The early days of the coronavirus pandemic brought a terrifying question into the minds of health leaders across the country: What happens if the virus overwhelms the nation’s health care system?
What happens if there’s not enough resources to treat everyone?
The question forced states to grapple with the concept of “crisis standards of care” — the protocols and mechanisms in place to triage patients and decide which ones receive life-saving care and which ones don’t.
Now more than a year and a half into the pandemic, a few states and hospitals have actually had to put those plans into place across the country as they are swamped by the surge of the virus’s delta variant. But Dr. Matthew Wynia, director of the Center for Bioethics and Humanities at the University of Colorado Anschutz Medical Campus, says the standards should have been used more widely during the pandemic.
Wynia is a national expert on formulating crisis standards of care. He was instrumental in helping Colorado to rewrite its crisis standards during the early weeks of the pandemic, and he has also provided guidance to states and hospitals nationwide.
His biggest surprise? That, despite having plans in place, states have often been slow to activate them when hospitals are strained — meaning the kinds of ad-hoc triage decisions that crisis protocols are designed to prevent have been happening anyway.
The Sun spoke with Wynia to hear how crisis standards of care have worked during the pandemic and what he has learned to make them better in the future. The following Q&A has been lightly edited for length and clarity.
Q: Let’s start with the basics. What are crisis standards of care?
A: The short answer is crisis standards of care are the protocols and strategies that you adopt when there are far too many people needing resources and not enough resources to go around. It derives from military triage, battlefield triage, and under normal standards of care, we don’t do that in American medicine. If you need something, within normal bounds, people get what they need, even if they can’t pay for it, usually.
But in a major hurricane, in a mass shooting, in a pandemic, where you have many people showing up at the hospital all at the same time, many people needing the same resources, you may have to make decisions about who gets those life-saving resources and who does not. With crisis standards of care, the general rule is you’re trying to use your limited resources to save as many people as you can.
Q: You mentioned these are often used for critical events — horrible things that are ultimately relatively short-lasting.The pandemic is unique in that it’s been a critical event happening every day for the last 19 months. Have crisis standards of care ever been used in this kind of sustained way before?
A: The examples that we had prior to the pandemic are major natural disasters that were entirely, really, in other countries. So the Haiti earthquake. There were crisis standards of care in operation there for many weeks afterwards, and many of the triage decisions there had to do with, “Is this someone who could be evacuated?” But also there, in some ways, similar problems. For example, there were places in Haiti where there were not enough oxygen canisters for all the people who needed oxygen. And so decisions had to be made about, “Where could we give this person half as much oxygen as you normally would, so that we can get some to this other person?”
Q: Crisis standards are currently being used at hospitals in Alaska and Idaho. Were there any places that implemented them previously in the pandemic?
A: Well, so there are two ways to answer that question. One is, there were two states where crisis standards were authorized: Arizona and New Mexico. And in both instances, the state basically said, “If you need to, you can do these triage protocols.” But they were not required. No one said, You have to set up a triage team. You have to do load balancing across different hospital systems.”
(Ed. note: One hallmark of crisis standards of care plans are triage systems where decisions about allocating resources for patients are made by high-level teams following a neutral formula, not doctors at the bedside. Another hallmark is a system to help transfer patients between full hospitals and those that have space.)
So those things were all kind of ad hoc, they weren’t organized by those states. And when you go to those states and talk to the hospital administrators, they will all say, “Oh, no, we never got to a point where we actually had to do triage.” When you talk to the doctors in those hospitals, they say, “Yeah, we never really set up the system. But of course we had to do triage.”
Triage is not something you decide you want to do. It’s something that’s forced upon you, right? It’s not a choice. It’s where there are more people who need something than you have of it. And so you have to decide who’s going to get it. But you can’t decide not to do triage.
So, that’s one way to answer it is, yes, there were a couple states, but that they never really formally fully implemented all the strategies of crisis standards of care because they sort of turned it over to the hospitals.
Q: What’s the other way to answer the question?
A: The other way to answer that is there were many places that were actually operating under crisis standard of care, that were doing triage. They were not just in those two states, but certainly in Florida, certainly in New York, certainly in California. There were multiple places where medical systems and doctors were deciding who gets what, when there wasn’t enough to go around. But they weren’t doing it with state declarations.
Q: Is that a strength of the system, that kind of flexibility? Or is that a failure of the system that the states weren’t authorizing these protocols and implementing them in a more organized way?
A: I think it’s an absolute failure of the system. And I should be clear here because it’s not a failure of the crisis standards of care idea. It’s a failure to actually implement the idea. That is what we should have done, right?
We should have had load balancing across multiple institutions; we should have had triage teams rather than having a surgeon at the bedside making these decisions. You want the doctor at the bedside to be able to serve as the advocate for their patient, not to be the one who has to decide which of their three patients is going to go to the intensive care unit and the others we’re just going to keep on the floor and do the best we can.
But in fact, that’s what happened because people did not implement triage teams, they did not implement load balancing mechanisms across a region or state. And, when this first happened in Alaska and in Idaho, we saw the same unfortunate dynamic. In Alaska, it was a hospital system that said, “We have to do this, whether we’re authorized to or not. We are being forced into this situation.” And then a few days later, the state came on board and said, “Oh, yeah, you’re right, you should.”
You should have some structure for this. So to me that’s a failure. It means that people were unwilling to make the declaration and to start implementing the strategies in a timely way.
Q: What should these states have done?
A: If you are looking like you’re about to have to do triage, you should be implementing these strategies in advance. Not withholding services, but you should pull your triage team together in advance; you should be creating the load balancing mechanisms across systems. And that really has to be done at the state level. No single hospital has the capacity to do that. And the biggest ethical failure is if you’ve got a doctor in one hospital saying, “I’m sorry, I don’t have an ICU bed for you” and you end up having to die because you can’t get the intensive care that you need when there was an ICU bed available but it was six miles away at a different hospital.
Q: Has that happened during the pandemic?
A: I don’t have a specific name of a person to tell you but, yeah, of course that happened. Because that’s inevitable when it’s uncoordinated.
Q: How much of this is a lack of organization and how much of this is wishful thinking on the part of the states just hoping that cases will go down before the worst happens?
A: I’m pretty sure it’s both, and there are probably other factors as well. Some of it is hopeful thinking that things aren’t going to keep getting worse. And you hear this in the language that people use. They say the health care system is “fraying,” or it’s “on the edge.” When, in reality, the health care system has been, frankly, broken and overrun. And instead of acknowledging that, what people want to say is “Boy we are really close to the edge here.”
To some extent I think those euphemisms probably harm us rather than being very blunt. Which, by the way, that’s what I admired about the Alaska system. They were very honest. They said look, “We aren’t fraying at the edges. We are overrun right now. It’s not failing; it has failed.”
The other stories are a number of examples now of people who have died because they had a treatable illness but nowhere to treat them. The veteran in Texas was the first one that I became aware of but there have been a number of similar stories where people, under normal circumstances, would have been admitted, they would have had their surgery, they would have gone home. But there were no beds available and you have these outlying hospitals calling around searching for a bed for their patient and all the other hospitals are saying, “Sorry, we’re full right now.”
That’s a failure of the system to allocate resources appropriately because those were people with very high success rates for their surgeries, they should have gone right to the top of the list, they should have been moved. But because you don’t have a centralized system to do that, you’ve got individual doctors making dozens of phone calls, trying to find someplace willing and able to take their patient.
That’s a failed system. In a circumstance like this, there needs to be some kind of central triage mechanism where you call that number and you say, “This is what’s going on with my patient,” and they say, “Okay, I’ll call you back in 15 minutes and tell you what we can do.”
Q: You’ve spent a lot of your career developing the ethical framework for crisis standards of care. What has surprised you most as they’ve been put into use during the pandemic?
A: There are definitely things that I did not expect, even though they are in some ways, exaggerations of things we knew. It’s not that we had no idea that there would be political challenges to getting declarations that would prompt people to start using these kinds of strategies for resource allocation. We knew that it would be chaotic. We knew that there would be some political pressure to not admit how bad things are. No governor wants to be the one who says, “I decided not to put your grandmother on a ventilator.”
These are terrible decisions, and so they roll downhill. They go to the person who can’t say, “No, I refuse to make that decision.” Which means they go to the doctor at the bedside, even though we’ve known for a long time that that’s not the right person to make those decisions. Ethically, it’s not the right person. And practically, the doctor at the bedside usually doesn’t have the necessary situational awareness to make really good triage decisions in terms of using resources optimally. You need to have a team with good situational awareness. And that team at your hospital needs to be in conversation with the team at the other hospitals. And everyone needs to be in conversation with a system-wide or a statewide team that’s looking across the whole state at where resources are and how to move things to where they’ll provide the most benefit.
But the higher up you go, the closer you get to the governor having to say, “Yeah, I approved the rules that led to your grandmother not getting a ventilator.” We knew that was going to be hard. I did not realize how difficult it was going to be.
Q: Any other big lessons for you?
A: These decisions are really nuanced. We used as our model for talking about these things, the idea of ventilators. The paradigm that we used was one ventilator for one person, and if you have three people who need a ventilator and only one ventilator, you’re going to have to decide who gets that ventilator.
But most resources are not like ventilators. Most resources are like a dialysis machine or a pill, which you could cut the pill in half or you can give the person less oxygen and maybe have some oxygen leftover for this other person. Or you could put someone on dialysis but only two days a week instead of three days a week. And that might allow you to stretch your dialysis capacity.
A lot of resources are stretchable. And the issues around how to stretch scarce resources in a way that is least dangerous is something that I think we’ve learned a lot about during this pandemic. And that’s something that we will take into the future is that these protocols probably need to be a lot more detailed.
Q: That sounds like a ton of work. Wouldn’t you have to have guidance for individual medicines — it’s OK to split this pill; it’s not OK to split this one? Is that asking too much during a pandemic when things can change very fast?
A: Well, the answer is you do the best you can, knowing it’ll never be perfect, and that you’ll always be learning more. But isn’t that the lesson of the whole pandemic? You do the best you can with the information you have at the top, knowing that you’re going to be integrating new information. And your moral obligation is to learn as fast as you can along the way. You don’t have a moral obligation to be perfect at the outset. You do have a moral obligation to learn as quickly as possible from what you’re doing.
Q: So it sounds like you are optimistic that we can do this better when the next pandemic or disaster comes around?
A: Undoubtedly, we are in a better place today than we were in early spring of 2020. Many, many more people have thought about these issues.
In 2018, we rewrote the Colorado crisis standards of care protocols. And at the time that this was being done, we actually tried to have these meetings all around the state to talk to stakeholders about these issues. And it was essentially impossible to get people to show up for the meetings. People didn’t want to didn’t want to think about it. It’s a depressing thing. We would hold these community meetings and you get a couple EMTs and a couple of nurses, and that’s who would show up. No, sort of general public. It was hard to get the general public engaged in questions about how we would perform triage if we had a pandemic before we had a pandemic. Now that we have a pandemic, I think we actually have a lot of opportunity to have these conversations with the public.
Q: Silver lining, I guess?
A: There will be silver linings for this. They will be hard to see. But we will come out of it somehow with new information and with new knowledge. And hopefully with new understanding and attitudes, including about some of the things that we think we’re doing the worst on right now, in terms of social cohesion and mutual trust and understanding of where people are coming from. I think all of those things, having a crisis like this, both exacerbates them and causes you to examine them and figure out how to move forward a little better.