What if Nebraska’s hospitals become overwhelmed? Dr. Steve Doran explains the state’s new crisis standards of care

As the number of people with COVID-19 increases, so too does the number of patients requiring hospitalization. Since the onset of the pandemic, much has been learned about how to treat patients with COVID. The mortality rate has fallen over time and less people are requiring hospitalization.

Even so, the number of patients with COVID has risen dramatically in recent weeks and will likely continue to increase as winter approaches. While so far hospitals in Nebraska have sufficient resources to care for all patients, including those hospitalized for reasons other than COVID, many hospitals throughout the state are straining at full capacity.

This raises important questions: What if there are more patients needing critical resources than the hospitals can accommodate? Who will receive these resources and who will not? How are those decisions made? These are the fundamental questions addressed in the Nebraska Crisis Standards of Care. 

In November 2020, a working group representing clinical, legal and ethical perspectives was convened to create a plan to focus on the health care surge. As a result, the Nebraska Medical Emergency Operations Center was established. One of its goals was to create and implement a crisis standards of care plan for Nebraska.

Dr. Steve Doran, an Omaha neurosurgeon and bioethicist for the Archdiocese of Omaha, was a member of the working group. The crisis standard of care guidelines the group authored have now been distributed throughout the state. They have been endorsed by a broad constituency, including physicians, hospitals, regional health care systems, the Nebraska Medical Association and the Nebraska Hospital Association.

As a follow-up to last month’s Q&A on the ethics of a COVID vaccine, Doran answered several more questions on the crisis standard of care guidelines and the Catholic ethical principles that support them.

Q: What is meant by “crisis standards of care”?

Under normal circumstances, hospitals operate under what is known as “conventional capacity,” which means the spaces, staff and supplies used to deliver care are consistent with daily practices.

If the demand for services starts to exceed what can be supplied by normal daily practices, hospitals then transition to what is known as “contingency capacity,” which means the spaces, staff and supplies used are not consistent with daily practices but care that is functionally equivalent to usual patient care is still provided. An example of this would be patients being placed in areas not typically used for inpatient stays, such as the surgical recovery room. Another example would be the continued use of equipment that is normally meant for single use, such as N95 masks.

In recent weeks, most hospitals in Nebraska are often operating under “contingency capacity.” What happens if demand increases even further? Hospitals and health care systems then activate “crisis standards of care,” which provides the best possible care to patients given the circumstances and resources available, but crisis care results in significant adjustments to normal standards of care.

Q: What is the purpose of having these guidelines?

There are several good reasons these guidelines have been developed:

• To help health care institutions and providers make fair and consistent decisions about the use and allocation of scarce medical resources;
• To ensure critical resources are conserved and distributed efficiently and ethically across the health care system;
• To promote transparent decision-making and public trust in the fairness and equity of the system;
• To protect those who might otherwise face barriers to accessing care; and
• To assure patients and their families they will receive fair access to care under the circumstances, regardless of where they live.

Q: How do the crisis standards of care come into play?

Crisis standards of care will be triggered only when there is no acceptable alternative, and their use will be discontinued as soon as possible. Crisis care may be triggered at a single hospital, but usually is triggered at a regional or state level.

The hospitals in Nebraska are organized into various coalitions based upon location and every effort is made to share the burden of COVID patients with nearby facilities. This requires a coordinated effort of transferring patients as needed, and Nebraska, unlike many states, is fortunate to have a state-wide transfer center to facilitate the movement of patients. CHI Health in Nebraska has provided the critical infrastructure for the transfer center.

Q: What is the fundamental ethical principle guiding these standards of care?

The foundation of this approach is that difficult decisions must be based on criteria that ensure every patient has equitable access to care. These criteria must be as clear, transparent and objective as possible, and must be based on medical factors that prioritize patients most likely to benefit from scarce resources. Factors that have no bearing on the likelihood of benefitting from this care should not be considered by providers making triage decisions.

Q: What are some of the Catholic ethical principles that support the establishment of such standards?

• Respect for Human Dignity – All health care providers demonstrate respect for human dignity by recognizing that the lives of all human beings are of inherent, equal and incalculable value. 
• Fairness/Justice – All patients will be treated with respect, care and compassion without regard to race, disability, gender, age, sexual orientation, gender identity, ethnicity, ability to pay, socioeconomic status, English language proficiency, perceived social worth, perceived quality of life, immigration status, incarceration status or homelessness. 
• Proportionality – All triage decisions will be proportional to the degree of emergency and the degree of scarcity of resources. 
• Solidarity/Common Good – When there are limited resources, all people must consider the greater good of the entire community.

Q: In real terms, what does it mean if health care facilities activate crisis standards of care?

Every effort will be made to avoid a situation where the crisis standards need to be utilized. However, if a health care facility becomes, or anticipates becoming, no longer able to provide the usual standard of care, they may decide to activate crisis standards of care. Due to the unique nature of health care delivery and the uneven distribution of resources across health care facilities, the resources at one facility may become exhausted well before another facility. 

Under these circumstances, hospitals will form triage teams who have the responsibility and authority to prioritize patients who would benefit most from critical care. Using well established measures of illness severity, the triage team will determine which patients would have the greatest probability of survival and therefore receive resources that are in scarce supply, such as an ICU bed or a ventilator. 

Patients with a low probability of survival would receive palliative care, which serves an important role in responding to a pandemic by assisting with symptom management, decision-support and emotional and spiritual support for patients and families.

Q: What are some additional considerations for Catholics on this difficult subject?

The following considerations have been adapted from the National Catholic Bioethics Center:

• Need for prayer and support. Health care providers in particular are facing scenarios of fatigue, danger to health and life, and moral distress. In addition to supporting the efforts of health care organizations and public authorities, Catholics should pray in particular for all those involved in direct clinical care during a pandemic, and they should seek additional ways to provide them with personal, social and spiritual support.
• Need for prudence. Prudential decision-making requires recognizing the reality of a variety of goods and deciding how best to protect or promote these in practical situations. Making prudential decisions in triage situations is essential. Sound triage protocols are necessary but not sufficient to achieve ethical outcomes because there is more to making ethical decisions than the mere application of standards. Health care professionals, especially Catholics, must strive to recognize and serve the good of each human person while working within the parameters of the clinical and legal standards.
• Need for charity. Catholics believe that God revealed the true nature of love through his Son, Jesus Christ, and empowers us to exercise a deeper form of love in union with him. First and foremost, charity is grounded in a relationship of life and love between the Christian and God. But Catholics are called and empowered to share this transcendent love with others. In the context of health care, while affirming the legitimacy of triage standards and the requirements of clinical care, charity can empower Christian health care professionals to engage in distinctive efforts to serve others or to promote their dignity in ways that others might miss.