key: cord-0693811-42ockyir
authors: Farrell, Timothy W.; Ferrante, Lauren E.; Brown, Teneille; Francis, Leslie; Widera, Eric; Rhodes, Ramona; Rosen, Tony; Hwang, Ula; Witt, Leah J.; Thothala, Niranjan; Liu, Shan W.; Vitale, Caroline A.; Braun, Ursula K.; Stephens, Caroline; Saliba, Debra
title: AGS Position Statement: Resource Allocation Strategies and Age‐Related Considerations in the COVID‐19 Era and Beyond
date: 2020-05-06
journal: J Am Geriatr Soc
DOI: 10.1111/jgs.16537
sha: dc774ed8970bc05f7e543f200a7491944d07ce7f
doc_id: 693811
cord_uid: 42ockyir

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, which inappropriately disfavors 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 de‐emphasizes 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.

framework of a just society with a specific focus on health care systems and reviewed legal considerations. We determined that it is important to include these three considerations in both this AGS position statement and in the companion manuscript.

The COVID-19 pandemic further highlights the widespread and urgent need for all adults to engage in advance care planning discussions and create an advance directive. Advance care planning discussions are of paramount importance to reduce the need to ration limited health care resources during an emergency because these discussions will identify people who do not wish to receive intensive care, including mechanical ventilation. A critical point in the discussion of advance care planning is that these discussions are not rationing and should not be confused with triage allocation decisions. Advance care planning discussions should occur before patients are in crisis and should be part of every patient's individualized care plan. 10,11 A conversation with older patients about what matters most to them 12 and their goals of care should not lead health care providers to incorrectly infer that simply having had a goals of care discussion signals a clear preference for limited interventions. Also, providers should be aware that care plans developed for anticipated longer term declines in health may not be applicable to sudden emergencies such as COVID-19, and it is inappropriate to infer from a do not resuscitate order that a particular patient would necessarily refuse mechanical ventilation. 13 Achieving Justice in Resource Allocation [14] [15] [16] A just health care system should treat similarly situated people equally, as much as possible. There is something particularly unjust about membership in a class, such as an age group, determining whether one receives health care. Not only is membership in a class defined by characteristics such as race, sex, or age, beyond the individual's control, but the use of these Accepted Article criteria might conceal implicit biases and other social inequities. As health care is critically important to many other goods in life across the life span, it may be distinct in terms of requiring equal access. These factors suggest that basing resource allocation decisions on advanced age may violate the ethical principle of justice.

Resource allocation strategies, such as those proposed in response to COVID-19, rely on different notions of distributive justice. There are many contested theories, and each theory claims to represent justice in the priority given certain factors or values when goods are distributed to society. This position statement defends a view of distributive justice that maximizes relevant clinical factors and either de-emphasizes or eliminates factors that place an arbitrary and disproportionate weight on advanced age.

The non-discrimination section of the Affordable Care Act, § 1557, prohibits discrimination in federally funded health care programs on the grounds prohibited by the Age Discrimination Act of 1975, 42 U.S.C. § § 6101-6107. The Age Discrimination Act applies to discrimination on the basis of age, which includes exclusion from, participation in, or denial of the benefits of, any program or activity receiving federal financial assistance. Allocation frameworks that use age as a categorical exclusion violate this provision of federal antidiscrimination law. Whether provisions of the Age Discrimination Act beyond identifying age as a category are also included by reference in § 1557 is an unsettled legal question, but if they are, they would permit age to be used as a proxy for some other characteristic, such as survivability, that is necessary to the statutory objective or to the business and that cannot practically be measured in an individualized way. The statute and implementing regulations would also permit use of reasonable factors other than age that have a disproportionate effect on persons of Accepted Article different ages, if the factor bears a direct and substantial relationship to the program's normal operation or statutory objective. 17 The legal question then would be whether factors such as longterm survival or life-years lived are reasonable factors other than age that meet this standard.

The AGS Ethics Committee is charged with ensuring that every older American receives high-quality, person-centered care by improving public and professional understanding of ethical and moral issues intrinsic in caring for older adults. The Committee developed these policy and clinical recommendations in collaboration with an interprofessional writing team of experts in ethics, law, nursing, and medicine (including geriatrics, palliative care, emergency medicine, and pulmonology/critical care). This team conducted a structured literature review and examined relevant reports and studies, which are outlined in the companion paper. 8

This statement represents the official policy position of the American Geriatrics Society.

It is intended to inform stakeholders including hospitals, health systems, and policymakers about ethical considerations involving older adults that should be considered when developing strategies for allocation of scarce resources during an emergency. The rationale for each position is provided in a companion paper 8 Accepted Article allocation method in emergency circumstances that require rationing due to a lack of resources. 4 . In order to avoid biased resource allocation strategies, criteria such as -life-years saved‖ and -long-term predicted life expectancy‖ should not be used, as they disadvantage older adults. 

Given the current and near-future implications of the COVID-19 pandemic, the AGS recommends the following strategies for immediate implementation. Given the urgent need to implement these strategies, we have included our rationale for each.

We recommend that institutions implement a multi-factor resource allocation strategy as the primary allocation method that equally weighs in-hospital survival and comorbidities contributing to short-term mortality (< 6 months), rather than implementing a resource allocation strategy based primarily on lifecycle principles. Age should never be used as a categorical exclusion; this violates the principle of justice and discriminates against older adults. Moreover, a robust body of literature demonstrates that chronological age alone is less predictive of mortality than other factors, such as functional trajectory 18 , multimorbidity 19, 20 , and frailty. 21, 22 Thus, age is a poor proxy for projected outcomes. Moreover, as discussed below, including chronic comorbidities unlikely to affect survival or 6 month mortality is ethically problematic. We recommend including only severe comorbidities likely to result in death over a short period of time, such as <6 months.

It is important to note that reliance on in-hospital survival as a strategy is not at odds with policies at many institutions that withhold care that offers no possibility of clinical benefit. The withholding of such futile care, although reducing resource use, is justified by the principle of beneficence that applies to persons of all ages.

In the event that resources are so constrained that emergency rationing must occur, and for circumstances in which consideration is given to withdrawing resources due to medical futility, -triage committees‖ and -triage officers‖ should be established and available around the Accepted Article clock to implement rationing strategies. These third parties, who are not members of the primary care team, could integrate objective considerations about decision making with rationing. Early initiation of these roles would alleviate moral distress among front-line clinicians. Being able to rely on a pre-existing rationing strategy allows them to focus on clinical care. Clinicians at the front lines should be applyingnot selectingemergency rationing criteria when resources are limited. In addition, transparent criteria developed by -triage committees‖ and -triage officers‖ can be systematically reviewed for their potential to cause differential impact on underrepresented groups.

States and health systems should communicate clearly and transparently about the ethical resource allocation strategies that are proposed and selected. Transparent communication is crucial in promoting greater adherence to these strategies. A clear description of legal and ethical accountability and responsibility regarding these policies is also needed. During the COVID-19 pandemic when information is changing rapidly, policies and chosen strategies should come from a centralized source for direct communication to healthcare providers and clinicians.

All older adults should be encouraged to develop individual care plans 24 that include information such as lists of medical conditions, medications, and health care providers, as well as advance directives. The Medicare Annual Wellness Visit is an ideal setting for health care providers to establish and update these individual care plans with patients and their caregivers.

Advance care planning must be prioritized both now and after COVID-19. The rate of advance directive completion is unacceptably low at about 50% of adults over age 60. 9 Medicare Accepted Article clinician's assessment of the patient's comorbidities and likelihood of survival following critical illness. 10, 25 Advance care planning discussions should be documented appropriately and clearly with reliable contact information for surrogate decision makers. Although less ideal, such discussions can also occur in the ED setting. Goals of care discussions should not attempt to dissuade patients from using a ventilator or focus on resource allocation generally, but rather should The shifting of outpatient care delivery (e.g. to telephone and virtual encounters) should include intensive outreach efforts in order to identify highly vulnerable patients (e.g. living alone, cognitively impaired) at high risk from the detrimental effects of social isolation and who, in the absence of intensive telephone or virtual outreach, would otherwise be less likely to engage in advance care planning.

In many cases, critical advance care planning discussions may need to be conducted with a surrogate who cannot be with the patient due to physical distancing (commonly referred to as social distancing) or facility visitation restrictions. These conversations can be appropriately performed as audio-only services. The Centers for Medicare and Medicaid Services (CMS) should allow payment for advance care planning that is provided via audio (telephone only) and extend changes to telehealth payment beyond the current emergency so that reimbursement is equivalent to in-person provision of advance care planning given the time-intensive nature of these discussions.

allocations created during the pandemic, and on developing and implementing ethical resource allocation strategies to be used when emergency rationing is required.

1. State and local governments and institutions should establish committees that include older adults to conduct a post-pandemic review of outcomes of emergency rationing strategies that were actually implemented. This review process should be conducted using de-identified data and should include results such as survival rates stratified by age group and comorbidities, with the goal of informing the development of a national framework that can guide institutions in developing decision-making strategies for resource allocation that are just and equitable.

2. Hospital ethics committees, state officials, and other relevant stakeholders should remove discriminatory provisions, including age-based cutoffs, which disfavor older adults from any resource allocation strategies including those that were developed during the COVID-19 pandemic.

3. Health care facilities and systems that did not develop and do not currently have a resource allocation strategy should develop an ethical framework or adopt an existing ethical framework that incorporates the principles described in this AGS position statement.

Emergency resource allocation strategies during the era of COVID-19, and during future pandemics, must not disproportionately disfavor older adults. Ideally, these strategies will be developed and integrated into institutional policies when an institution is not in crisis. When developing and implementing such strategies, key stakeholders including ethics committees, Accepted Article health care systems, and policymakers must not apply categorical age exclusions since such exclusions are unethical and violate anti-discrimination law. Ethical multi-factor resource allocation strategies exist that rely on in-hospital survival and severe comorbidities contributing to short-term (<6 month) mortality. Extreme care must be taken to consider the disparate impact on older adults of assessing comorbidities as part of resource allocation strategies, as older adults are heterogeneous with respect to burden of comorbidities and functional status. Racial and ethnic minorities are at even greater risk of the disparate impacts of assessing comorbidities in resource allocation strategies.

Moreover, our understanding of COVID-19 is rapidly evolving with respect to its pathophysiology, genetics, transmissibility, clinical trajectory, immune response, optimum management strategies, and individual and public health approaches. This incomplete understanding of the disease limits the ability to prognosticate about its clinical course and therefore makes the application of ethical frameworks even more difficult. Front-line providers should not be expected to make rationing decisions in isolation, and therefore must have guidance from clear, consistent, transparent, and uniformly applied ethical resource allocation strategies as well as triage officers and committees who have updated information about the availability of health care resources so that resource allocation strategies are not activated by hospital or health system leadership too early or too late. Now and in the future, intensive efforts to provide meaningful advance care planning must occur to ensure that patients' wishes are respected. Older adults would be well served by an intensive post-pandemic review of resource allocation strategies. As public health measures, creative use of resources, and shifting resources between states and communities become more commonplace, the need for rationing may be reduced or eliminated. When adequate resources are available, patient preferences for care Accepted Article

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