A state task force of doctors and medical ethicists yesterday released guidelines for hospitals should things get so bad that ICUs become overloaded and doctors have to choose who gets ventilators or other potentially life saving treatments during the Covid-19 pandemic.

The "crisis standards of care" guidelines are designed for a hospital system in the process of collapse - too many sick people and not enough medicine equipment and healthcare providers to care for them all - possibly because they themselves might be knocked out by the virus.

When that happens, and patients are coming in faster than hospitals can provide intensive care for them, doctors will have to switch from trying to care for each individual patient to trying to maximize total "life years saved" for the community as a whole, the task force concluded.

To do that, a designated a triage doctor will assign patients scores based on such factors that include not just the severity of their Covid-19 infection but their age and preexisting conditions, with points added for each. Doctors, nurses and other healthcare workers, as well as paitents who otherwise would be involved in "maintaining societal order," however, would have points subtracted. Women far enough along in pregnancy that their fetus would survive would get a better score than non-pregnant women or men. In the event of a tie score between two patients, the younger one would "win," because of the priority of maximizing total "life-years" saved.

A key part of the determination would be based on a patient's Sequential Organ Failure Assessment score - which is based on how well six of a critically ill patient's major body systems are doing.

Patients with the lowest scores would then have their medical records color coded - so that ICU staffers know at a glance who's next for a ventilator - possibly even if that means removing somebody with a higher score from one. Red-tagged patients would be first in line, orange next and then all the older, sicker patients would be marked as yellow.

The guidelines emphasize that even in such a crisis, people denied potential life-saving care would not simply be dumped somewhere, but should be given care to help ease their pain and discomfort, at the least. "Where palliative care specialists are not available, the treating clinical teams should provide primary palliative care."

Hospital leaders and the Triage Team will make determinations twice daily, or more frequently if needed, about what priority groups will have access to critical care services. These determinations will be based on real-time knowledge of the degree of scarcity of the critical care resources, as well as information about the predicted volume of new cases that will be presenting for care over the following several days. For example, if there is clear evidence that there is an imminent shortage of critical care resources (i.e. few ventilators available and large numbers of new patients daily), only patients in the highest priority group (Red group) should receive the scarce critical care resource. As scarcity subsides, additional priority groups (e.g. first Orange group, then Yellow group) should have access to critical care interventions.

The guidelines also discuss the possibility of removing some patients from ventilators or other treatment should other patients come in with lower scores:

The Triage Team will conduct periodic reassessments of all patients receiving critical care/ventilation. These assessments will involve re-calculating SOFA scores and consulting with the treating clinical team regarding the patient's clinical trajectory. Patients showing improvement will continue with critical care/ventilation until the next assessment. If there are patients in the queue for critical care services, then patients who upon reassessment show substantial clinical decline as evidenced by worsening SOFA scores or overall clinical judgment, or demonstrate a failure to progress towards discharge from an intensive care unit, should not receive ongoing critical care/ventilation. Although patients should generally be given the full duration of a trial, if patients experience a precipitous decline (e.g. refractory shock and DIC) or a highly morbid complication (e.g. massive stroke) that portends a very poor prognosis, the Triage Team may make a decision before the completion of the specified trial length that the patient is no longer eligible for critical care treatment. Patients who are no longer prioritized for critical care treatment should receive medical care including intensive symptom management and psychosocial support. If available, specialist palliative care teams will be available for consultation.

The guidelines emphasize that a patient's race or ethnicity cannot be used for developing a score. Boston City Councilor Ricardo Arroyo (Hyde Park, Mattapan, Roslindale), however, says that's what might happen anyway, because of higher rates of chronic disease among black and Hispanic populations.