This rapid expert consultation explains the key principles, elements, and messages for Crisis Standards of Care (CSC) decision-making, emphasizing the key distinction of moving from a focus on the individual patient to what is best for an entire group of patients during a crisis where critical resources are scarce. The document also concludes that it is reasonable to anticipate a need to shift to CSC in response to COVID-19.
The Institute of Medicine, now part of the National Academies of Sciences, Engineering, and Medicine, issued a comprehensive series of reports on CSC in 2009, 2012, and 2013. The National Academies’ Standing Committee on Emerging Infectious Diseases and 21st Century Health Threats issued this consultation document specifically to provide a rationale for implementing CSC in response to COVID-19/SARS-CoV-2.
CSC are intended to apply during a pervasive or catastrophic disaster in which usual healthcare standards are unattainable. CSC is one of three levels of the “continuum of care” that reflects the relationship between resource supply and demand surge. The first level is conventional care, which is everyday healthcare services. The second level is contingency care, which applies when demand begins to exceed supply, but functionally equivalent care remains the goal with appropriate adjustments to usual care as necessary. CSC are the third level, when functionally equivalent care is no longer possible due to resource depletion.
The guiding principles of CSC are:
- Healthcare planning must do everything possible never to need CSC.
- CSC have the joint goals of extending the availability of key resources and minimizing the impact of shortages on clinical care.
- CSC strive to save the most lives possible, recognizing that some individual patients will die, who would survive under usual care.
- CSC implementation requires facility-specific decisions on allocation of limited resources, including how patients will be triaged to receive life-saving care.
The expert consultation provides and explains the key elements of CSC planning:
- Ethical grounding;
- Engagement, education, and communication;
- Legal considerations;
- Indicators, triggers, and responsibility; and
- Evidence-based clinical operations.
The Committee emphasizes that shifting to CSC during resource scarcity “represents not a rejection of ethical principles but their embodiment.” The Committee also stresses that preparation at all levels of government must include taking all feasible measures to prevent or delay the need for CSC and that such preparations must include decision-making transparency and trustworthy communication with all stakeholders.