Faced with possible shortages due to COVID-19, many states updated or rapidly developed Crisis Standards of Care (CSCs) and other pandemic preparedness plans (PPPs) for rationing resources, particularly ventilators.
How have U.S. states incorporated the controversial standard of rationing by age and/or life-years into their pandemic preparedness plans?
Investigator-initiated, textual analysis conducted from April-June 2020, querying online resources and in-state contacts to identify PPPs published by each of the 50 states and Washington, D.C. Analysis included the most recent versions of CSC documents and official state PPPs containing triage guidance as of June 2020. Plans were categorized as rationing by (A) short-term survival (<1 year), (B) 1-5 expected life-years, (C) total life-years, (D) "fair innings," i.e., specific age cut-offs, or (O) other. The primary measure was any use of age and/or life-years. Plans were further categorized based on whether age/life-years was a primary consideration.
35 states promulgated PPPs addressing the rationing of critical care resources. Seven states considered short-term prognosis, seven considered whether a patient had 1-5 expected life-years, thirteen rationed by total life-years, and one used the fair innings principle. Seven states provided only general ethical considerations. Seventeen of the twenty-one plans considering age/life-years made it a primary consideration. Several plans borrowed heavily from a few common sources, though use of terminology was inconsistent. Many documents were modified in light of controversy.
Guidance with respect to rationing by age and/or life-years varied widely. Over half of PPPs, many following a few common models, included age/life-years as an explicit rationing criterion; the majority of these made it a primary consideration. Terminology was often vague, and many plans evolved in response to pushback. These findings have ethical implications for the care of older adults and other vulnerable populations during a pandemic.

Copyright © 2021. Published by Elsevier Inc.