State revises guidelines for who gets ventilators in crisis, following complaints about equity

Massachusetts has revised its guidelines for who should get lifesaving medical care if hospitals become overwhelmed by COVID-19 patients, a shift that comes in response to widespread concern that the state’s initial plan would allow more people from disadvantaged groups to die.

The guidelines, which are not mandatory, are intended to help shape the decisions hospitals would make if they do not have enough life-saving equipment, such as ventilators, to serve every patient in need.

An earlier version of the plan, developed with the help of medical experts from around the state, included provisions that took into account patients’ prospects for long-term survival. But those elements have been scaled back amid complaints that such distinctions would prioritize young people without underlying disabilities or health issues that often go hand-in-hand with socioeconomic and racial disadvantages.

The recommendations envision choices that doctors hope they never encounter, but that the crisis is pushing them to consider in advance.

Dr. Thea James, associate chief medical officer at Boston Medical Center, participated in the revision of the document. She said the medical system here has not faced such shortages yet, but “it certainly feels better having some guardrails in place in the event that we do need it.”

James added that she hopes the difficult conversations surrounding the document lead to a deeper understanding of the ways that social conditions can determine people’s health: “Maybe, in general, society will not try to get back to where it was but where it should be.”

The revisions leave in place a priority for medical professionals involved in delivering life-saving care, and they also give preference to women with viable pregnancies. In the event that patients’ circumstances are otherwise essentially equal, younger people are given priority.

In a statement, the state Department of Public Health said the recommendations “have been revised to reflect the direct input of stakeholders to develop guidelines that clarify concerns regarding equity and disparities.”

“The recommendations were created to prevent unconscious bias against people of color, people with disabilities and other community members who are marginalized,” the statement said. The department said the guidelines have not been needed, as the state’s hospitals have so far been able to stay ahead of the demand for critical care associated with the coronavirus pandemic.

The new guidelines emphasize patients’ short-term prospects of survival, and they remove discussion of “co-morbid” conditions that could affect the long-term chances of those who recover from COVID-19.

The discussion of those underlying conditions had been a particular area of concern for opponents, including a group of hundreds of front-line health care workers who sent a letter to the state following the release of the guidelines, arguing that the use of the guidelines would compound existing inequalities in the health care system.

Dr. Alister Martin, an emergency room doctor in Boston who was part of that group, said members believe the changes have improved the document. But he remains concerned about whether hospitals will carry them out consistently.

He pointed to a provision that would allow medical decision-makers to take into account a patient’s survival for up to five years, which he believes would still disadvantage people with existing conditions.

“These social determinants of health are still very much going to drive who’s going to get a ventilator and who’s not going to get a ventilator,” Martin said.

Colin Killick, executive director of the Disability Policy Consortium, an advocacy group, said the revision makes a “genuine effort” to tell providers to avoid bias. But he also worries about the five-year time frame.

“Emergency room staff, in the middle of a crisis, with limited access to diagnostic tools and time, are going to be asked to determine somebody’s life span at that kind of scale,” he said. “I don’t know how you avoid falling back on stereotypes and on broad assumptions based on somebody’s diagnosis rather than their individual case.”

Dr. Lachlan Forrow, director of ethics and palliative care at Beth Israel Deaconess Medical Center and a member of the committee that has been working on the guidelines, said the five-year window is an attempt to avoid grim outcomes such as the choice about whether to save someone who has a terminal illness, but whose death may not come within a year.

Without a measure discussing five-year survival, the guidelines could mean “that we would give a ventilator to that person equally to a person who has a 30-year life expectancy,” Forrow said. “That just seemed wrong.”

Also Monday, the state issued an order that a Department of Public Health official said requires “mandatory reporting, oversight and monitoring of any hospital that implements crisis standards of care as well as the convening of an advisory group to advise on disparities and inequities.”

State Representative Jon Santiago of Boston, an emergency room doctor who had also criticized the initial guidelines, said he is pleased by the revision.

“It’s a promising development on an issue that I think has been sorely neglected, and that’s health equity across race and class,” Santiago said.

Liz Kowalczyk of the Globe staff contributed to this report.