New AGS Position Statement Addresses One of Health Care’s Most Difficult Issues: Allocating Scarce Resources in the COVID-19 Era

The COVID-19 pandemic has placed unprecedented pressure on societies worldwide, given the pandemic’s rapid and often deadly spread. In health care, the pandemic has raised the pressing question of how society should allocate scarce resources during a crisis. This is the question experts addressed in a new position statement published by the American Geriatrics Society (AGS) in the Journal of the American Geriatrics Society (doi:10.1111/jgs.16537). The statement focuses primarily on whether age should be considered when making decisions to allocate scarce resources. 

“A just society strives to treat all people equally, so there’s something particularly unjust about characteristics beyond our control—like age—determining whether we receive care,” explains Timothy W Farrell, MD, AGSF, who led the writing group responsible for the statement. “The AGS believes we must focus on the most relevant clinical factors for each person and case when considering how to distribute resources fairly without placing arbitrary weight on age.”

COVID-19 continues to impact older adults disproportionately when it comes to serious consequences, from severe illness and hospitalization to increased risk for death. Concerns about potential shortages of ventilators, hospital beds, and other supplies to address these shortages have focused attention on decision-making about who gets access to these resources. 

After reviewing existing frameworks, recommendations, and research, an expert panel of interprofessional experts, AGS leaders, and members of the AGS Ethics Committee devised seven principles aimed at helping develop strategies to allocate resources equitably when they remain in short supply:

1. Age should never be used as a means for categorically excluding someone from what is ordinarily the standard of care, nor should age “cut-offs” be used in allocation strategies.

2. When assessing comorbidities, decision makers should carefully consider the impact of race, ethnicity, and other “social determinants,” especially since these often are beyond a person’s control.

3. Strategies for making allocation decisions should primarily—and equally—weigh how severe comorbidities and survival in hospital might contribute to the short-term risk for death. This means that health professionals should focus primarily on what is most within their control: potential outcomes over the next 6 months (and not beyond, which could disproportionately impact care for older people).

4. In order to avoid bias in decision making, health professionals also should avoid criteria that might disadvantage us all as we age. These include characteristics such as:

• “Life years saved” (how many years could be added to someone’s life by treatment).
• “Long-term predicted life expectancy” (the long-term view of length of life from this point in time).

5. Committees and officers tasked with triage also need to be chosen carefully. Ideally, these individuals not only have expertise in medical ethics and geriatrics but also work outside “day-to-day” care so triage officers can maintain impartiality. 

6. Institutions should develop resource allocation strategies that are transparent and applied uniformly. Ideally, that means leveraging advanced planning and input from multiple disciplines, including ethics, law, medicine, and nursing. To make the work of an officer or committee transparent, institutions also should develop consistent strategies available to all for review. “Clinicians at the front lines should be applying—not selecting—emergency-rationing criteria when resources are limited,” the AGS position statement explained.

7. The COVID-19 pandemic highlights the critical importance of appropriate advance care planning (ACP). While engaging in these conversations early and often remains critical, they also never should be viewed as a form of rationing, nor should someone be compelled into documenting care preferences primarily because of a broader health crisis. ACP is most effective when it lives up to its name: a conversation in advance, planned with personal preferences at heart.

“Health care is unlike other ‘goods’ or services in that it’s a prerequisite for pursuing virtually every other opportunity that makes life meaningful,” summarized Dr Farrell. “Our position statement is aimed at recognizing resource allocation shouldn’t be a question of ‘if’ but rather how we can make decisions safely and smartly, making good on our societal commitment to treat all people fairly.”