By: Joseph Park, M.D.
Faculty Editor: Emily Cleveland, M.D.
“I will not permit considerations of religion, nationality, race, and social standing to intervene between my duty and my patient…”
During the past few months, thousands of newly matriculated medical students swore the Physician’s Oath, pledging to guide all patient care with equity and medical ethics. At the same time, physicians around the world found themselves facing a dilemma that challenged these very tenets; which of their patients would get a ventilator?
During the COVID-19 global pandemic, some hospital systems were overwhelmed by the sheer number of critically ill patients. In some places, including in Italy and some hospitals in New York City, resources became limited, and not all patients could be offered standard of care. In response, regional committees in several states, Massachusetts included, developed a framework to help guide the allocation of resources. On April 7, 2020, an advisory committee convened by the Commissioner of Massachusetts Department of Public Health proposed a Crisis Standards of Care Planning Guidance for the COVID-19 Pandemic. However, this was revised less than two weeks later after an extraordinary advocacy effort by healthcare experts and politicians who expressed concerns about structural biases within these policies that could further threaten the inequities in healthcare. At a recent gathering of the BMC Emergency Medicine Journal Club, we explore some of these issues that are not only considerations in the setting of the pandemic but, more broadly, are also inherent systemically, deeply embedded in our approach to medical research, education, and clinical decision making.
The Crisis Standards of Care (CSC) guidelines for Massachusetts prioritize patients for care based on severity of the present illness as well as consideration of prognosis for short-term and long-term survival. Short-term survival is assessed using the Sequential Organ Failure Assessment (SOFA) score, which uses laboratory values and clinical presentation as biomarkers of organ failure to predict mortality. Longer-term survival is based on clinician review of comorbid health conditions that affect prognosis for 1- and 5-year survival. Patients with a lower score have a better prognosis and are given higher priority in critical care resources.
Two major discussion points were raised by the Journal Club group. The first point of concern is the utility of the SOFA score in prioritizing COVID-19 patients. A study from 2017, Prognostic Accuracy of the SOFA Score, SIRS Criteria, and qSOFA Score for In-Hospital Mortality Among Adults With Suspected Infection Admitted to the Intensive Care Unit, demonstrated a greater prognostic accuracy of the SOFA score for in-hospital mortality. That being said, it’s important to recognize that the SOFA score was initially designed for predicting mortality among ICU patients with suspected sepsis, and not as a triage tool. So how relevant is the SOFA score to the COVID-19 patient population?
The study assessing prognostic accuracy reviewed a retrospective cohort of 184,875 patients primarily with bacterial infections (most commonly pneumonia, urinary tract infections, and GI infections). In fact, patients with viral infections only composed 2.9% of the study cohort and those with respiratory infections were only 2.3%. Moreover, if CSC were implemented, they would be used to triage all patients requiring ICU care (e.g., trauma patients, post-surgical patients, etc.). It is unclear how well SOFA might predict survival in these other groups. Where do these patients stand in the priority score of the CSC? Despite the lack of data to support its use as a triage tool, and the lack of clarity around how well it might predict mortality among non-sepsis patients, the SOFA score has been incorporated into nearly all CSC allocation frameworks.
In addition to concerns about the appropriateness of using SOFA scores for prioritizing patients to receive scarce resources, concerns have emerged about racial and ethnic disparities in the severity of COVID-19. The second article discussed, Disparities in the Population at Risk of Severe Illness From COVID-19 by Race/Ethnicity and Income, quantifies what we already suspect: among those younger than 65 years old, 33% of Blacks and 42% of American Indians were at higher of severe COVID-19, compared to 27% of white adults. This has significant implications for equity in allocation of resources under CSC; if white patients are likely to be less critically ill than Black patients, they will be given higher priority for allocation of resources, further exacerbating systemic inequities in mortality and health outcomes.
The second major issue that emerged from the discussion relates to prediction of longer term survival. By CSC guidelines, patients with life-limiting health conditions receive lower priority for critical care resources. In so doing, the most vulnerable populations are penalized for the chronic conditions to which they are already predisposed as a result of longstanding inequities in the distribution of adverse social determinants of health. Massachusetts, like many other states, explicitly state, “Factors […] including but not limited to race, […] socioeconomic status, […] are not to be considered by providers making allocation decisions”. The dangers of this color-blind approach were discussed in a recent article by Dr. Cleveland, a BMC EM faculty member. In Inequity in Crisis Standards of Care, she and her co-authors write that even if the intent in using a color-blind approach to resource allocation is to ensure equity, if applied to a problem that disproportionately affects people of color this “will almost certainly ensure the opposite, with devastating effects on disadvantaged communities”. They urge policymakers to “consider identity as well as systematically apply an equity lens to understand how social factors unfairly benefit some people.” Less access to health care and preventative medicine, chronic conditions, poor living conditions, less ability to socially distance, and higher-risk essential jobs all play a huge role in both increasing the risk of contracting COVID-19, as well as in scoring higher on the CSC point system, and thus being deprioritized for access to critical care resources.
It comes as no surprise that the healthcare system and its policies are not exempt from institutionalized racism. What we have witnessed during this pandemic, however, was a swift and spirited response from both healthcare providers and politicians whose advocacy brought real change and awareness to the medical community. The reality of our profession is that we are far from perfect, and our patients know that all too well. The distrust that patient populations have with the medical field and healthcare system are founded on historic and lived experiences. If we are to uphold the Physician’s Oath we made to ourselves and our patients, we must continue to challenge every aspect of medicine in its equity and access. Anything less will be a betrayal of the trust that we often take for granted.
Bebinger, Martha. “After Uproar, Mass. Revises Guidelines On Who Gets An ICU Bed Or Ventilator Amid COVID-19 Surge | CommonHealth.” WBUR, WBUR, 20 Apr. 2020, https://www.wbur.org/commonhealth/2020/04/20/mass-guidelines-ventilator-covid-coronavirus.
Cleveland Manchanda, Emily, et al. “Inequity in Crisis Standards of Care.” New England Journal of Medicine, vol. 383, no. 4, Massachusetts Medical Society, July 2020, p. e16. Crossref, doi:10.1056/nejmp2011359.
D’Olimpio, Laura. “The Trolley Dilemma: Would You Kill One Person to Save Five?” The Conversation, The Conversation. n.p., 3 June 2016, https://theconversation.com/the-trolley-dilemma-would-you-kill-one-person-to-save-five-57111.
Raifman, Matthew A, and Julia R Raifman. “Disparities in the Population at Risk of Severe Illness From COVID-19 by Race/Ethnicity and Income.” American journal of preventive medicine vol. 59,1 (2020): 137-139. doi:10.1016/j.amepre.2020.04.003
Raith, Eamon P et al. “Prognostic Accuracy of the SOFA Score, SIRS Criteria, and qSOFA Score for In-Hospital Mortality Among Adults With Suspected Infection Admitted to the Intensive Care Unit.” JAMA vol. 317,3 (2017): 290-300. doi:10.1001/jama.2016.20328
The Commonwealth of Massachusetts, Executive Office of Health and Human Services, Department of Public Health. “Crisis Standards of Care Planning Guidance for the COVID-19 Pandemic (April 07,2020)”. https://www.mass.gov/doc/statewide-advisory-committee-recommendations-for-standards-of-care/download?_ga=2.117036865.691315970.1597003543-1021986585.1597003543.