December 8, 2020
These principles can inform crisis care, surge planning during resource-constrained events
PORTLAND, Ore. -- Oregon Health Authority is publishing new crisis care principles to help the state’s health care system manage public health crises -- such as the recent surge of COVID-19 cases -- that threaten to overwhelm hospitals dealing with scarce resources.
Principles in Promoting Health Equity During Resource Constrained Events is a significant shift from Oregon’s previous crisis care guidance created by health system partners, including OHA representatives, in 2018. In September 2020 OHA determined it would no longer reference the 2018 guidance due to its potential for perpetuating discrimination and health inequities. Since then, OHA has met with community partners and health care experts to co-create a new and inclusive process, with the goal of creating new crisis care guidance centered in health equity.
While the development of official guidance will take more time to establish, OHA recommends that health systems take immediate next steps to incorporate the newly published principles into crisis care planning and procedures.
"With the recent surge of COVID-19 cases and emerging health system capacity constraints, as well as in response to community partner input thus far, we recognize the pressing need to articulate health equity principles, prevent discrimination, and support our health system partners at this critical time," said Dana Hargunani, M.D., M.P.H., OHA’s chief medical officer.
Input by advocates from the disability community, communities of color, health system ethicists, and public health community advisors helped inform these principles as an interim step. OHA plans for robust, transparent, and continued community engagement and collaboration to develop Oregon’s future equity-centered crisis care guidance, including consultation with Oregon’s nine Federally Recognized Tribes.
Oregon State Senator Sara Gelser (Corvallis/Albany), who has advocated for communities experiencing disabilities, communities of color and improved health equity within the state’s health care system, said these principles "help center health equity for this specific, critical moment in time with the COVID-19 surge. The principles position Oregon as a national leader in health care justice work, providing a model to other leaders doing this work across the county," she said. "This is only the start of the discussion."
Emily Cooper, legal director at Disability Rights Oregon, said that as COVID-19 infection rates continue to rise, health care providers must understand their obligations to treat all patients equitably. "No patient should be denied care due to their disability or assumptions about how long they are expected to live with their existing health conditions," she said. "We look forward to continuing to work with the state as they work toward developing longer-term guidance."
OHA Equity and Inclusion Division Director Leann Johnson said it’s imperative -- when upholding health equity principles and practice, and preventing bias in the allocation of critical resources -- that "we don’t further disadvantage people and communities most impacted by health inequities and the long-standing burden of racism and oppression."
"The toxic stress of racism can make people more susceptible to chronic disease and underlying conditions, so it is important that those diseases and conditions not factor into the decision-making equation for life saving measures," Johnson said.
Rebecca Lavelle-Register, a member of the Multnomah County Public Health Advisory Board, said the new principles represent a small but important step toward improving health equity in Oregon.
"2020 will be seen as a mournful year for our nation, with losses felt across the country, but also the year we reaffirmed that the lives of all Oregonians, regardless of race, disability, or status, are worth protecting," she said. "Health equity needs to be at the forefront of everything we do. We are challenging all health care organizations to do better. It is time to come together and address the inequities faced by our community's most vulnerable populations."
Robert Macauley, M.D., pediatric palliative care specialist at Oregon Health & Science University, said crisis care is complex and critically important, especially in the context of the current pandemic. "OHA’s commitment to developing principles to ensure all Oregonians -- particularly communities of color, tribal communities and people with disabilities -- have the resources they need is an important next step," he said.
OHA’s four key principles:
- Non-discrimination -- Crisis care principles must align with civil rights laws that protect people in Oregon from discrimination based on race, ethnicity, color, national origin, disability, age, sexual orientation, sex and gender identity. Civil rights norms and laws are not suspended or waived, even in times of disaster.
- Health equity -- Approaches to resource allocation in the face of worsening constraints should account for the reality that systemic discrimination and racism have deeply and pervasively impacted individual and community health long before the COVID-19 pandemic. Centering health equity goes beyond the traditional crisis care approach of saving the most lives or life-years through allocation of scarce health care resources during a crisis, which ignores historical and current health inequities and leads to further inequitable access to life-saving resources.
- Patient-led decision making -- Patients must be able to partner with their care team in making decisions guided by their values. Patient care and treatment preferences, patient decision making support needs, and patient communication needs must be considered during the allocation of scarce resources for all patients.
- Transparent communications -- The public and patients should be informed when health system crisis care plans are activated, and should have up-to-date and open information about those plans, including how resources will be allocated differently from conventional care plans.
In OHA’s judgement, when applying the principles of non-discrimination and health equity, the following factors should be excluded from consideration when allocating scarce resources in a public health crisis:
- Underlying conditions or disability: any approach to triaging care should not exclude patients on the basis of a known or suspected co-morbidity or underlying health condition, including but not limited to disability status such as the presence of physical, mental or behavioral health conditions, or intellectual, developmental or other disability.
- Life expectancy, in which people of color, people with disabilities and other communities are disadvantaged due to long-standing toxic stress, trauma, systematic genocide, colonization and other factors.
- Resource utilization and quality of life, which can lead to the systematic deprioritization of resources for individuals with developmental, intellectual, and other disabilities, older adults, and individuals from communities of color.
- Personal ventilators, which some patients with chronic conditions are dependent upon outside a public health crisis.
The principles also state that any approach to triaging care when resources are limited should not be based on "morally or scientifically irrelevant considerations," such as socio-economic status, race/ethnicity, gender identity, sexual orientation, national origin, immigration status, faith orientation, parental status, ability to pay, insurance coverage, disability, or solely on the basis of age.
"Our hope is that Oregon never faces constraints in health care resources that requires crisis standards of care, but if we ever do, we hope these principles will guide decision-making, mitigate the impacts of implicit and explicit bias, and prevent discrimination at this critical time," Hargunani said.
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