State revises regs on crisis care

THE BAKER ADMINISTRATION revised its voluntary guidelines for who should receive scarce treatments like ventilators during the COVID-19 crisis by prioritizing those likely to survive for the next five years and ignoring longer-term health outcomes.

The change downplays underlying conditions that might not hinder a person’s ability to recover in the short-term but could in the long-term. Many of those underlying conditions, such as asthma or diabetes, are believed to reflect socioeconomic factors that tend to impact people of color more.

“The recommendations were created to prevent unconscious bias against people of color, people with disabilities, and other community members who are marginalized,” a Department of Public Health spokeswoman said of the updated guidelines.

The guidelines, which may become little more than a theoretical exercise if new cases continue to decline and so-called crisis standards of care never have to be implemented, have become a flashpoint in the debate over inequality.

Jeff Markuns, a physician at Boston Medical Center, wrote on Friday in CommonWealth that “The very foundation of these standards – and the direct correlation between societal disadvantages and health outcomes – ensures that many of these same characteristics will, in fact, play a substantial role in who lives and who dies.”

The revisions announced on Monday are perhaps best exemplified by changes to the wording of a section on priority scoring for adult patients.

Here is the original wording: “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.”

Here is the same section in the revised guidelines: “The allocation framework has two primary scoring components: one, prognosis for hospital survival and two, prognosis for near-term survival beyond the acute incident. …The presence of underlying conditions in such an advanced state that they would limit duration of benefit to no more than five years from the episode of acute illness is used to characterize patients’ prognosis for near-term survival.”

Collin Killick, a disability rights advocate, told WBUR that five years out is still too far out to look. He said New York uses a patient’s one-year prognosis as its yardstick, which he believes is fairer.

Dr. Lachlan Forrow, director of ethics and palliative care at Beth Israel Deaconess Medical Center and a member of the committee that has been working on the guidelines, told the Boston Globe the five-year window is an attempt to avoid situations where someone with a terminal illness but unlikely to die within a year is chosen over someone with a 30-year life expectancy.

“That just seemed wrong,” Farrow said.