ICU Care in a Pandemic.

This letter to the editor responds to commentaries in the September-October 2021issue of the Hastings Center Report by Douglas B. White and Bernard Lo, by Govind Persad, and by Virginia A. Brown, which were themselves responding, in part, to the article "Life-Years and Rationing in the Covid-19 Pandemic: A Critical Analysis," by MaryKatherine Gaurke, Bernard Prusak, Kyeong Yun Jeong, Emily Scire, and Daniel P. Sulmasy.

Life-Years & Rationing in the Covid-19 Pandemic: A Critical Analysis.

Prominent bioethicists have promoted the preservation of life-years as a rationing strategy in response to the Covid-19 pandemic. Yet the philosophical justification for maximizing life-years is underdeveloped and has a complex history that is not reflected in recent literature. In this article, we offer a critical investigation of the use of life-years, arguing that evidence of public support for the life-years approach is thin and that organ transplantation protocols (heavily cited in pandemic-response protocols) do not provide a precedent for seeking to save the most life-years. We point out that many state emergency-response plans ultimately rejected or severely attenuated the meaning of saving the most life-years, and we argue that philosophical arguments in support of rationing by life-years are remarkably wanting. We conclude by offering a fair alternative that adheres to the standard duties of beneficence, respect for persons, and justice.

Rationing With Respect to Age During a Pandemic: A Comparative Analysis of State Pandemic Preparedness Plans.

BACKGROUND: Faced with possible shortages due to COVID-19, many states updated or rapidly developed crisis standards of care (CSCs) and other pandemic preparedness plans (PPPs) for rationing resources, particularly ventilators. RESEARCH QUESTION: How have US states incorporated the controversial standard of rationing by age and/or life-years into their pandemic preparedness plans? STUDY DESIGN AND METHODS: This was an investigator-initiated, textual analysis conducted from April to June 2020, querying online resources and in-state contacts to identify PPPs published by each of the 50 states and for Washington, DC. Analysis included the most recent versions of CSC documents and official state PPPs containing triage guidance as of June 2020. Plans were categorized as rationing by (A) short-term survival (≤ 1 year), (B) 1 to 5 expected life-years, (C) total life-years, (D) "fair innings," that is, specific age cutoffs, or (O) other. The primary measure was any use of age and/or life-years. Plans were further categorized on the basis of whether age/life-years was a primary consideration. RESULTS: Thirty-five states promulgated PPPs addressing the rationing of critical care resources. Seven states considered short-term prognosis, seven considered whether a patient had 1 to 5 expected life-years, 13 rationed by total life-years, and one used the fair innings principle. Seven states provided only general ethical considerations. Seventeen of the 21 plans considering age/life-years made it a primary consideration. Several plans borrowed heavily from a few common sources, although use of terminology was inconsistent. Many documents were modified in light of controversy. INTERPRETATION: Guidance with respect to rationing by age and/or life-years varied widely. More than one-half of PPPs, many following a few common models, included age/life-years as an explicit rationing criterion; the majority of these made it a primary consideration. Terminology was often vague, and many plans evolved in response to pushback. These findings have ethical implications for the care of older adults and other vulnerable populations during a pandemic.

Interpreting COVID-19 Test Results in Clinical Settings: It Depends!

Tests for Coronavirus disease 2019 (COVID-19) are intended for a disparate and shifting range of purposes: (1) diagnosing patients who present with symptoms to inform individual treatment decisions; (2) organizational uses such as "cohorting" potentially infected patients and staff to protect others; and (3) contact tracing, surveillance, and other public health purposes. Often lost when testing is encouraged is that testing does not by itself confer health benefits. Rather, testing is useful to the extent it forms a critical link to subsequent medical or public health interventions. Such interventions might be individual level, like better diagnosis, treatment, isolation, or quarantine of contacts. They might aid surveillance to understand levels and trends of disease within a defined population that enables informed decisions to implement or relax social distancing measures. In this article, we describe the range of available COVID-19 tests; their accuracy and timing considerations; and the specific clinical, organizational, and public health considerations that warrant different testing strategies. Three representative clinical scenarios illustrate the importance of appropriate test use and interpretation. The reason a patient seeks testing is often a strong indicator of the pretest probability of infection, and thus how to interpret test results. In addition, the level of population spread of the virus and the timing of testing play critical roles in the positive or negative predictive value of the test. We conclude with practical recommendations regarding the need for testing in various contexts, appropriate tests and testing methods, and the interpretation of test results.