Rationing Limited Healthcare Resources in the COVID-19 Era and Beyond: Ethical Considerations Regarding Older Adults

doi:10.1111/jgs.16539

. 2020 Jun;68(6):1143-1149.

doi: 10.1111/jgs.16539.

Rationing Limited Healthcare Resources in the COVID-19 Era and Beyond: Ethical Considerations Regarding Older Adults

Timothy W Farrell^{1

2

3}, Leslie Francis^{4

5}, Teneille Brown^{6

7}, Lauren E Ferrante⁸, Eric Widera^{9

10}, Ramona Rhodes^{11

12}, Tony Rosen¹³, Ula Hwang^{14

15}, Leah J Witt^{9

16}, Niranjan Thothala^{17

18}, Shan W Liu¹⁹, Caroline A Vitale^{20

21}, Ursula K Braun^{22

23}, Caroline Stephens²⁴, Debra Saliba^{25

26

27}

Affiliations

¹ Division of Geriatrics, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA.
² VA SLC Geriatric Research, Education, and Clinical Center, Salt Lake City, Utah, USA.
³ University of Utah Health Interprofessional Education Program, Salt Lake City, Utah, USA.
⁴ University of Utah S.J. Quinney College of Law, Salt Lake City, Utah, USA.
⁵ Department of Philosophy, University of Utah, Salt Lake City, Utah, USA.
⁶ Center for Law and the Biomedical Sciences, University of Utah S.J. Quinney College of Law, Salt Lake City, Utah, USA.
⁷ Program in Medical Ethics and Humanities, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA.
⁸ Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA.
⁹ Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.
¹⁰ San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.
¹¹ Division of Geriatric Medicine, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA.
¹² Central Arkansas Veterans Healthcare System, Geriatric Research, Education, and Clinical Center, Little Rock, Arkansas, USA.
¹³ Department of Emergency Medicine, Division of Geriatric Emergency Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York, USA.
¹⁴ Department of Emergency Medicine & Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
¹⁵ Geriatric Research, Education and Clinical Center, James J. Peters VAMC, Bronx, New York, USA.
¹⁶ Division of UCSF Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, San Francisco, California, USA.
¹⁷ Hospitalist Division, Department of Medicine, Good Samaritan Hospital, Vincennes, Indiana, USA.
¹⁸ Hospitalist Division, Department of Medicine, Union Hospital, Terre Haute, Indiana, USA.
¹⁹ Department of Emergency Medicine, Division of Geriatric Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
²⁰ Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.
²¹ VA Ann Arbor Geriatric Research, Education, and Clinical Center (GRECC), Ann Arbor, Michigan, USA.
²² Section of Geriatrics and Palliative Medicine, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.
²³ Rehabilitation and Extended Care Line, Michael E. DeBakey VA Medical Center, Houston, Texas, USA.
²⁴ University of Utah College of Nursing, Salt Lake City, Utah, USA.
²⁵ UCLA Borun Center for Gerontological Research, Los Angeles, California, USA.
²⁶ VA Los Angeles Geriatric Research Education and Clinical Center, Los Angeles, California, USA.
²⁷ RAND Corporation, Santa Monica, California, USA.

PMID: 32374466
PMCID: PMC7267288
DOI: 10.1111/jgs.16539

Rationing Limited Healthcare Resources in the COVID-19 Era and Beyond: Ethical Considerations Regarding Older Adults

Timothy W Farrell et al. J Am Geriatr Soc. 2020 Jun.

. 2020 Jun;68(6):1143-1149.

doi: 10.1111/jgs.16539.

Authors

Affiliations

¹ Division of Geriatrics, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA.
² VA SLC Geriatric Research, Education, and Clinical Center, Salt Lake City, Utah, USA.
³ University of Utah Health Interprofessional Education Program, Salt Lake City, Utah, USA.
⁴ University of Utah S.J. Quinney College of Law, Salt Lake City, Utah, USA.
⁵ Department of Philosophy, University of Utah, Salt Lake City, Utah, USA.
⁶ Center for Law and the Biomedical Sciences, University of Utah S.J. Quinney College of Law, Salt Lake City, Utah, USA.
⁷ Program in Medical Ethics and Humanities, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA.
⁸ Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA.
⁹ Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.
¹⁰ San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.
¹¹ Division of Geriatric Medicine, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA.
¹² Central Arkansas Veterans Healthcare System, Geriatric Research, Education, and Clinical Center, Little Rock, Arkansas, USA.
¹³ Department of Emergency Medicine, Division of Geriatric Emergency Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York, USA.
¹⁴ Department of Emergency Medicine & Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
¹⁵ Geriatric Research, Education and Clinical Center, James J. Peters VAMC, Bronx, New York, USA.
¹⁶ Division of UCSF Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, San Francisco, California, USA.
¹⁷ Hospitalist Division, Department of Medicine, Good Samaritan Hospital, Vincennes, Indiana, USA.
¹⁸ Hospitalist Division, Department of Medicine, Union Hospital, Terre Haute, Indiana, USA.
¹⁹ Department of Emergency Medicine, Division of Geriatric Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
²⁰ Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.
²¹ VA Ann Arbor Geriatric Research, Education, and Clinical Center (GRECC), Ann Arbor, Michigan, USA.
²² Section of Geriatrics and Palliative Medicine, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.
²³ Rehabilitation and Extended Care Line, Michael E. DeBakey VA Medical Center, Houston, Texas, USA.
²⁴ University of Utah College of Nursing, Salt Lake City, Utah, USA.
²⁵ UCLA Borun Center for Gerontological Research, Los Angeles, California, USA.
²⁶ VA Los Angeles Geriatric Research Education and Clinical Center, Los Angeles, California, USA.
²⁷ RAND Corporation, Santa Monica, California, USA.

PMID: 32374466
PMCID: PMC7267288
DOI: 10.1111/jgs.16539

Abstract

Coronavirus disease 2019 (COVID-19) continues to impact older adults disproportionately with respect to serious consequences ranging from severe illness and hospitalization to increased mortality risk. Concurrently, concerns about potential shortages of healthcare professionals and health supplies to address these issues have focused attention on how these resources are ultimately allocated and used. Some strategies, for example, misguidedly use age as an arbitrary criterion that disfavors older adults in resource allocation decisions. This is a companion article to the American Geriatrics Society (AGS) position statement, "Resource Allocation Strategies and Age-Related Considerations in the COVID-19 Era and Beyond." It is intended to inform stakeholders including hospitals, health systems, and policymakers about ethical considerations that should be considered when developing strategies for allocation of scarce resources during an emergency involving older adults. This review presents the legal and ethical background for the position statement and discusses these issues that informed the development of the AGS positions: (1) age as a determining factor, (2) age as a tiebreaker, (3) criteria with a differential impact on older adults, (4) individual choices and advance directives, (5) racial/ethnic disparities and resource allocation, and (6) scoring systems and their impact on older adults. It also considers the role of advance directives as expressions of individual preferences in pandemics. J Am Geriatr Soc 68:1143-1149, 2020.

Keywords: COVID-19; ethics; older adult; rationing; triage.

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Conflict of interest statement

The authors have declared no conflicts of interest for this article.

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References

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[1] Verity R, Okell LC, Dorigatti I, et al. Estimates of the severity of coronavirus disease 2019: a model‐based analysis. Lancet Infect Dis. 2020;20:30243‐7. 10.1016/S1473-3099(20)30243-7. - DOI - PMC - PubMed

[2] Verity R, Okell LC, Dorigatti I, et al. Estimates of the severity of coronavirus disease 2019: a model‐based analysis. Lancet Infect Dis. 2020;20:30243‐7. 10.1016/S1473-3099(20)30243-7. - DOI - PMC - PubMed

[3] Novel Coronavirus Pneumonia Emergency Response Epidemiology Team . The epidemiological characteristics of an outbreak of 2019 novel coronavirus disease (COVID‐19) in China [in Chinese]. Zhonghua Liu Xing Bing Za Zhi. 2020;41(2):145‐151. - PubMed

[4] Novel Coronavirus Pneumonia Emergency Response Epidemiology Team . The epidemiological characteristics of an outbreak of 2019 novel coronavirus disease (COVID‐19) in China [in Chinese]. Zhonghua Liu Xing Bing Za Zhi. 2020;41(2):145‐151. - PubMed

[5] CDC COVID‐19 Response Team . Severe outcomes among patients with coronavirus disease 2019 (COVID‐19) ‐ United States, February 12‐March 16, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(12):343‐346. - PMC - PubMed

[6] CDC COVID‐19 Response Team . Severe outcomes among patients with coronavirus disease 2019 (COVID‐19) ‐ United States, February 12‐March 16, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(12):343‐346. - PMC - PubMed

[7] D'Adamo H, Yoshikawa T, Ouslander JG. Coronavirus disease 2019 in geriatrics and long‐term care: the ABCDs of COVID‐19. J Am Geriatr Soc. 2020;68(5):912‐917. 10.1111/jgs.16445. - DOI - PubMed

[8] D'Adamo H, Yoshikawa T, Ouslander JG. Coronavirus disease 2019 in geriatrics and long‐term care: the ABCDs of COVID‐19. J Am Geriatr Soc. 2020;68(5):912‐917. 10.1111/jgs.16445. - DOI - PubMed

[9] White DB, Lo B. A framework for rationing ventilators and critical care beds during the COVID‐19 pandemic. JAMA. 2020;323(18):1773‐1774. 10.1001/jama.2020.5046. - DOI - PubMed

[10] White DB, Lo B. A framework for rationing ventilators and critical care beds during the COVID‐19 pandemic. JAMA. 2020;323(18):1773‐1774. 10.1001/jama.2020.5046. - DOI - PubMed

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Rationing Limited Healthcare Resources in the COVID-19 Era and Beyond: Ethical Considerations Regarding Older Adults

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Rationing Limited Healthcare Resources in the COVID-19 Era and Beyond: Ethical Considerations Regarding Older Adults

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