Following several months of coordinated advocacy by CPR and an impressive, diverse group of stakeholders, Massachusetts released a third, revised version of its Crisis Standards of Care (CSC), memorializing critical changes intended to guard against the discriminatory allocation of scarce medical resources. CPR staff, joined by representatives of health equity, aging, racial justice and disability organizations, engaged in a months-long advocacy effort with the Baker Administration, seeking the development of comprehensive, anti-discriminatory crisis standards. More recently, CPR worked with the reconstituted CSC Advisory Committee to secure additional protections for Massachusetts patients should the triage process need to be invoked.
Among the most significant changes the CSC are: 1) the removal of intermediate prognosis (a prediction of life expectancy between 2-5 years) as a triage criteria; and 2) the elimination of age as a tiebreaker between similarly situated adult patients. Instead, patients with the same priority score will be assessed based on individualized medical evidence and their respective likelihood to survive the acute illness. The revised CSC also underlines important protections for patients with disabilities, clearly articulating facilities’ obligation to provide reasonable accommodations at all stages of the triage process, to guard against implicit bias and disability-based discrimination, and to avoid policies which steer or coerce patients and their families towards Do Not Resuscitate/Do Not Intubate orders.
Unfortunately, the CSC still calls upon triage teams to predict individual patients’ likelihood of death within one year – a process fraught with potential inaccuracy and vulnerable to bias assumptions – even under normal standards of care. Should a one-year prognosis be used to deprioritize a patient for life-saving care, two physicians must agree, and that prognosis must be based on individualized medical evidence. Any decision to deny or withdraw lifesaving treatment under the CSC can be challenged within the treating hospital, using an expedited appeal process. Although the CSC urges selection of a diverse triage team, and the provision of training on implicit bias in health care and triage decisions, it will be incumbent on individual hospitals and hospital systems to implement these provisions.
CPR and its partners will continue to monitor access to care during the pandemic, including any future invocation of Crisis Standards of Care. The revised Massachusetts CSC is available here and at: https://www.mass.gov/info-details/covid-19-hospital-capacity-and-surge-response.