Rationing Limited Healthcare Resources in the COVID-19 Era and Beyond: Ethical Considerations Regarding Older Adults

Timothy W Farrell; Leslie Francis; Teneille Brown; Lauren E Ferrante; Eric Widera; Ramona Rhodes; Tony Rosen; Ula Hwang; Leah J Witt; Niranjan Thothala; Shan W Liu; Caroline A Vitale; Ursula K Braun; Caroline Stephens; Debra Saliba

doi:10.1111/jgs.16539

Rationing Limited Healthcare Resources in the COVID-19 Era and Beyond: Ethical Considerations Regarding Older Adults

J Am Geriatr Soc. 2020 Jun;68(6):1143-1149. doi: 10.1111/jgs.16539.

Authors

Timothy W Farrell^{1

2

3}, Leslie Francis^{4

5}, Teneille Brown^{6

7}, Lauren E Ferrante⁸, Eric Widera^{9

10}, Ramona Rhodes^{11

12}, Tony Rosen¹³, Ula Hwang^{14

15}, Leah J Witt^{9

16}, Niranjan Thothala^{17

18}, Shan W Liu¹⁹, Caroline A Vitale^{20

21}, Ursula K Braun^{22

23}, Caroline Stephens²⁴, Debra Saliba^{25

26

27}

Affiliations

¹ Division of Geriatrics, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA.
² VA SLC Geriatric Research, Education, and Clinical Center, Salt Lake City, Utah, USA.
³ University of Utah Health Interprofessional Education Program, Salt Lake City, Utah, USA.
⁴ University of Utah S.J. Quinney College of Law, Salt Lake City, Utah, USA.
⁵ Department of Philosophy, University of Utah, Salt Lake City, Utah, USA.
⁶ Center for Law and the Biomedical Sciences, University of Utah S.J. Quinney College of Law, Salt Lake City, Utah, USA.
⁷ Program in Medical Ethics and Humanities, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA.
⁸ Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA.
⁹ Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.
¹⁰ San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.
¹¹ Division of Geriatric Medicine, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA.
¹² Central Arkansas Veterans Healthcare System, Geriatric Research, Education, and Clinical Center, Little Rock, Arkansas, USA.
¹³ Department of Emergency Medicine, Division of Geriatric Emergency Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York, USA.
¹⁴ Department of Emergency Medicine & Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
¹⁵ Geriatric Research, Education and Clinical Center, James J. Peters VAMC, Bronx, New York, USA.
¹⁶ Division of UCSF Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, San Francisco, California, USA.
¹⁷ Hospitalist Division, Department of Medicine, Good Samaritan Hospital, Vincennes, Indiana, USA.
¹⁸ Hospitalist Division, Department of Medicine, Union Hospital, Terre Haute, Indiana, USA.
¹⁹ Department of Emergency Medicine, Division of Geriatric Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
²⁰ Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.
²¹ VA Ann Arbor Geriatric Research, Education, and Clinical Center (GRECC), Ann Arbor, Michigan, USA.
²² Section of Geriatrics and Palliative Medicine, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.
²³ Rehabilitation and Extended Care Line, Michael E. DeBakey VA Medical Center, Houston, Texas, USA.
²⁴ University of Utah College of Nursing, Salt Lake City, Utah, USA.
²⁵ UCLA Borun Center for Gerontological Research, Los Angeles, California, USA.
²⁶ VA Los Angeles Geriatric Research Education and Clinical Center, Los Angeles, California, USA.
²⁷ RAND Corporation, Santa Monica, California, USA.

Abstract

Coronavirus disease 2019 (COVID-19) continues to impact older adults disproportionately with respect to serious consequences ranging from severe illness and hospitalization to increased mortality risk. Concurrently, concerns about potential shortages of healthcare professionals and health supplies to address these issues have focused attention on how these resources are ultimately allocated and used. Some strategies, for example, misguidedly use age as an arbitrary criterion that disfavors older adults in resource allocation decisions. This is a companion article to the American Geriatrics Society (AGS) position statement, "Resource Allocation Strategies and Age-Related Considerations in the COVID-19 Era and Beyond." It is intended to inform stakeholders including hospitals, health systems, and policymakers about ethical considerations that should be considered when developing strategies for allocation of scarce resources during an emergency involving older adults. This review presents the legal and ethical background for the position statement and discusses these issues that informed the development of the AGS positions: (1) age as a determining factor, (2) age as a tiebreaker, (3) criteria with a differential impact on older adults, (4) individual choices and advance directives, (5) racial/ethnic disparities and resource allocation, and (6) scoring systems and their impact on older adults. It also considers the role of advance directives as expressions of individual preferences in pandemics. J Am Geriatr Soc 68:1143-1149, 2020.

Keywords: COVID-19; ethics; older adult; rationing; triage.

Publication types

Research Support, N.I.H., Extramural

MeSH terms

Aged
Aged, 80 and over
Betacoronavirus*
COVID-19
Coronavirus Infections*
Female
Geriatrics / ethics*
Health Care Rationing / ethics*
Humans
Male
Pandemics*
Pneumonia, Viral*
SARS-CoV-2
United States / epidemiology

Abstract

Publication types

MeSH terms

Grants and funding