Rhode Island hospitals are in crisis right now because of staffing shortages, with the winter COVID-19 uptick adding to the burden. Its largest health care system recently issued guidance for how to deal with that scarcity, underlining the ethical considerations of denying advanced care to patients who need it or withdrawing it to give it to someone else.
Lifespan’s chief clinical officer, Dr. Kenneth Wood, described these “modified standards of care” in an internal memo late last week that was obtained by the Globe. They differ from the first-come, first-served or “sickest first” strategies. They will often involve independent reviews, appeals and ethical consultations.
“The goal is to direct scarce resources to those patients who are likely to benefit the most,” Wood wrote Jan. 14.
He also said: “Our position remains that near-term prognosis for survival from the current illness is the fairest way to decide priority for distribution of scarce resources.”
Lifespan’s adult acute-care hospitals include Rhode Island Hospital and the Miriam Hospital, both in Providence, and Newport Hospital.
In an emailed response to a request for comment on this story, Lifespan didn’t directly address how often these “modified standards of care” are being used right now, and how often advanced care is denied or withdrawn due to scarcity. The memo said, though, there were times when demand for intensive care and other specialty services was outstripping supply.
“As is standard practice in emergency planning responses, Lifespan issued guidance to appropriate clinical staff for ethical decision making during a health crisis, so our medical teams can provide the best care possible to as many patients as possible when resources are limited,” Wood said in an emailed statement. “Modified standards of care are used only when absolutely required, and when implemented, follow a fair, transparent and accountable process that includes input from a multidisciplinary care team. Having to consider MSC (modified standards of care) is never something that a clinical team wants to do, and it weighs heavily on clinicians, as they want to always provide the highest level of care possible for all patients.”
But the fact these discussions are happening at a high level speaks to the precarious position that the state’s hospitals and their patients find themselves in. A top emergency doctor at Rhode Island Hospital described crisis standards in the ICUs and emergency department; Wood’s memo represents a formal advancement of that practical reality playing out in Rhode Island, while also incorporating ethical guidelines.
The state has not declared crisis levels of care statewide; Rhode Island’s crisis standards are available online.
Asked about how often these standards have had to be used, Lifespan spokeswoman Kathleen Hart said in an email:
“We have taken a number of steps to stretch our scarce resources including expanding nurse to patient ratios and placing patients who need ICU level of care in non-traditional ICU beds. Regrettably, we simply do not have the staff to care for all the patients who need our help. Our healthcare workforce is working tirelessly to find solutions each day to this unprecedented crisis. In response to appeals from hospital and state leadership, this week a team of military medical personnel arrives to provide much needed assistance in the units where they are most needed by our patients and staff members.”
Staffing shortages spurred by burnout and lucrative travel nursing jobs are forcing hospitals to close units even as waiting rooms overflow. The congestion is reverberating throughout the system, from the emergency departments where patients might spend hours or even days to the intensive care units that have lost a quarter of their capacity.
The COVID-19 wave of the winter of 2021-2022 added to the pressures that had been building for months. Though the COVID wave may be ebbing, hospitals will still face immense challenges.
Hospital leaders have acknowledged for weeks that they are not providing the same level of care they’re accustomed to. Wood’s memo Friday puts guidance behind that grim reality. Guidelines that promise perfect clinical and ethical decisions “would be difficult, if not impossible,” Wood wrote.
No single thing should determine which patients receive a scarce resource, Wood wrote; instead, “we aspire to an allocation process that is based on clinical efficacy and, if appropriate and time permits, validated assessment scores, that treats all patients similarly, and does not use scarcity to worsen health disparities.”
In cases where there’s a disagreement between clinicians over whether someone will get an ICU bed, for example, an emergency ethics team could be consulted. In any case where advanced care is denied due to scarce resources and some cases where advanced care is provided and later withdrawn, the hospital will conduct an independent review process. Decisions about withdrawing advanced care to reallocate scarce resources will require an independent physician and ethics adviser, with the ability to appeal those decisions, the memo said.