This forthcoming article assesses challenges for rural communities and rural hospitals, which often face limitations and disparities in health care workforce and resources, in responding to COVID-19 and potential scarcity of critical care resources.
Rural communities include 20% of the total US population and an above-average share of older adults with preexisting medical comorbidities. Legal and ethical challenges will affect all types of health care providers and facilities responding to COVID-19, but rural hospitals and the communities they serve are likely to face additional struggles due to resource disparities. Among other difficulties, smaller hospitals, including many community and rural hospitals, have less organized or non-existent ethics teams. Additionally, overlapping local relationships in rural areas may complicate ethical assessments if objective parties with appropriate knowledge and perspective are not available.
The authors discuss the development and importance of hospital ethics committees and note that some health systems that include both large and small hospitals are able to coordinate to share resources and ensure ethical decision-making processes include concerns of different types of facilities. They emphasize the need to create an ethics team “with all voices at the table” for development of a resource allocation protocol.
They also discuss key action items to prepare for anticipated ethical challenges of a pandemic:
- Creating and maintaining a dashboard of daily resource utilization
- Defining clinical criteria for scarce resources and survival/recovery quantification
- Identifying triage teams with a focus on clinical skills, community reputation, leadership, and communications skills
- Keeping the bedside care team separate from the triage team
- Identifying thresholds to trigger actions (e.g., predetermined percentage of ventilators already in use)
- Public engagement
- Patient and family education (especially discussions regarding the outcomes, and advance planning for worst outcomes) upon admission
- Clear and well-defined appeal process.
These approaches track those advanced by many state guidelines for crisis standards of care and allocation of scarce resources during a public health emergency.