It’s prudent to prepare for a crisis — to anticipate worst-case scenarios, to develop a plan of action that will ensure survival in the face of catastrophe. In the event of a tsunami, earthquake or severe power outage, we are encouraged to have emergency food, water and other supplies on hand, ready to use if necessary. Being proactive produces level-headed, thoughtful, consistent responses more often than reacting to the immediacy of the crisis.
The COVID-19 pandemic forcibly pushed our health care system against a wall of uncertainty, a crisis of health care in an island state that cannot call upon additional resources nearby for help. With limited hospital resources approaching critically low levels across Hawaii, hospitals needed a plan ready to implement just in case demand — the number of COVID-19 patients — exceeded supply — beds, respirators and medical equipment.
In mid-September, the state Department of Health posted on its website a 37-page document, Hawaii’s Crisis Standards of Care, Triage Allocation Framework. Medical specialists spanning the spectrum of health care developed “a living document, intended to be updated and revised to reflect timely advances,” according to the posting.
This document is not an easy read for a lay person. The plan serves as a tool guide for medical professionals to prioritize triage (critical) care using an evaluation process. It involves a computer algorithm which calculates multiple health factors of individual patients diagnosed with COVID-19, along with projections of their responses to levels of treatment. The algorithm assigns scores to rank patient outcome and survival.
On page 19 of the plan, age trumps the algorithm as a factor to determine who gets the care.
Paragraph 8(b) under the section, “Difficult Decisions or Tie-breakers,” reads as follows:
Age is used only in a tie-breaking situation. Evidence from multiple countries including the U.S show that age >65 yo (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 >65 who is also COVID-positive is less likely to benefit from the scarce resource.
This section raises several questions and troubling concerns.
First, what is the likelihood of a triage score between two individuals being equal?
Second, how can age be used in a tie-breaker situation when federal law prohibits age discrimination?
Third, in the sole state with the highest life expectancy nationwide at 81.3 years old, why are we using evidence from elsewhere — that is, “multiple countries including the U.S.,” as an indicator for poor prognosis here?
Since the initial posting of the Triage Allocation Plan, the health care landscape has dramatically improved from critical to stable. For now, the possibility of having to implement this guide is on hold. Let’s take advantage of the downtime to revisit and update the plan for everyone’s benefit.
The Policy Advisory Board for Elder Affairs (PABEA) has reached out to the State and the Core Development Team (the triage allocation plan authors) to respectfully submit revisions to the current plan that reference age bias and life cycle considerations. At the top of our recommendations is the deletion of Section 8(b) using >65 as a tie-breaker to determine patient care in a critical situation.
Moreover, we strongly urge that a renewed discussion to update the plan has additional seats at the table for gerontologists and/or geriatric specialists to participate in this vital effort.
The time to do that is now.
In Hawaii, honoring, respecting and treating our elders, our kupuna, with dignity is what defines us as a statewide community. It’s a social construct whose meaning is understood without words. Aloha, rather than age, should trump an algorithm.
Roberta Wong Murray, of Kailua-Kona, is vice chair of the Policy Advisory Board for Elder Affairs (PABEA), comprised of volunteers who advocate for Hawaii’s kupuna.
