
This allocation framework is based on two considerations: 1) saving the most lives; and 2) saving the most life-years. Patients who are more likely to survive with intensive care are prioritized over patients who are less likely to survive with intensive care. Patients who do not have serious comorbid illness are given priority over those who have illnesses that limit their life expectancy. As summarized in Table 1, the Sequential Organ Failure Assessment (SOFA) score is used to characterize patients’ prognosis for hospital survival. The presence of significant life-limiting comorbid conditions is used to characterize patients’ longer-term prognosis.
Points are assigned for SOFA score category (1-4 points) and the presence of comorbid conditions (2 points for major life-limiting comorbidities, 4 points for severely life-limiting comorbidities (Table 2)). These points are then added together to produce a total priority score, which ranges from 1 to 8. Lower scores indicate higher likelihood to benefit from critical care; priority will be given to those with lower scores.
SOFA = Sequential Organ Failure Assessment
*Persons with the lowest cumulative score will be given the highest priority to receive critical care services.Regarding the use of the SOFA score as a marker of prognosis for short-term survival, there are several objective scoring systems used to assess severity of critical illness and likelihood of survival, but each has limitations and all should be applied in the context of clinical judgment.
Other scoring considerations:
1. Pregnancy: Pregnant patients will be assigned a priority score based on the same framework used for non-pregnant patients. If a pregnant patient is at or beyond the usual standards for fetal viability, the patient will be given a two-point reduction, giving her a higher priority score.2. Limited data: If laboratory values or other elements needed for the priority score are not available prior to the need for a time sensitive decision by the Triage Officer, the Triage Officer will do his/her best to approximate a priority score
3. Individuals who perform tasks that are vital to the public health response, including all those whose work directly to support the provision of care to others, should be given heightened priority. This category should be broadly construed to include those individuals who play a critical role in the chain of treating patients and maintaining societal order.
