“It kept me up almost every night.”
Dr. Peter DePergola, Baystate’s Chief Ethics Officer, reflected on his time helping the Massachusetts state government decide how to allocate medical supplies if they became scarce during the COVID-19 pandemic.
“It is an unusual amount of power given to a group of individuals, namely clinicians, who already have a disproportionate amount of power. Because it’s our judgement that decides what treatment goes where.”
Governor Baker selected a team of 15 experts from around the state to form The Massachusetts Department of Public Health Crisis Standards of Care Advisory Committee. The committee included experts in law, medicine, and ethics. They were tasked with finding the fairest way to distribute scarce medical resources in a COVID-19 emergency.
Dr. DePergola was the only one chosen from western Massachusetts, and the youngest member on the committee.
Baystate Health: A Leader in Healthcare
Before he was picked for the committee, Dr. DePergola had already developed a 45-page document about the exact topic – but for Baystate Health. In the document, DePergola tackled difficult ethical problems to do with how the health system would use its resources when stretched.
For example, Baystate Health only has six extracorporeal membrane oxygenation (ECMO) machines. These are heart and lung bypass machines, potentially lifesaving for someone suffering from an especially severe case of COVID-19. If the hospital system was overwhelmed by a surge of people infected with severe cases, there would be the potential for a shortage. Baystate Health would then use the plan to decide how to allocate the ECMO machines.
With the blessing of Baystate Health leadership, Dr. DePergola shared this document with the committee.
“A great deal of the state document, maybe 70%, is based on what I had written for Baystate,” Dr. DePergola said.
Maintaining Equity in the Face of Shortages
With a rush on toilet paper early in the pandemic and grocery shelves emptying, it was clear that people were afraid. Hospitals around the country rushed to get enough personal protective equipment for their healthcare workers.
With this in mind, the committee worked hard to make the distribution process fair and equitable – in case the situation took an even bigger turn for the worse.
“We wanted to make sure that we were getting it right,” Dr. DePergola said. “Vulnerable populations felt like this could be another instance in which they were discriminated against and easily discriminated against in the name of public health emergency. And unfortunately, we have not been morally responsible as a people in the past.”
Some people worried that doctors might end up deciding for themselves whether people with disabilities or certain diseases had lives worth living – and treating – during a shortage.
Preventing Racial Disparities in Medical Care
There are many factors to determining who gets medical resources when they become scarce.
One of those factors is sequential organ failure assessment (SOFA). It assigns a number to a person depending on their health. The lower the number, the healthier a person is – each ailment or condition adding on a point.
Dr. DePergola says this point system has its flaws, at times giving people with disabilities or minorities a disadvantage.
Part of the SOFA takes a look at how a person’s kidneys are functioning.
“Chronic kidney disease disproportionately affects people of color,” says Dr. DePergola.
The committee had to take away some of that bias, without invalidating the scoring system altogether. To do this, the committee made certain ailments or measurements worth fewer points. This would help even out the playing field.
Preventing Discrimination against Those with Disabilities or Disease
There’s another scoring system used called the Glasgow Coma Score. It measures, among other things, how well a person is able to communicate with their eyes.
Under typical circumstances, the system would be used to see if someone had brain activity after, for example, a brain injury. But people who have severe intellectual disabilities sometimes have difficulty communicating with their eyes, giving them a disadvantage under this system.
The committee also adjusted the scoring system to prevent this type of discrimination.
“It takes a lot of delicate bedside clinical prudence, and taking this on a case by case basis to make sure that we’re not discriminating against people for race, religion, disability, or anything else,” Dr. DePergola said.
The best of the worst scenario
“Part of the difficulty was crafting criteria that I knew the people I loved most would not meet.”
That includes his own mother, who he said wouldn’t meet the criteria against someone healthier.
“That’s a tough pill to swallow. But you know that it’s right to do even if it’s difficult. And I think the moral courage of our providers to make the difficult decision, even when it felt personally terrible…Making the small decision a thousand times to put someone else’s wellbeing ahead of their own, I think is the definition of moral courage for us.”
Dr. DePergola said their plan is as equal and fair as possible, considering the circumstances the state experiences.
“Sometimes the least bad thing to do is the best we can do,” Dr. DePergola said.
The Centers for Disease Control says there are a number of outside, systemic factors that may disadvantage someone during a time of crisis.
- Where you live: A study found that areas with higher social and economic inequities had higher rates of COVID-19. These areas had higher proportions of Hispanic and non-White residents.
- What your housing situation is: Living in a crowded home or inadequate housing (like bad plumbing) can make it easier for COVID-19 to spread from person to person within the home. Minorities are disproportionately losing their jobs during the pandemic which could lead to greater risk of eviction and homelessness or sharing housing. In some cultures, it is common for family members of many generations to live in one household. One report found that a higher percent of people from minority groups lived in crowded housing (ex. more than one person per room) compared to non-Hispanic White people.
- What your job is: Minority groups are disproportionately represented in essential work settings such as healthcare facilities, farms, factories, food services, etc. These workers have more chances to be exposed to COVID-19.
- What your education level is: People with lower education levels may be limited in future job options, which could mean less flexibility to leave a job that may put them at higher risk of being infected with COVID-19.
Because of all these factors, Dr. DePergola says it’s important to consider things on a case by case basis, instead of trying to find a one-size-fits-all solution.
“The problems that the city of Holyoke are facing are different than the problems that the town of Longmeadow are facing. They have different issues that they’re dealing with,” Dr. DePergola said.
How the plan is activated
To activate the committee’s plan, Governor Baker would have to declare that the state has entered a “crisis standards of care.”
Although many hospitals have been strained under the flood of COVID-19 patients, it didn’t come to that in 2020.
Dr. DePergola doesn’t know exactly how Baystate Health was able to sustain such a good supply of medical resources like ventilators. But he says it likely has a lot to do with good planning and distribution access, especially by Dr. Andrew Artenstein, Baystate Health’s Chief Physician Executive and Chief Academic Officer, as well as the Incident Commander for Baystate Health’s COVID-19 response.
“He was securing PPE in an almost James Bond- like manner,” Dr. DePergola said.
Compared to hospitals in other parts of the state, Dr. DePergola said Baystate Health was more prepared for a crisis.
“I really do feel like we’re the unmined gem of New England.” Dr. DePergola said. “It really is a special place, and it has to do with the people and the leadership.”
If resources become scarce in the coming months or years, Dr. DePergola says the work the committee did will be comforting to some.
“At the end of the day, our providers and our patients and their families need to know that they did everything they could for the people they love most,” Dr. DePergola said. “And I think these guidance documents, these conversations, can help people say, ‘I gave everything…I gave everything I had.”
Learn more about Baystate's response to COVID-19.