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Farrell TW, Ferrante LE, Brown T, Francis L, Widera E, Rhodes R, Rosen T, Hwang U, Witt LJ, Thothala N, Liu SW, Vitale CA, Braun UK, Stephens C, Saliba D. AGS Position Statement: Resource Allocation Strategies and Age-Related Considerations in the COVID-19 Era and Beyond. J Am Geriatr Soc 2020; 68:1136-1142. [PMID: 32374440 PMCID: PMC7267615 DOI: 10.1111/jgs.16537] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 04/30/2020] [Indexed: 01/14/2023]
Abstract
Coronavirus disease 2019 (COVID-19) continues to impact older adults disproportionately, from severe illness and hospitalization to increased mortality risk. Concurrently, concerns about potential shortages of healthcare professionals and health supplies to address these needs have focused attention on how resources are ultimately allocated and used. Some strategies misguidedly use age as an arbitrary criterion, inappropriately disfavoring older adults. This statement represents the official policy position of the American Geriatrics Society (AGS). It is intended to inform stakeholders including hospitals, health systems, and policymakers about ethical considerations to consider when developing strategies for allocating scarce resources during an emergency involving older adults. Members of the AGS Ethics Committee collaborated with interprofessional experts in ethics, law, nursing, and medicine (including geriatrics, palliative care, emergency medicine, and pulmonology/critical care) to conduct a structured literature review and examine relevant reports. The resulting recommendations defend a particular view of distributive justice that maximizes relevant clinical factors and deemphasizes or eliminates factors placing arbitrary, disproportionate weight on advanced age. The AGS positions include (1) avoiding age per se as a means for excluding anyone from care; (2) assessing comorbidities and considering the disparate impact of social determinants of health; (3) encouraging decision makers to focus primarily on potential short-term (not long-term) outcomes; (4) avoiding ancillary criteria such as "life-years saved" and "long-term predicted life expectancy" that might disadvantage older people; (5) forming and staffing triage committees tasked with allocating scarce resources; (6) developing institutional resource allocation strategies that are transparent and applied uniformly; and (7) facilitating appropriate advance care planning. The statement includes recommendations that should be immediately implemented to address resource allocation strategies during COVID-19, aligning with AGS positions. The statement also includes recommendations for post-pandemic review. Such review would support revised strategies to ensure that governments and institutions have equitable emergency resource allocation strategies, avoid future discriminatory language and practice, and have appropriate guidance to develop national frameworks for emergent resource allocation decisions. J Am Geriatr Soc 68:1136-1142, 2020.
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Affiliation(s)
- Timothy W Farrell
- Division of Geriatrics, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA.,VA SLC Geriatric Research, Education, and Clinical Center, Salt Lake City, Utah, USA.,University of Utah Health Interprofessional Education Program, Salt Lake City, Utah, USA
| | - Lauren E Ferrante
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Teneille Brown
- Center for Law and the Biomedical Sciences, University of Utah S.J. Quinney College of Law, Salt Lake City, Utah, USA.,Program in Medical Ethics and Humanities, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Leslie Francis
- University of Utah S.J. Quinney College of Law, Salt Lake City, Utah, USA.,Department of Philosophy, University of Utah, Salt Lake City, Utah, USA
| | - Eric Widera
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.,San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Ramona Rhodes
- Division of Geriatric Medicine, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA.,Central Arkansas Veterans Healthcare System, Geriatric Research, Education, and Clinical Center, Little Rock, Arkansas, USA
| | - Tony Rosen
- Department of Emergency Medicine, Division of Geriatric Emergency Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York, USA
| | - Ula Hwang
- Department of Emergency Medicine & Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research, Education and Clinical Center, James J. Peters VAMC, Bronx, New York, USA
| | - Leah J Witt
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.,Division of UCSF Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Niranjan Thothala
- Hospitalist Division, Department of Medicine, Good Samaritan Hospital, Vincennes, Indiana, USA.,Hospitalist Division, Department of Medicine, Union Hospital, Terre Haute, Indiana, USA
| | - Shan W Liu
- Department of Emergency Medicine, Division of Geriatric Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Caroline A Vitale
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.,VA Ann Arbor Geriatric Research, Education, and Clinical Center (GRECC), Ann Arbor, Michigan, USA
| | - Ursula K Braun
- Section of Geriatrics and Palliative Medicine, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.,Rehabilitation and Extended Care Line, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | | | - Debra Saliba
- UCLA Borun Center for Gerontological Research, Los Angeles, California, USA.,VA Los Angeles Geriatric Research Education and Clinical Center, Los Angeles, California, USA.,RAND Corporation, Santa Monica, California, USA
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Boldt J, Schöllhorn T. [Ethics and monetary values. Influence of economical aspects on decision-making in intensive care]. Anaesthesist 2009; 57:1075-82; quiz 1083. [PMID: 18825352 DOI: 10.1007/s00101-008-1443-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Healthcare expenditure continues to grow and the demand for cost-cutting measures has increased. Critical care medicine is characterized by extremely high expenditure and thus appears to be a suitable candidate for rationing. Based on the hospital address book of Germany, a questionnaire consisting of 25 multiple choice questions was sent out to 1,000 intensive care units (ICU). The questionnaire was focused on obtaining information on whether and how rationing takes place in Germany. A total of 540 questionnaires were returned and analyzed. Only approximately 25% of intensive care units stated that a special budget is available. Approximately 59% answered that therapeutic decisions were never or rarely influenced by economic reasons, but in 9% economics often influenced decisions. Advanced age was not considered to be a reason to limit the use of extremely expensive medication or the use of renal replacement therapy (RRT) in 88% of the answers. Incurable cancer was also no reason to refuse RRT (91%). For 35% of the answers there were no contraindications for admission to intensive care, whereas for 35% an incurable disease was a contraindication, for 10% a non-resuscitation order and for 84% the patients' wishes played a decisive role. Of the intensive care units 67% were convinced that rationing is a matter of fact in ICUs in Germany and 53% were of the opinion that rationing should not occur. Of the answers 43% considered that limiting ICU therapy would be the best when rationing is necessary. Rationing therapy in critical care appears to occur daily in German ICUs. Due to the high costs, intensive care therapy will represent a very important battleground in the inevitable healthcare spending limitations of the future. Rationing cannot be determined exclusively by ICU doctors, thus clear and probably unpopular decisions on this issue are expected to be announced by the politicians.
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Affiliation(s)
- J Boldt
- Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum der Stadt Ludwigshafen gGmbH, Bremserstr. 79, 67063 Ludwigshafen, Deutschland.
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