Hawaii is not yet rationing health care, but patients 65 and older could be denied medical assistance under certain provisions of the state’s “crisis standards of care” plan if the current COVID-19 surge escalates.

The state Department of Health on Saturday reported 836 new COVID-19 infections and 12 deaths, with 404 people hospitalized with the virus.

If conditions worsen, Hawaii could find itself in the same situation as other states such as Idaho, where public health leaders last week enacted a “crisis standards of care” plan and are now rationing health care at the state’s northern hospitals.

It’s unclear exactly what a similar situation would look like here since Hawaii’s “crisis standards of care” plan has not been made public. However, a copy of the plan has caught the critical eye of senior advocacy groups such as AARP Hawaii.

On Sept. 1, Hawaii Gov. David Ige quietly signed an order releasing health care facilities and health care workers from liability if they have to ration health care. Ige’s order referenced the crisis standards of care plan but did not provide the guidelines.

An August 2020 version of Hawaii’s plan obtained by the Honolulu Star-Advertiser indicates that “if there are not enough resources to provide to all patients within a priority group, younger patients will be prioritized.”

“Age is used only in a tie-breaking situation,” the plan reads. “Evidence from multiple countries including the U.S. show that age (greater than 65 years old) is an indicator for poor prognosis in COVID-19 patients. If the triage score is equal between two individuals, the Triage Officer/Review Committee should use the consideration that a patient (greater than 65 years old) who is also COVID-positive is less likely to benefit from the scarce resource.”

DOH Director Dr. Elizabeth Char said in a statement to the Star-Advertiser that Hawaii’s Crisis Standards of Care Triage Allocation Framework is part of the state’s effort to plan for COVID-19 worst-case scenarios in the event there are not enough medical resources for everyone.

“It is a tool to help provide the best care and most dignity to every single person needing medical care,” she said.

Char said the framework was developed last year by 21 Hawaii physicians representing health care systems across the state “after extensive and thoughtful review of evidenced-based medicine around the nation.”

She said the group, which was appointed by hospital leadership, “also obtained input from critical care providers, ethics consultants, pharmacists, respiratory therapists, hospital leadership, state disabilities leadership and palliative care specialists.”

“Consistent with practice around the nation, age is not an independent factor in decision making,” she said. “There is one exception that involves life cycle considerations only as a tie breaker when everything else is equal, specifically for COVID-­­19, because the prognosis of people with COVID-­19 in evidenced-­based medicine is tied to age. For other conditions, there is no metric for age as an independent factor.”

Officials said in the framework they would enact it only “if critical care capacity is, or will shortly be, exceeded, or a regional-level authority has declared a State of Emergency.”

State officials have said the goal and focus of the entire health care system across the islands is on stopping the spread of COVID-19 and ensuring Hawaii hospitals are able to provide the highest level of care for every patient.

Hawaii seniors also were prioritized in Hawaii’s COVID-19 vaccination plan, and DOH statistics show that nearly 100% of residents 65 and older are fully vaccinated, which has resulted in a lower hospitalization death rate for Hawaii’s elderly versus last year.

The Healthcare Association of Hawaii declined to comment on Hawaii’s crisis standards of care plan, and referred questions to the Health Department. The Star-Advertiser asked a copy of the plan Friday but was told that it was not available.

Drawing scrutiny

Keali‘i Lopez, state director of AARP Hawaii, is among the critics of the plan and the lack of transparency surrounding it.

“We are concerned because the governor made reference to that document and we had hoped that the document was readily available,” she said. “Ideally the document would have been part of (the governor’s) executive order.”

Lopez said AARP also is concerned that Ige’s legal immunity order also covered nursing homes, which she said should not be in the same triage situations as hospitals.

AARP said problems with infection control and mistakes at Hawaii’s nursing homes earlier in the pandemic also are a good reason to exclude them.

Lopez said officials must provide transparency in regard to crisis care plans, which differ from state to state. She said residents and visitors across Hawaii have a right to know how health care providers will make decisions about their care, especially since the plan has an appeals process.

Lopez said Hawaii’s health care rationing plan should remove age from consideration just as it has removed other factors such as race, ethnicity, gender, sexual orientation, disability status, limited English proficiency, perceptions of societal worth, immigration status, religion, insurance status, and socio-economic and housing status.

She said AARP believes the Hawaii plan’s choice to single out those 65 years and older seems arbitrary. She said the organization believes that important health care decisions should be guided by “current science and the prognosis and clinical needs of individual patients,” not by “age bias.”

AARP succeeded in getting California’s Department of Health to remove age-­related rationing from its crisis standards of care guidelines. The organization said California also modified its guidance to call on health care workers to receive training on “avoiding implicit bias, respecting disability rights, (and) diminishing the impact of social inequalities on health outcomes.”

AARP state offices in Arizona, New Jersey and Texas also have questioned the use of age as a criteria for determining care.

Lopez said Hawaii’s plan, which also might be applied in mass disasters such as hurricanes, tsunamis and terrorist attacks, is drawing similar scrutiny from AARP.

Larry Geller, a member of the senior advocacy group Kokua Council, said he would oppose any plan that was not based on consideration of “the general health situation of both patients.”

“I would oppose this the way that it is stated. An older person with the vaccination in general good health is more likely to survive than a younger person without the vaccination who is experiencing major symptoms,” said Geller, who was speaking for himself.

The Centers for Disease Control and Prevention said Friday that a new study showed that as the delta variant surged in early summer, the unvaccinated were 4.5 times more likely than the fully vaccinated to get infected, over 10 times more likely to be hospitalized and 11 times more likely to die.

Geller, like AARP, also was concerned Hawaii hasn’t been transparent enough about how it intends to make critical health care decisions if the current situation deteriorates into a crisis.

Lt. Gov. Josh Green, who is an emergency room physician, agrees the state’s crisis standards of care plan should be made public and said he does not support rationing care “under any circumstance.”

Green acknowledges that COVID-19 has strained health care in Hawaii and elsewhere, but said avoiding rationing is “purely a function of whether you are willing to invest in enough extra services during a crisis.”

Green said he’s glad people are debating Hawaii’s plan and is considering hosting a public forum to promote further discussion.

“I reject it personally because I think there are other ways to find the resources,” he said. “We still haven’t scratched the surface of redirecting financial resources if necessary to save lives. We’ve relied on FEMA, but we have not used our own monies yet for such a crisis. Standing by and allowing cases to go up when you can do other things is not a solution.”

Green recommends increasing options for care by empowering student nurses, hiring traveling nurses from the mainland and other countries, and expanding services at facilities that are currently unoccupied.

He also favors taking more aggressive steps to reduce community spread of COVID-19 such as allowing fewer gatherings, reducing the size of gatherings and implementing short “safer-at-home” periods like the 72-hour pause he had recommended for the Labor Day holiday weekend.

“I was personally shocked that (rationing health care) was floated rather than many of these other proposals first because it scares people, and it’s not ever something that we should ever really let happen,” he said.

Protecting kupuna

Waikiki resident Kathryn Henski said the fear is real. Henski said she glimpsed the horrors that Hawaii could face from watching her 94-year-old father Don Stark’s losing battle with COVID-19 in Florida, where hospital patients with illnesses that weren’t contagious were being treated in hallways.

Henski said her father caught the virus from an asymptomatic worker in his assisted-living facility during a period when it had been locked down to protect the patients.

“I wouldn’t give nursing homes immunity because if you are going to bring the disease into the facility, why do you get a free ride?” Henski said.

Henski said it’s unconscionable for Hawaii to put doctors and health care workers in a situation where they are “playing God.”

“My father died from COVID, and I can’t imagine how much worse it would have been if they had denied him care.”

Moreover, Henski said, implementing a health care rationing plan that discriminates against Hawaii’s kupuna is not in keeping with local values.

“If you look at the history of Hawaii, it was the elderly that passed on the information. And now, we are just going to let them die. There’s no excuse for that,” she said. “You’ve earned your place in life, and if you survived this long you should have the right to survive longer. There’s no reason for you to be cast aside like a piece of garbage.”

Hawaii Crisis Standards of Care Triage Allocation Plan and FAQs by Honolulu Star-Advertiser on Scribd