FEMALE SPEAKER: Welcome to Mayo Clinic COVID-19 Expert Insights and Strategies. The following activity is supported in part by an independent medical education grant from Pfizer Inc, and is in accordance with ACCME guidelines.

ALEX NIVEN: Welcome to the Mayo Clinic Critical Care Insights COVID edition. My name is Alex Nevin. I'm a consultant in the division of Pulmonary Critical Care and Sleep Medicine here at Mayo Clinic in Rochester, Minnesota, and also the education chair for both our division and for the independent, multi-specialty, critical care practice.

The COVID pandemic has changed the way that we practice, likely forever. And the critical care community has been particularly impacted by the current pandemic. Critical Care Insights COVID-19 edition is intended for health care providers who are caring for patients with COVID-19, across the world, in the ICU.

Best practices to care for these patients have been rapidly evolving, and busy bedside providers-- I know I have-- struggle to keep up with the volume of information, especially given that the information sources that have been providing it are frequently less than rigorously peer reviewed. In response, the Mayo Clinic has developed an Ask Mayo Experts COVID-19 task force that have collected and curated the available contents into a free public website under the Mayo Clinic Ask Mayo experts COVID-19 navigator.

This source provides basically a curated site for best practice recommendations in the care of COVID-19 patients developed collaboratively by an interprofessional stakeholder group of Mayo Clinic sub-specialists. And this information is continuously informed by rapid literature scoping reviews performed by the current Center for the Science of Health Care Delivery.

This online CV course is designed to speed dissemination and implementation of these best evidence-based guidelines, best practice innovation, and provide discussion of ongoing clinical controversies that we face in critical care as we take care of these patients. These discussions will feature the original authors of the content that is available on Ask Mayo Experts and allow them to discuss the evidence and best practices that they have used to provide these recommendations and the why behind the information that they've shared.

We will be continuously updating this content as time goes on, based on the available high-quality evidence that comes through our rapid scoping reviews and our evolving innovations and evolution of clinical practices within our own health care delivery platform here at Mayo Clinic. This initial CV offering consists of seven lectures, including topics from intubation safety, infection control, workflow considerations, navigating drug shortages, maximizing team performance, mindset training for the individual, humanizing critical care, respiratory therapy innovations, among others.

We will continue to evolve this content as time goes on with new information on the epidemiology, virology, clinical features of COVID-19 patients, and also evolving recommendations with regards to testing and the care and additional infection control considerations in this challenging population. We hope that you enjoy this work. This information has been has been provided as a series of Grand Rounds presentations to our critical care community over the course of the last five weeks and will continue to evolve over time. Welcome to Critical Care Insights. I hope you enjoy our work.

Well, welcome to critical care Grand Rounds on this Thursday, June 4. And it is my true pleasure to introduce Erin DeMartino, who is a member of the Pulmonary and Critical Care Division here at Mayo Clinic, who is going to speak to us about ethical issues within the-- or during the COVID pandemic.

Erin is, again, she is a member of our Pulmonary and Critical Care faculty. She attended Williams College and then Dartmouth Medical School and completed her internal medicine residency at Dartmouth before coming to Mayo for her pulmonary and critical care fellowship. During her training, she had completed an additional one-year fellowship at the University of Chicago's McClain Center for Clinical Medical Ethics.

Her interests include critical care ethics, surrogate decision making, and health care policy. And her ethics research has been published in the Mayo Clinic Proceedings, JAMA, and The New England Journal of Medicine. Erin has been advising hikes and our Mayo clinic leaders on pandemic ethics and also represents Mayo clinic on several statewide policy groups. So I guarantee you that you are in for a treat today. Erin, I will pass the microphone to you, virtual microphone.

ERIN DEMARTINO: Thank you. [LAUGHS] So first let me just start by saying how I've never been more proud to be part of this critical care workforce and the group of professionals with whom I'm working, who span from our nurses and respiratory therapists and our physical and occupational therapists, pharmacists, our house staff and staff physicians, or NPs and PAs coming together to take care of patients at a really difficult time and also taking care of our community as a whole. I'm very inspired by your dedication and professionalism.

I don't have any financial conflicts, and I will state that my knowledge of this topic is in constant evolution. As a roadmap, we'll start with some basic principles of disaster preparedness, then we'll talk about crisis standards of care, and that's where we're going to spend the bulk of our time today, about what goes into preparing a triage protocol, how objective our scoring systems really are, and what a scoring system looks like, and how we operationalize triage principles that we put forth as priorities for us, including how to protect populations that are deserving of additional consideration.

Finally, I want, especially with this as my audience, to spend a little bit of time about the delicate balance between personal risk and professional obligation or responsibility. The objectives for today's talk include being able to describe, at least on a high level, what the difference is between the different standards of care within the surge continuum, from standard care to crisis standard of care, also to be able to discuss the basic ethical principles that underlie fair triage protocols or procedures, and potentially even to be able to critique a triage protocol, so predict where fault lines might be and to have the ability to analyze how well we're doing with triage protocols.

Before we launch into emergency medicine or emergency management one-on-one, so to speak, I did want to briefly reorient you to the foundational principles of biomedical ethics. Anybody who's taken a board exam in any type of medical field, I'm sure, including our nurses, will be familiar with the four basic principles, including autonomy, where somebody has the self-efficacy to direct his or her own care, beneficence, doing good for our patients. Justice, meaning that we are paying attention to how each individual's care contributes to potential inequity or allocation of resources to other individuals, and non-maleficence, in other words, first do no harm.

So a few words on disaster preparedness. If you are like me, you probably didn't learn about this in medical school. But the backbone of Emergency Management is around looking at three S's, Staff, Space, and Supplies. So when a health care system faces an overwhelming public health need, demand will outstrip the supply. And we have to anticipate and mitigate shortages in these three major categories of staff, space, and stuff.

But emergencies are heterogeneous. As you can imagine, a pandemic is different from a mass casualty event or a natural disaster. Different in terms of the types of medical needs, but also the tempo at which patients present and the duration of their need and the duration of new presentations or new admissions into the health care system.

And so our crisis planning has changed since I became engaged in these efforts in early February, as we have come to understand more about what the anticipated duration and tempo of the pandemic is in our region.

I've always found this to be a useful resource. And it's not necessarily meant for you to be able to read every word, but to get a general gestalt. This comes from the Chest Task Force on mass critical care, of which Dr. Niven is actually a co-author of this publication.

And it lists down the left column these same categories, staff, space, and stuff, and across the top, shows the different phases in a continuum of care, where we surge from conventional into contingency and into crisis, and it delineates the ways in which these different resources or shortages of these resources can be impacted and can look different when we're in a contingency phase, versus a crisis phase of medical management.

So just a few more details on that. In the conventional system of care, conventional standard of care, maybe we are maximizing all the ICU beds we currently have, or we have a little bit of overflow, but we are generally operating at our maximum capacity. We may have called in a few backup staff members.

Whereas contingency is when we have enough patients where we're about double the normal number of ICU patients that we would be caring for. And we might begin to do some things that you've seen us do, like conserve and reuse resources that were previously single-use. We might stretch our staffing ratios, and we might repurpose areas of the hospital that are traditionally not used to deliver critical care, like the PACU, for use as an ICU.

Whereas when you move into a crisis standard of care, we're using very non-traditional areas, such as potentially the operating rooms, and using anesthesia machines to provide mechanical ventilation. We might be employing people who are deployed from the outpatient practice to help in the inpatient world, under the supervision of those of us who have more critical care expertise. And we are lacking critical supplies to the point that we may not have enough functional ICU beds, meaning an ICU bed that is adequately staffed and has adequate equipment to meet the needs of all the individuals coming in. So these are obviously extremely austere conditions.

This is another way of looking at it, a pictorial depiction, where we are moving on this continuum, from conventional care, on the left side of the screen, where patients receiving care in the hospital may be in the contingency phase. We've surged to the point where we have a tent adjacent to the hospital, where we're providing overflow intensive care services. And we have a lot more patients than we're used to, but the patients' needs are currently being met, even if we're having to be a little creative about how we meet them.

And finally, on the right is when we're in a crisis mode where, unfortunately, we may not being able to meet the needs of all the patients who we would normally offer intensive care to. And in that circumstance, patients may be triaged to receive only supportive hospice care or may not even be able to be admitted to the hospital.

Before we talk much about crisis standard of care, I think it's really important to focus a lot of attention and energy on mitigating strain on our resources. One way in which we can do this, everybody can do it, and we can do it now, is through targeted goals of care conversation with everybody who's admitted to the hospital, trying to understand how somebody is feeling about their own illness and what they would want if their disease were to cause a deterioration in their health status.

Likewise, it's important to do community outreach around advance care planning and maybe some targeted community outreach to high-risk populations with chronic illness or nursing home residents. And I will tell you that our palliative care colleagues have been fantastic partners in this and very proactive, have been working on it for months. Very innovative outreach programs that they are participating in, and also finding ways to screen large numbers of inpatients to identify those who are most deserving of a palliative care consult early in the course of their hospitalization, or even in the emergency department, before they're admitted.

We can also mitigate resource strain by changing our policies. There are a lot of different ways to do that. We've already seen some of this in Rochester, by deferring elective procedures. And then at a more extreme end of this, by thinking about withholding CPR.

So if you imagine a circumstance in which every single ICU bed is already full, and we have patients waiting in the emergency room who are sick enough to need intensive care, then we have a floor patient who has a code, and we achieve ROSC, then where does that patient go?

So there are circumstances in which-- extremely austere circumstances-- in which, on a case by case basis, it might be the most appropriate thing not to resuscitate patients. But that is a decision that would be made on an institutional or even regional level, as we reach more of a crisis standard of care.

Finally, I think it's important to talk about pooling resources. So not only within the Mayo Clinic Health System, but also with neighbors. I heard a wonderful piece on NPR when I was driving into a hikes meeting early in the pandemic about hospitals who were previously competitors in New Jersey sharing masks. And this was in March.

So when everybody was really fearful about running out of masks, gowns, and ventilators, with each other, meeting each other's needs, communicating on a daily basis, indicating that they had never had any formal training to do this and a month ago had been sworn competitors and would never have considered helping each other out. But doing this and rising to the occasion to meet the needs of their population.

You'll also notice this radioactive sign that I've put on the screen. That's intentional. Because there are certain aspects of this presentation that are highly controversial. And the questions around resuscitation status fall into that category where I've been part of more conversations and conference calls about these issues on a statewide level and institutionally than I could even begin to express to you right now. But you'll see that several times through the presentation, where I indicate some of the more hot button topics.

So as the landscape around us shifts, so too do our priorities about how to provide care for patients. So in the traditional Western model, those four principles of biomedical ethics, usually autonomy floats to the top. And in the United States, at least, autonomy prevails. It's an extremely-- we are an extremely autonomy-driven culture when it comes to medical decision making, as I think all of us know and feel.

We also highly value benevolence, non-maleficence. But there has traditionally been little emphasis, at the bedside, at least, on justice. So how an individual's care decisions might impact the care of other patients in the hospital or even future patients who are at home but getting sicker and might be presenting to care in the next week.

But with scarcity, that lens widens. So the focus shifts from the individual patient to the community. We're then focusing more on justice, and autonomy shrinks into the background, and can, in certain circumstances, be completely overridden.

So if a number of individuals are competing for the same resource, all of whom are desirous of maximal care, but we simply do not have enough staff, space, or stuff to provide that care safely to the patient, then there may be circumstances in which that autonomous decision of the patient is overridden for the good of the community. And that's a really distressing and difficult place in which to be. And we've heard dispatches, of course, from around the world about how challenging that's been as other health systems have been overrun.

The shift then focuses on lives saved or life years saved, depending on the set of values to which you ascribe. Most-- and I will describe again what the difference is between these two paradigms in a future slide. But in Minnesota, our triage protocols will focus on the number of lives that we can save instead of life years saved.

So I don't mean to be tongue in cheek about this at all. This is not a facetious question. I think a lot of people might feel at the bedside at any given point in time that they can identify when we are in a crisis mode. The important thing to know is that this is not a call that is made at the bedside. It's a call that's made by somebody with a bird's eye view, not just of our critical care practice here at Mayo, not just of our hospital practice here at Mayo, or even throughout the Midwest, or even in the other destination health centers throughout their regions.

These are calls that are made by regional authorities or state authorities. So by feeding information into the Minnesota Department of Health, we are able to contribute to this perception and declaration of whether or not we are in a crisis, in which case our standard of care, as I've mentioned, deviates officially into more of a triage and scarce resource allocation stance.

Before we reach that point, withholding or withdrawing life-sustaining treatments shouldn't occur in a unilateral manner. Of course important goals of current conversations contextualized within the scarce resources of the pandemic are still appropriate without unduly influencing people or leaning too heavily on people's sense of altruism. We want them to still be able to make autonomous decisions. We don't want individuals to feel coerced to forgo therapies.

But on the other hand, we should not be unilaterally withholding or withdrawing life sustaining therapies in a patchwork manner, meaning if we still have enough ventilators in one hospital, but 10 or 50 miles down the road, there are insufficient ventilators for the number of patients who need those, then we need to be sharing resources in a very systematic way, so that the people who are in that local region aren't disadvantaged.

I'm going to pause here. Alex, I think, has been monitoring Slido to see if there are any questions or clarifications related to those before we transition to talking about crisis standards of care.

ALEX NIVEN: And right now, we don't have any questions listed on Slido. Erin, can I just ask one question, as you've given us the opportunity to pause and think about things a minute? When it comes to the states making a call that we are in a crisis situation, what level of coverage does the state provide an individual provider or a health care system as they transition to a less than otherwise considered standard of care.

ERIN DEMARTINO: I'm so glad you brought that up, because we will be discussing that toward the end of the presentation in terms of are you asking around resource allocation or resources brought to bear, or are you asking about professional liability?

ALEX NIVEN: I was asking more about professional liability, but certainly both could be a consideration.

ERIN DEMARTINO: Yeah. And I think I can briefly talk about resources that are being held and are ready to be deployed at the state level. And then I'll table the rest of my answer until later, when I discuss professional liability.

So many of you may have been listening on the news and understand that there is a strategic national stockpile that contains a certain number of transport ventilators. Additionally, our state has been working very hard to procure transport ventilators or other kind of rudimentary ventilators and resources, masks, gloves, and medications, et cetera.

And so we would be looking for a hybrid of support, both from federal resources as well as state resources, to help individual health systems that are finding themselves very taxed in terms of a given, say, supply, or even staffing. So there may be FEMA nurses or FEMA physicians who come to the site where there's a hot spot-- and this has happened in other regions of the country-- to lend additional hands.

And then we can talk at greater length about the liability in a few minutes. But this is such an unusual format for an ethics talk, and normally, these are pretty controversial topics, and they spark a lot of conversation and thought. And I welcome you guys to write in with questions, or if I say something that doesn't sit well with you, I'd love to hear it. But for now, I will keep going.

ALEX NIVEN: Erin, can I just-- there's a question that just came through. So this question says, why do we need a crisis to spread care needs between hospitals? Why don't those patients without insurance get proportionately sent to Rochester for care normally? Or why don't those patients without insurance get proportionately sent to Rochester for care normally? That's the question. I'm not sure if I can speak to proportionality of uninsured versus non-insured patients coming to Rochester, but I guess maybe I'll pose that question to you.

ERIN DEMARTINO: No, and that's an excellent point. We don't necessarily need a declaration of crisis to be helping our neighbors. And in fact, we've seen that already in our own practice in the last week, where we've been taking care of patients who would otherwise have been admitted to intensive care units in the metro region, because of the atmosphere in the metro region and their surge capacity in their own ICUs.

It's an excellent point and very important for hospitals throughout the region to be helping each other. And it's part of the mitigation strategy not to reach a crisis mode and trying to continue to right size our own operations to help our community as a whole. So when we look at crisis standards of care, there was a kind of a blossoming of research in literature in this area in 2009 for-- it's not a coincidence-- during the H1N1 epidemic.

And the Institute of Medicine put out these ethical principles that should be foundations for any triage situation and crisis standards of care. Those include fairness, stewardship of resources, transparency-- and we'll get back to that-- consistency across health care systems. Proportionality, so not overreacting to a situation and starting to ration care before we reach crisis mode, but also not underreacting and just continuing to provide care as normal. Accountability. And then of course what we all feel is the duty to care, the duty to respond.

I want to tell you a little bit about the efforts that I have been part of in the State of Minnesota, just so you understand what extraordinary things are really happening in Minnesota and have been happening for months now to prepare us if we were ever to change our footing to crisis mode of care. So there is a group that convened of ethicists, attorneys, public health professors, social workers, chaplains, very heterogeneous group, including also physicians, called the Minnesota Ethics Collaborative, COVID's ethics collaborative.

And in parallel to this is a working group from the critical care compact that started with just the metro region critical care groups and now has representation from every hospital system in the state of Minnesota. And that group is mostly intensive, as there are a few palliative care doctors who are on those calls as well. And the groups share an infrastructure and organizational structure and have some bi-directional communication that comes through the Minnesota Department of Health and the Minnesota Hospitals Association. And there are a few of us who participate in both. And I have been participating in both from their inception.

So Minnesota has developed an ethical framework based off work that we did as a state back in 2009 for the pandemic ethics project that was based out of Minnesota Department of Health and the University of Minnesota's ethicists. And these principles are really important. They were informed by a lot of community engagement research. And we have said as a community that we would make allocation decisions without reference to sex, gender identity, sexual orientation, religion, citizenship, immigration status, criminal record, ability to pay, disability, and age.

So at first glance, this sounds like a really important, fair list. But I think you already probably know from coverage, both in the medical and media, medical literature and media, that these questions around disability and age have become really important areas for conversation and exploration. And I'll delve into that further in coming slides.

So these groups really started by holding up our different triage protocols that we were coming up with, and in an organic sense, in each health system, we were looking at the situation that we were facing and trying to write our own triage protocols to deal with this particular pandemic. And we matched them up against each other, looked for common themes, looked for areas in which they conflicted with each other, and over the course of several months have generated a shared set of triage standards.

And this is crucially important. Because you don't want people, say if you use the metro area as an example, to present to one hospital and subject it to one group of triage criteria, but be able to drive 10 minutes down the road and have a completely different set of triage criteria, where in one place you may be offered life sustaining therapies, and the other place you would be triaged to receive only supportive cares. And so it's important that we harmonize to the best of our ability across systems in a region. And this has been really painstakingly difficult work to arrive at a consensus, and we have a very mature draft of a triage document at this point that has been shared with the scientific advisory team for Governor Walz and with the state health commissioner.

So how do we assign triage prioritization? How do we figure out who gets what resource? So of course their medical condition plays into this decision, because all comers don't stand an equal chance of benefiting from a scarce resource like an ICU bed.

The components of how to figure out and assign a score generally include what is supposed to be an objective measure, like the SOFA score, the Sequential Organ Functional Assessment. It also incorporates consideration of whether patients have comorbid condition, what the burden of those illnesses are, and specifically, we're looking at illnesses that are likely to impact their six-month survival.

And six months is not an accident, that's do they meet hospice criteria. And if so, then they would receive a deprioritization. They would be upscored, meaning they would have a higher score, and therefore be sorted into a group of patients less likely to receive a scarce resource.

We also-- and this is different. We diverge from some states in that we are proactively looking at anticipated length of stay. So a patient who is say admitted for flash pulmonary edema, where we expect their length of stay, at least in the ICU, may not last for a week or more, like a COVID-19 patient, they would be relatively prioritized.

So I should back up and be transparent about the fact that these criteria would apply to any patient who is needing intensive care, not just patients who are there because of the prevailing pathology of the pandemic. So overdose patients, patients who have heart failure, anaphylaxis, any other patient who requires critical care would be subjected to the same set of criteria.

And the scoring system, the composite score that I've just described would then help assign the patients into a prioritization category with good prognosis, low priority individuals, maybe such good prognosis that they don't even really need an ICU bed. Under normal circumstances, we might admit them for observation, but in this case, we would send them to a floor.

And the blue group, it's also important to emphasize that we don't prospectively exclude very many people from receiving a score. But the patients who receive the very highest score, the very sickest patients, particularly if they are, say, being actively resuscitated with CPR, or they're in a persistent vegetative state, or something just where they are at the very extreme margins of an individual who would even receive intensive care under conventional standards, that those patients end up in the blue group, and they would receive the lowest priority to have an ICU bed. So they're not excluded from consideration for care, but they are deprioritized in an extreme way.

I'll say that we have not just me, a lot of people who have been working in this field for the past few months, significant misgivings. And I'll be honest about that, about the way in which we can triage people in 2020. SOFA hasn't traditionally been used for a large-scale triage. In fact, it hasn't been prospectively validated.

We have to decide as a society and as a region what is the outcome when we're saying who would benefit from intensive care. What is the outcome we're looking for? Right now, the definition is really survival to the hospital discharge.

We're not looking at 10-year survival. Is that the right metric? I don't know. There is controversy in that area. I will be honest with you about that. But there are also concerns about disability rights, health inequities that start to pop up as you try to project, and prognostic uncertainty, as you start to project out further and further into the future about what somebody's 5 or 10 year survival might be.

Finally, in order to formulate a SOFA score or to understand a person's burden of illness, there is a substantial amount of clinical judgment that goes into making these determinations and assigning these scores. So even a SOFA score that looks at the outset like such a clean, objective measure. First of all, the SOFA score that's generated through Epic, and many of the health systems in our state use that, was, until recently, spitting out a SOFA score that treated an absent value as normal.

So SOFA includes bilirubin. If the patient's bilirubin hadn't been checked within the previous 24 or 72 hours, then they would be assigned normal liver function, even if they didn't have normal liver function. Likewise, it incorporates the Glasgow coma score.

Well, that's a really difficult thing to assess when you have a patient who's deeply sedated because they're in ARDS. And so we are using these scores not just to assign priorities and assign beds to patients who are waiting for ICU resources, but also to consider reallocating for patients who have been in the ICU for a while, have received a time limited trial, and are either not improving or maybe even deteriorating. Which is why it's important to think about how we could objectively measure these parameters for patients who are both coming in and presenting for the first time, but also who are consuming resources in the ICU on an ongoing basis. Likewise, whose judgment is it that we're relying on to determine whether somebody has a sufficient burden of comorbid illness that they would have hospice eligibility.

And yet there is tremendous value in harmonizing our efforts with our regional neighbors. And I will say, our national community in critical care, and our international community, about 90% of the triage protocols that I have seen, SOFA is the backbone. So SOFA is flawed, but SOFA is as uniform as we have right now, in 2020.

And teams are working fast to develop better predictive models, but at the moment we-- SOFA is the best we have, and we have to rely on that. But understanding our misgivings about that scoring system has caused us, as intensivists, especially, to push extra hard for the role of clinical judgment playing in here and to have people with critical care expertise at the table, helping to make decisions and compare patients who might have the same score on paper, but might look very different when you start to dig into their chart and understand information about their comorbid illnesses and the trajectory of their illness.

So there are some populations that are deserving of additional consideration. Those include children, pregnant women, disabled persons, historically underserved people. And also I'll just briefly mention here, essential workers. So there have been proposals around the country, around the world, for prioritization of health care workers in triage systems, so that they were being kind of pushed, if not to the front of the line, further up the line, both as a reward for their bravery in providing care under difficult circumstances at substantial self risk, but there's also an argument which is described in the ethics literature as instrumental value.

So to save the life of a health care worker may allow, down the road, more individuals in the pandemic to be saved. You can't necessarily make that same argument, remember, in a mass casualty event, where the person who survives because they've received ICU care wouldn't be able to immediately turn around and care for the other individuals who were deprioritized. But in a pandemic that stretches over months, it's conceivable that a person who is a health care provider or plays a part in a health care team could return to the workforce and continue to help the overall good of the population.

I alluded to this earlier. Early in the course of different health care institutions sharing their triage protocols, there was a push for this consideration of life cycle stage. So younger individuals receiving a higher priority because to save their life would mean more life years of benefit from those critical care resources. So a 20-year-old, even if gravely ill, if that 20-year-old were felt to have a good chance of recovery with application of life-sustaining therapies versus saving two 80-year-olds, you could imagine that 20-year-old might have 70 more life years to live, and the two 80-year-olds would not have 70 more life years to live.

As this has evolved, this is where advocacy has really influenced policy. And advocacy not just from disability and human rights groups, but even from individuals who have sued governments in their region's state governments who have endorsed policies that prioritize this concept of life years over individual lives. And so the pendulum in the past few months has swung, as nine states, I believe, have faced civil rights complaints through HHS, the Office of Civil Rights, and/or lawsuits to individual institutions or states that have endorsed approaches that prioritize life years over individual number of lives saved.

Likewise, I think it's important to acknowledge here as a profession, maybe even as a society, but certainly as a profession, there's a very large body of literature that support the fact that we consistently undervalue the lives of people with disabilities. And so some people have argued that maybe we shouldn't be looking at the chronological life years. So somebody is 80 years old, maybe we should be looking at their functional status.

Well then you get into this very difficult situation to disentangle when functional status may also be influenced by disability that has no impact on somebody's likelihood of long-term survival. And so there's this kind of tug of war I've started to observe between ageism and ableism, and it's been really well written about. I have a few references at the bottom of this slide-- I'm happy to provide more-- around this tension.

Even before the events of the past few weeks this has been a high priority at Mayo and across the state of Minnesota. And so I do want you to know that the attention to mitigating systemic racism has been added from the beginning of our working groups. Understanding that burden of comorbid illness is influenced by individuals' access to health care, and that they may not-- individuals who have been historically disenfranchised don't have access or may present later in the course of their illness.

And so it's really important for us to think about ways in which our policies going forward influence or potentially exacerbate existing inequities in our healthcare system. So some examples of this, colorblind reporting of burden of illness is making it more difficult to understand the disproportionate impact of COVID-19 on African-American communities. But what we know is that in counties that are predominantly African-American, the test positive rate is three to six times that of predominantly white counties. So there are a lot of indicators that would allow us to understand that these are not just theoretical concerns, but they are real, and they are materializing as this pandemic proceeds.

No emergency management lecture would be complete without referencing Dwight Eisenhower. He is commonly quoted in these circles. And I think that it's worth stating that the effort that has gone in at Mayo and also across our region to the thoughtfulness that has gone into our planning for a potential crisis standard of care is invaluable and that we have to be nimble, and we might need to change our stance quickly as we face more austere conditions. But the fact that we've established these working relationships with our partners around the state, and we have communication strategies now to communicate back and forth with the Department of Health, share resources, pool resources, et cetera, that is invaluable.

A few just brief points about implementing a crisis standard of care. How would this look? First of all, if we reached a crisis standard of care, you should be looking for communication, not just from within our institution, but from state authorities, to medical professionals, but also to patients and their families and to the broader community, publicizing how things are changing and what they should expect. And those plans are underway and are being written, and I've been involved in some of that work, only to be deployed if we were to really reach or be surging to the point where it looked like we were going to reach a crisis standard of care.

It's critically important to understand that we would not be expecting the bedside team to triage resources for their own patients. We would be looking to deploy independent multidisciplinary triage teams that might include off-duty ICU or emergency room nurses, off-duty ICU or emergency room physicians and PPAs, also ethicists and diversity and inclusion representatives. Again, this has been part of our plan from the inception of these planning processes.

It's important that there be an appeals process in case a triage decision made to, say, disadvantage or even to allow a patient to continue to receive ongoing care that doesn't sit right with the ICU team, that there is an appeals process whereby the team and/or family could appeal the decision to a secondary review board. And likewise, it's important that there be oversight in a very systematic way and documentation of how patients are examined and triaged, so that we make sure that we're adhering to these high principles that we have set forth. I will stop for maybe one question, Alex, if one has arisen. Otherwise, I can talk about these the professional and personal risk.

ALEX NIVEN: So there's several questions that have come up while you've been talking. And I think the one that's risen to the top is particularly timely with regards to your last slide. So the comment was that the individual felt that communicating with patient relatives regarding decisions like withholding CPR due to resource limitation will be most challenging. Do you have any recommendations on how to convey sensitive information, especially if you're thinking about off-duty intensivists as part of a triage team potentially engaging in that process.

ERIN DEMARTINO: Yes. And thank you for that question. We are working to deploy also communication teams who would be communicating triage decision outcomes to patients and families, so that burden is not, ideally, placed on the shoulders of their bedside providers. Of course we would invite and encourage bedside providers to participate in those difficult conversations if they wanted to or if it was beneficial. And it may very well be, because they would have a therapeutic relationship with a patient and family, as opposed to a kind of a de novo interaction.

But crucially important, we would not be relying primarily on the bedside providers to deliver this type of bad news that's coming from institutional triage policy. So I want to finally take a moment to acknowledge the tension that we face as a critical care workforce between personal risk and professional obligation. You'll note that I haven't-- this is an image reference or an image source, but this is not a medical literature reference, because I really haven't found good literature that addresses the particular set of challenges that we deal with in our field.

I think a lot of people choosing a career in the critical care world knew that we face, say, an enhanced risk of a blood borne infection or violence against us in the workplace and understood that, but didn't conscript ourselves to exchange our lives for the lives of our patients. Right? And in a world in which there are concerns about scarcity of protective equipment to protect ourselves as we provide care during the pandemic, these are very real tensions, and they're very individual. And they depend a lot on an individual's own risks, both of their own health status, but also of the health status of others who rely on them.

And just like it's discriminatory, we talked about discrimination around age and disability, it's not possible, legally, for your supervisors to reach out to you on an individual basis and make sure you are fit for duty, but it is incumbent on you to think about these risks that you're taking, make sure that you feel safe, talk to your supervisors about accommodation if you don't. And I do want to acknowledge that, because I know that we all are facing a different kind of risk, and nobody in this group, when they decided to join this profession, was signing up to be in the Secret Service and exchange our lives for the life of somebody else.

I want to just close by talking a little bit about liability. So this is germane to Alex's question about civil and criminal liability that health care providers face as we deliver care in crisis mode. So there is a precedent in crisis mode of individuals who are following crisis standards of care being sued civilly, facing civil lawsuits for negligence, malpractice, filed by survivors of patients who have died. And they need to prove a deviation from the standard of care, which is why it's critically important that as a region, we adhere to and agree upon a triage protocol.

Likewise, there is a precedent for criminal charges to be filed for homicide for failure to intervene or for withdrawing and reallocating a resource from an individual under a crisis standard. Health care providers have been charged by prosecutors for manslaughter or even murder, depending on the certainty of death, when resource is withheld or withdrawn. So I don't mean this to strike fear into your hearts. Alex Azar, who's the secretary for HHS, has earlier in this year written an open letter to all of the governors, including Governor Walz, pleading for variations of existing liability protections to protect health care professionals who are providing care under a crisis.

There have been various approaches to this. Some states have had their governors issue executive orders protecting health care professionals. Some have actually written COVID-specific recommendations or liability protections. Minnesota currently does not have liability protections for individuals who are providing care outside of the standard of care. That said, if our entire state shifts from conventional care to a crisis standard of care, presumably the providers would be covered under those existing liability protections. But know that the Minnesota Hospitals Association and the MMA are working very hard, lobbying very hard for additional protection, authorized either by the legislature or by the governor.

So in summary, as we move into a crisis standard of care, our obligations shift from the individual to the population. We have to keep an eye on staff, space, and supplies. The declaration of a crisis standard of care really happens at a regional level, and it happens from a government agency.

We need to ensure that our triage protocols are equitable, they're proportional to the situation, and they are transparently communicated to the individuals who are providing the health care, the individuals receiving health care, and the broader community. Finally, I want to acknowledge the delicate balance of personal and professional risk, both our physical challenge and also liability risk.

If you read one paper of all the references that I've listed on my slide, this would be the one. And it's particularly important, I think, in the past couple weeks. It's about inequity in crisis standards of care. So I highly recommend this one reference.