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Ethical dilemmas exist with decision-making regarding resource allocations, such as critical care, ventilators and other critical equipment, and pharmaceuticals during pandemics. Triage artificial intelligence (AI) algorithms based on prognostication tools exist to guide these decisions; however, implicit bias may affect the decision-making process leading to deviation from the algorithm recommendations. Conflict within the ethical domain may be affected as well. A knowledge gap was identified within the Adult-Gerontology Acute Care Nurse Practitioner (AG-ACNP) curriculum regarding ethics in crisis standards of care (CSC) medical decision-making. Incorporating a CSC simulation looked to address this knowledge gap. A simulation-based learning (SBL) experience was designed as a critical access setting where CSC are in place and three diverse, medically complex patients in need of critical care present to the hospital where one critical care bed remains open. Given the complexity of the simulation scenario, a table-top pilot test was selected. Three AG-ACNP fourthquarter students in their critical care rotation volunteered for the pilot test. Students were provided with the topic, "ethics crisis standards of care" and the article, "A catalogue of tools and variables from crisis and routine care to support decision-making during pandemics" by M. Cardona et al. (2021), to read in advance. Students were provided with the triage AI algorithm (M. Cardona et al., 2021) utilizing prognostication tools to prioritize which patient requires the critical care bed. The expectationwas that implicit biaswould enter the decision-making process, causing deviation from the triage AI algorithm and moral distress. The debriefing session revealed that students deviated from the triage AI algorithm, experienced implicit bias, moral distress, and utilized clinical judgment and experience to care for all three patients. The pilot test results support that a CSC SBL experience addresses a critical knowledge gap in AG-ACNP education and an SBL experience incorporating ethical decision-making curriculum with standardized patients should be developed and trialed as the next step. [ABSTRACT FROM AUTHOR]

Objectives: Here, we report the management of a catastrophic COVID-19 Delta variant surge, which overloaded ICU capacity, using crisis standards of care (CSC) based on a multiapproach protocol.Design: Retrospective observational study.Setting: University Hospital of Guadeloupe.Patients: This study retrospectively included all patients who were hospitalized for COVID-19 pneumonia between August 11, 2021, and September 10, 2021, and were eligible for ICU admission.Intervention: Based on age, comorbidities, and disease severity, patients were assigned to three groups: Green (ICU admission as soon as possible), Orange (ICU admission after the admission of all patients in the Green group), and Red (no ICU admission).Measurements and Main Results: Among the 328 patients eligible for ICU admission, 100 (30%) were assigned to the Green group, 116 (35%) to the Orange group, and 112 (34%) to the Red group. No patient in the Green group died while waiting for an ICU bed, whereas 14 patients (12%) in the Orange group died while waiting for an ICU bed. The 90-day mortality rates were 24%, 37%, and 78% in the Green, Orange, and Red groups, respectively. A total of 130 patients were transferred to the ICU, including 79 from the Green group, 51 from the Orange group, and none from the Red group. Multivariate analysis revealed that among patients admitted to the ICU, death was independently associated with a longer time between ICU referral and ICU admission, the Sequential Organ Failure Assessment score, and the number of comorbidities, but not with triage group.Conclusions: CSC based on a multiapproach protocol allowed admission of all patients with a good prognosis. Higher mortality was associated with late admission, rather than triage group. [ABSTRACT FROM AUTHOR]

Keywords: COVID-19; crisis standards of care; disaster; intensive care unit preparedness; surge; triage EN COVID-19 crisis standards of care disaster intensive care unit preparedness surge triage 148 150 3 12/19/22 20230101 NES 230101 In mid-2001, the Johns Hopkins Center for Health Security in conjunction with the National Security Council of the United States engaged in a table-top exercise to inform debate on the threat posed by biologic agents and to simulate challenges in decision making during times of healthcare strain. In this case, the system described for access to an ICU bed applied only to patients with COVID-19, and there were significant numbers of non-COVID-19 patients competing for the same beds. During the study period, patients were assigned to one of three color-coded ICU admission priority groups based on age, comorbidities, and disease severity: green - ICU admission as soon as possible; orange - admission after all patients in green were admitted; and red - no ICU admission. [Extracted from the article]

Objectives: The coronavirus disease 2019 pandemic has overwhelmed healthcare resources even in wealthy nations, necessitating rationing of limited resources without previously established crisis standards of care protocols. In Massachusetts, triage guidelines were designed based on acute illness and chronic life-limiting conditions. In this study, we sought to retrospectively validate this protocol to cohorts of critically ill patients from our hospital.Design: We applied our hospital-adopted guidelines, which defined severe and major chronic conditions as those associated with a greater than 50% likelihood of 1- and 5-year mortality, respectively, to a critically ill patient population. We investigated mortality for the same intervals.Setting: An urban safety-net hospital ICU.Patients: All adults hospitalized during April of 2015 and April 2019 identified through a clinical database search.Interventions: None.Measurements and Main Results: Of 365 admitted patients, 15.89% had one or more defined chronic life-limiting conditions. These patients had higher 1-year (46.55% vs 13.68%; p < 0.01) and 5-year (50.00% vs 17.22%; p < 0.01) mortality rates than those without underlying conditions. Irrespective of classification of disease severity, patients with metastatic cancer, congestive heart failure, end-stage renal disease, and neurodegenerative disease had greater than 50% 1-year mortality, whereas patients with chronic lung disease and cirrhosis had less than 50% 1-year mortality. Observed 1- and 5-year mortality for cirrhosis, heart failure, and metastatic cancer were more variable when subdivided into severe and major categories.Conclusions: Patients with major and severe chronic medical conditions overall had 46.55% and 50.00% mortality at 1 and 5 years, respectively. However, mortality varied between conditions. Our findings appear to support a crisis standards protocol which focuses on acute illness severity and only considers underlying conditions carrying a greater than 50% predicted likelihood of 1-year mortality. Modifications to the chronic lung disease, congestive heart failure, and cirrhosis criteria should be refined if they are to be included in future models. [ABSTRACT FROM AUTHOR]

Context: COVID-19 has prompted debates between bioethicists and disability activists about Crisis Standards of Care plans (CSCs), triage protocols determining the allocation of scarce life- saving care. Methods: We examine CSCs in 35 states and code how they approach disability, comparing states that have revised their plans over time to those that have not. We offer ethical and legal analyses evaluating to what extent changes to state policy aligned with disability rights law and ethics during the early pandemic and subsequently as stakeholder engagement grew. Findings: While disability rights views were not well represented in CSCs that were not updated or updated early in the pandemic, states that revised their plans later in the pandemic were more aligned with advocate priorities. However, many CSCs continue to include concerning provisions, especially the reliance on long-term survival, which implicates considerations of both disability rights and racial justice. Conclusions: The disability rights movenient's successes in in fluencing state triage policy should inform future CSCs and set the stage for further work on how stakeholders influence bioethics policy debates. We offer thoughts for examining bioethics policy making reflecting the processes by which activists seek policy change andthe tension policy makers face between expert delegation and mediating values conflicts. [ABSTRACT FROM AUTHOR]

During the Covid‐19 pandemic, the University of California convened the University of California Critical Care Bioethics Working Group, a team of twenty individuals tasked with developing a set of triage procedures. This article highlights several crucial components of the UC procedures and describes the reasoning behind them. The recommendations and the reasoning in the UC protocol are distinctive because of the emphasis the working group placed on grounding its decisions on the public's preferences for triage protocols. To highlight the distinctiveness of the recommendations and reasoning, this article contrasts the UC procedures with the triage procedures known as the "Pittsburgh framework." Among the specific topics discussed are age discrimination, disability discrimination, the prioritization of critical workers for scarce resources, and triage priority for pregnant patients. [ABSTRACT FROM AUTHOR]

The Covid‐19 pandemic has highlighted many of the difficult ethical issues that health care professionals confront in caring for patients and families. The decisions such workers face on the front lines are fraught with uncertainty for all stakeholders. Our focus is on the implications for nurses, who are the largest global health care workforce but whose perspectives are not always fully considered. This essay discusses three overarching ethical issues that create a myriad of concerns and will likely affect nurses globally in unique ways: the safety of nurses, patients, colleagues, and families; the allocation of scarce resources; and the changing nature of nurses' relationships with patients and families. We urge policy‐makers to ensure that nurses' voices and perspectives are integrated into both local and global decision‐making so as to minimize the structural injustices many nurses have faced to date. Finally, we urge nurses to seek sources of support throughout this pandemic. [ABSTRACT FROM AUTHOR]

When the Covid‐19 pandemic reached the United States in spring 2020, many states and hospitals announced crisis standards of care plans that used age as a categorical exclusion criterion. Such age choosing was quickly flagged as discriminatory, and so some states and hospitals shifted to embedding age as a tiebreaker deeper in their plans. Different rationales were given for using age as a tiebreaker: that younger patients were more likely to survive than older patients, that saving younger patients would save more life years, and that younger patients deserved a chance to live through life's stages. We provide a critical analysis of these three rationales, noting the differences between them, and then questioning the ethical and legal justifications for such age choosing. [ABSTRACT FROM AUTHOR]

I was a member of the Massachusetts advisory working group that wrote the Commonwealth's crisis standards of care guidance for the Covid‐19 pandemic, and I was proud of the work we did, thinking carefully about whether age should matter and whether priority should be given to essential workers if there was a scarcity of medical resources, about whether protocols should address issues of structural racism, and so forth. But as a critical care physician, I have concluded that, no matter how sophisticated the ethical analysis, the fundamental approach we proposed was flawed and virtually impossible to implement. All the existing allocation protocols that states developed are based on the assumption that clinicians will be faced with the task of selecting which patients will be offered a ventilator from among a population of patients who are each in need of one. The protocols then assign patients a priority category, and the protocols specify "tie‐breaking" criteria to be used when necessary. The problem with this approach for ventilator allocation is that it has no relationship whatsoever to what happens in the real world. [ABSTRACT FROM AUTHOR]