Elder Law Prof Blog

New Brief from APS Technical Assistance Resource Center

APS TARC has released a new brief, Trauma-Informed Approach for Adult Protective Services. This brief includes a discussion trauma and of "The Four Rs of a Trauma-Informed Approach" (realize, recognize, respond and resist). The brief includes information from experts in the field,  discusses COVID and APS, and then concludes 

As outlined in this brief and highlighted by the guest experts above, there are tools to approach recent challenges posed by COVID-19 using trauma informed approaches. APS research and practice was already beginning to understand the critical intersections between adult maltreatment and trauma and now it’s time to pivot quickly and move forward with research, practice, and training for all levels of APS staff using a trauma-informed framework.

The American Public Human Services Association (APHSA), recommends these steps for organizations to “Lead Ahead” during times traumatic times:
 Vision - Developing a vision for moving forward
 Ask questions – Be curious, be direct
 Plan – Develop a plan
 Respond – Execute the plan
 Innovate – Practice continuous quality improvement (CQI)
(American Public Human Services Association, 2020)
All the APHSA steps listed above can be conducted through a trauma-informed approach framework to  cultivate safety, support and resiliency.  The road ahead, in light of the COVID-19 pandemic, will be challenging to navigate for everyone. Let us all maintain and grow the resiliency of leadership, staff, and clients to move from urgent, trauma response to recovery response and planning in the days and weeks ahead.

Reduced SNF Training Requirements Because of COVID

Politico reported that the Trump team relaxed training rules for nursing home staff just as pandemic hit.

Shortly after the first coronavirus outbreak ravaged a nursing home in Kirkland, Wash., the Trump administration moved to fulfill a longstanding industry goal — waiving the requirement that nurse’s aides receive 75 hours of training and allowing people who study only eight hours online to become caregivers during the pandemic.

The industry had been fighting for years to reduce training requirements, saying they make it harder to recruit staff. The day after the administration announced the change, the industry rolled out a free online training program for certifying the new role — called a "temporary nurse aide" — that has since been adopted by at least 19 states.

The article reports that advocates for elders and others think this was poorly timed and may have resulted in the spread of COVID in SNFs, especially when considering that CNAs are typically  "the main caretakers of residents, some of whom need round-the-clock monitoring; nurse’s aides are also on the front lines in implementing the cleaning and disinfecting practices that prevent the spread of Covid-19." CMS emphasized this is temporary and as soon a COVID is done with us, the  CNA 75 hour training requirement will resume.

However, we don't know how well this is working. "[C]ritics are questioning why the waivers were applied so quickly and broadly, and why they’re lasting months into the pandemic when little is known about whether there are, in fact, larger-than-usual staff shortages in nursing homes. They also question the wisdom of waiving the rules for removing residents and making quarterly reports on their condition, which are among more than two dozen regulations temporarily suspended by the administration."

Stay tuned.

Visiting Family at SNFs-6' Apart

Some SNFs and ALFs are now allowing visits for residents, with proper precautions, rather than an absolute ban on visits.  Kaiser Health News  ran an update, States Allow In-Person Nursing Home Visits As Families Charge Residents Die ‘Of Broken Hearts’.

For the most part, visitors are required to stay outside and meet relatives in gardens or on patios where they stay at least 6 feet apart, supervised by a staff member. Appointments are scheduled in advance and masks are mandated. Only one or two visitors are permitted at a time.

Before these get-togethers, visitors get temperature checks and answer screening questions to assess their health. Hugs or other physical contact are not allowed. If residents or staff at a facility develop new cases of COVID-19, visitation is not permitted.

Slightly over half of the states have have allowed these SNF visits, after he release of revised guidance from CMS, while slightly less than half of the states have allowed ALFs to follow the same path. This change is something of a balancing act, and the article notes this can change if COVID cases show up. Although the prohibition on visits was intended as protection, 

[A]nguished families say loved ones [suffered]too much, mentally and physically, after nearly four months in isolation. Since nursing homes and assisted living centers closed to visitors in mid-March, under guidance from federal health authorities, older adults have been mostly confined to their rooms, with minimal human interaction.

A separate, but related issue, the right of visitation at the end of life, has not been evenly applied.

Although federal guidance says visitors should be permitted inside long-term care facilities at the end of life, this is not happening as often as it should, said Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care, an advocacy group.

She wants family visitation policies to be mandatory, not optional. As it stands, facility administrators retain considerable discretion over when and whether to offer visits because states are issuing recommendations only.

Smetanka’s organization has also begun a campaign, Visitation Saves Lives, calling for one “essential support person” to be named for every nursing home or assisted living resident, not just those who are dying. This person should have the right to go into the facility as long as he or she wears personal protective equipment, follows infection control protocols and interacts only with his or her loved one.

The article also includes a map of states allowing visitation.

Has the Time Come to Reinvent the Nursing Home? Or Change the Funding?

Charlie Sabatino, the rock star of elder law and the Director of the ABA Commission on Law & Aging recently wrote an opinion piece for Next Avenue  on this important topic. OPINION: It’s Time to Defund Nursing Homes: How the traditional nursing home model can be replaced. Sabatino writes that:

[T]he COVID-19 pandemic ravaging nursing home residents underscores a deep-seated ageism inherent in our institutional model of nursing home care. I believe it is time to defund the institutional model and replace it with a radically different model.

Today’s typical nursing home has never come close to meeting the public’s desire for humane and dignified long-term care. Warehousing large numbers of frail elders in hospital-like buildings with residents in double or triple rooms along with staff turnover as high as 100% unavoidably creates a high risk for resident safety and compromises quality of care.

We've all read the stories about the horrors occurring in the nursing homes as the pandemic rolls across the country (for patients and caregivers too). A number of calls for change have been made, but as Sabatino aptly observed, "

[M]ultiple recommendations for change have gained attention. They include ensuring adequate personal protective equipment in nursing homes; disaster plans that facilitate quarantining; more and better trained staff and heightened monitoring and oversight of care.

But let’s be clear: These measures do little more than rearrange the deck chairs in a failing system.

The COVID-19 pandemic is a 9/11 moment for nursing home care and a test of our ability to reimagine nursing home care that puts the “home” into nursing homes.

Sabatino then turns to specifics regarding change and suggests the key to change is to tie it to Medicare and Medicaid funding. 

As the largest payor for nursing home care, Medicare and Medicaid hold the key. Now is the time to change facility requirements to gradually limit participation in the program only to facilities that provide the following:

• Small home-like facilities

• Single rooms and bathrooms

• A flattened, more flexible staff hierarchy with cross-trained staff

• A culture focused first on residents’ goals, interests and preferences.

Sabatino concludes "[a]s long as the nursing home industry can rely on the flow of federal money for the current model of care, it has no financial incentive to change, not even after the coronavirus catastrophe. ... Change that flow, and a major cultural change in long-term care will follow."

Hello Congress??

Stay safe and healthy everyone.

Assessing Your COVID Risk To Go Outside When You Are Older?

When I read the following New York Times article, all I could think of was the Clash song, "Should I Stay or Should  I Go?  The article, You’re a Senior. How Do You Calculate Coronavirus Risk Right Now? focuses on the decision to stay home or to venture out into the world (with precautions of course) when you are in a high risk group (or any group for that matter but this is the elderlawprof blog!)

"Early on in the pandemic, most public health officials warned older adults to simply stay at home, except to buy food or medicine or exercise outdoors apart from others. Now, with states and cities reopening (and some re-closing) at varying paces, the calculations grow steadily more complicated."

What to do? What to do? One study from MIT economists "in a recent paper suggesting age-targeted lockdowns ... proposed protecting people over 65 by having them isolate for an estimated 18 months until a vaccine becomes available; younger people, facing less health risk, would return to work."  As the article notes, that "approach also assumes that older adults’ only  interest lies in not dying."  Well, that is a big one, but still.....

There's so much info out there, what is one to do?  The article offers a couple of insights

A calculator developed by researchers at the Cleveland Clinic may provide a clearer sense of individual risk.

Geography matters too. Older people in New Hampshire or Maine — where new cases were falling last week — may reasonably opt for less restrictive behavior than those in Florida and Arizona, where Covid has been surging. Pay attention to which counties are seeing cases rise and which are doing a good job at observing guidelines.)

So in the meantime, back to the question asked by the Clash..."should I stay or should I go".... places....

(P.S.-I'm from Florida, so I'm staying for now).

 

NYT: Boom(er?) Time for Planning where Death Triggers Next Events

The New York Times has an article that might be particularly useful for faculty members teaching Wills, Trusts & Estates or Elder Law courses in the Fall.  

From the article, titled "Boom Time for Death Planning:"

The coronavirus pandemic has drawn new buiness to startups that provide end-of-life services, from estate planning to a final tweet. . . . 

Before the pandemic, end-of-life start-ups — companies that help clients plan funerals, dispose of remains and process grief — had experienced steady to moderate growth. Their founders were mostly women who hoped a mix of technology, customization and fresh thinking could take on the fusty and predominantly male funeral and estate-planning industries.

Still, selling death to people in their 20s and 30s wasn’t easy. Cake’s team sometimes received emails from young adults, wondering if the site wasn’t a tad morbid. Since Covid-19, this has changed. Millennials are newly anxious about their mortality, increasingly comfortable talking about it and more likely to be grieving or know someone who is.

Interesting Reactions to a Standard Question for Mini-Mental Exams: Who is the President?

As most of us who have accompanied an elderly parent to a doctor are aware, standard questions in most mini-mental exams include asking the individual to identify the day of the week and the date, and to name the president of the United States.  During my mother's physical decline after age 90, she was watching cable news programs obsessively and we later joked that we should have paid more attention to her when she insisted during the summer of 2016 that the "polls predicting Hillary Clinton's election are wrong."  After the election, when asked to identify the president, she would cast a rueful gaze on the questioner and make it clear she both knew who it was and whether she approved.

But apparently there is a much deeper history to older persons' responses.  Without getting too political about my selection here, the history can be summarized in one report from a recent twitter feed:

"I work as a Paramedic and often one of my questions for patients to determine cog is to ask who the president is.. The replies I get are often correct and almost always followed up with interesting adjectives. I've been doing this 26 years and only last few [have] been that way."

Some of the other comments involve more poignant humor, but, still, interesting!  Can you get "extra credit" points on a mini-mental exam? 

Are Older Adults Now the Proverbial Canaries in the Global Mines?

During an AALS-sponsored online "hang-out" session this week, the featured host, Syracuse Law Professor Nina Kohn, helped faculty think about better ways to conduct online courses, including Elder Law.  We also talked about our research projects for the summer.  Nina commented that she has never before had "so much to write about and so little time to do so," which I suspect has something to do with her wonderfully active children!  But, I also think that most of us in the AALS Section on Law and Aging are feeling the same way.  It is as if our client base -- older persons -- are at the epicenter of so much tragedy.  Sadly, the COVID-19 illness has hugely impacted older persons, as documented frequently on this Blog.  

And now the news that in Japan, seasonal rains that have become steadily worse over the years for reasons associated with climate change, have triggered extraordinary flooding, resulting in the drowning deaths of many elders in their nursing homes or while trying to shelter at home.  From the New York Times article, Japan's Deadly Combination: Climate Change and an Aging Society:yAlthough the Japanese gird every June and July for the rainy season — known as tsuyu — this year the rainfall has set records in Kyushu, with more rain expected to blanket central Japan by the end of this week.

 

Older residents accustomed to year after year of summer rains may believe they know how to ride out the downpours at home. Yet they may not understand the growing severity of the rains or the increased dangers of flooding.

 

“Under the emerging impact of global warming, there is an increasing risk or potential that rainfall amounts could be at a level that we haven’t experienced in the past,” Professor Nakamura said. “So I think that citizens must realize that their previous experience may no longer work. We have to act even earlier or faster than what we have experienced in the past.”

 

Evacuation itself can pose a risk to the elderly. Conditions in evacuation centers inevitably fall short of those in nursing homes designed for old-age care. For the frailest patients, the moves can cause injury or destabilize long-term care plans....

 

In the case of the Senjuen nursing home, Aki Goto, its director, told The Kumamoto Nichinichi Shimbun, a local newspaper, that she had been more concerned about mudslides than flooding. When the waters came, she added, the caregivers could not move quickly enough to move all the residents upstairs.

 

Six of the workers were on call the night of the floods last weekend, the newspaper reported. That still left each caregiver in charge of more than 10 aging residents, some of whom were unable to walk without help. Even with the aid of local volunteers, they could not bring everyone to safety upstairs as the floodwaters rapidly rose and deluged the ground floor.

Whether it is hurricanes in the Carribean and US, wildfires in western US states, extraordinary storms or unique diseases around the world, our elderly are often seeming to take the heaviest blows.  Isolated and with inadequate protective equipment or assistance, the pattern of "unexpected" deaths continue.  Unexpected?  

 

Upcoming in July: AALS/CLEA Virtual Clinical Conference to include Pandemic-Impact Speakers on Clinics that Serve Older Adults

AALS's Clinical Section and CLEA are hosting a free Virtual Clinical Conference that begins Tuesday, July 21, running through Thursday, July 23.  The conference offers two plenary sessions, a webinar, asynchronous videos, large group discussions, small group discussions focued on specific topics or within affinity groups, very timely programs sponsored by Clinicians of Color, and a final community building session.

Jam-packed! -- but also easy to navigate through the virtual platform.  Here's the link to the full schedule.  The sessions will begin each day at noon, Eastern Daylight Savings Time. Register for the Conference here.  

And did I mention it is FREE?!

Elder Law/Disability Law Clinical gurus Martha Mannix (University of Pittsburgh) and Mary Helen McNeal (Syracuse) will be facilitators for three afternoon sessions on "Student Representation of Elderly and Special Needs Clients in Virtual and COVID World" and the brainstorming topics include: 

    1. Discussion on how we might reimagine our encounters with our elderly clientss or clients with disabilities through communications technology or creative reconfiguring of in-person client meetings.

    2. Discussion on the role of students.  Does the COVID-19 emergency require us to restructure or reimagine the role of the clinic student and our supervision of them in light of the challenges presented by remote learning and representation and institutional desires to shield student from risk?

    3. Discussion on whether we might consider altering the nature of our legal work in clinical settings: Is this the moment best met by continuing individual representation or should we turn our ckubucak efforts to addressing systemic issues or engagement in policy advocacy?  

And to add to the intrigue -- the final session of the three-day program includes a Dance Party!  Let your inner "Hairspray" shine! 

What Does It Mean to Do Contact Tracing for Communicable Diseases, Especially for Air Travelers?

Last month I made my first roundtrip, domestic airline flight following 90+ days of lockdown and gradual easing of travel restrictions.  I scheduled this quick trip cautiously, for family-related reasons, and with a goal of returning to my Pennsylvania home well in advance of any return to work with students in my law school. I'm not a timid flyer, but I did my best to try to minimize risk factors, including selection of an airline that advertised "vacant" middle seats, masking requirements, and updated standards for cleaning the airplane and social distancing. I am writing here because an individual on the return leg of my flight in my same row (but across the aisle) became seriously ill during the flight. This post is about my growing concern about what it means to respond to the potential for a communicable illness while traveling, especially but not exclusively in the time of COVID-19. 

When the individual became ill (seeming to lose consciousness and vomiting-- more ill than what I associate with "mere" air sickness), the flight attendants responded to his needs with plastic bags and napkins.  On the positive side, they kept everything low key and talked to the individual softly.  I think it was another, closer passenger who summoned them and everyone tried to respect the privacy of the individual.  Eventually, the ill passenger was moved to the rear of the plane.  Shortly after that, all passengers were informed the seatbelt signs had been activated and everyone should stay in their seats for the remainder of the flight.   There were no further announcements and nothing said about the ill passenger specifically. When the flight arrived at its regular destination, I did not see the individual leave the plane.

What does it mean for any state health department or CDC program official to say they will follow a plan for contact tracing?  Each step of the process needs clarity, including that first step of identifying the ill traveler and other potentially affected travelers, right?   

I received a traditional customer satisfaction "survey" form from the airline the morning of my return via email, asking me to describe the flight. This made me realize that I should be talking directly to the airline about this specific incident.  Was the individual in question experiencing a communicable illness, especially COVID-19?  I made a short, emailed report to the airline less than 12 hours after the end of the flight, and made a follow up inquiry and a second report by telephone and email.   The most I have learned is that the airline is "researching" whether there is any record of the incident or illness on board that flight.  Taking a week (or more?) to determine whether the crew made a report is not reassuring. At a minimum, shouldn't there be a record of that plane being taken out of service for some period of time for cleaning?  

The Pennsylvania governor, for reasons unrelated to my account above, has recently asked all residents returning from the departure state in question (and certain other states experiencing surges in COVID-19) to self-quarantine for 14 days. That makes sense.  Even though I had been exceptionally careful during my time out-of-state, the airline incident was a stark reminder that travel, even with the lessons learned during the last several months, involves factors that are completly outside the control of any of the passengers.  "Being careful" on an individual basis may not be enough and when something happens that involves risk to others, we need clear lines  for any investigation and communication.    

Everyday we are learning new things about how to deal with communicable illnesses, including ones that may be life-threatening. I think what I'm realizing is that as individuals and consumers, we cannot be passive about these steps.

I contacted the CDC and was told there is a process for "contact investigations" by the CDC, but that triggering such an investigation cannot be done easily, at least not if you are a mere passenger.  They recommended I contact the health department in the state where my plane landed.  Here is what CDC sent me by email:  https://www.cdc.gov/quarantine/contact-investigation.html

Weaknesses clearly exist in the protocols. The airline and CDC have been quick to warn me that they cannot give any information about the "patient."  I'm not asking to know the patient's identity in any way. But shouldn't any potentially affected traveler be entitled to know:

a. Whether there was a report of the illness made by the crew to the airline and/or other authorities.

b. The result of any investigation, especially in terms of public health implications.

c.  Whether a specific, communicable illness or disease was identified.

d.  Whether there are specific steps that should be taken by passengers in light of the history.

Shouldn't the CDC want to know whether others on that plane have experienced similar symptoms? (Thankfully, I have not, but although I was in the line of sight of his seat, there were others between us, and in front and behind him, who were much closer.)  I have realized that short of contacting every passenger on the plane, it might be difficult  for some airlines to help with "contact" tracing. They may be relying on a manifest rather than a chart for assigned seats.  Certainly, no one asked me or other, closer passengers on the flight for contact information. I hope the ill individual has recovered fully and quickly, and that for his sake this was a temporary illness.  I'm being calm, even as I'm frustrated.  I'm frustrated not just for myself, but for the larger public.  The  passengers on this plane included all ages, including older individuals.  Earlier during my trip, I overheard one older traveler say to another, "I just want to live long enough to see my grandchildren again."

CMS Coronavirus SNF Commission

More good news from CMS-the members of the Independent Coronavirus Commission on Safety and Quality in Nursing Homes have been announced.  The 25 experts

The commission members are:

• Roya Agahi, RN, MS HCM, WCC; Chief Nursing Officer, formerly of NYC Health + Hospitals, soon to be of CareRite, New York

• Lisa M. Brown, PhD, ABPP; Professor of Psychology, Palo Alto University, California

• Mark Burket, CEO, Platte Health Center Avera, South Dakota

• Eric M. Carlson, JD; Directing Attorney, Justice in Aging, California

• Michelle Dionne-Vahalik, DNP, RN; Associate Commissioner, State Health and Human Services Commission, Texas

• Debra Fournier, MSB, BSN, ANCC RN-BC, LNHA, CHD, CPHQ; COO, Veterans’ Homes, Maine

• Terry T. Fulmer, PhD, RN, FAAN; President, The John A. Hartford Foundation, New York

• Candace S. Goehring, MN, RN; Director, State Department of Social and Health Services, Aging and Long-Term Support Administration, Washington

• David C. Grabowski, PhD; Professor of Healthcare Policy, Harvard University, Massachusetts

• Camille Rochelle Jordan, RN, BSN, MSN, APRN, FNP-C, CDP; Senior Vice President of Clinical Operations & Innovations, Signature Healthcare, Kentucky

• Jessica Kalender-Rich, MD, CMD, AGSF, FAAHPM, FACP; Medical Director, Post-Acute Care, University of Kansas Health System, Kansas

• Marshall Barry Kapp, JD, MPH; Professor Emeritus of Law, Florida State University, Florida

• Morgan Jane Katz, MD, MHS; Assistant Professor of Medicine, Johns Hopkins University, Maryland

• Beverley L. Laubert, MA; State Long-Term Care Ombudsman, State Department of Aging, Ohio

• Rosie D. Lyles, MD, MHA, MSc, FACA; Director of Clinical Affairs, Medline Industries, Illinois

• Jeannee Parker Martin, MPH, BSN; President and CEO, LeadingAge California

• G. Adam Mayle, CHFM, CHC, CHE; Administrative Director of Facilities, Memorial Healthcare System, Florida

• David A. Nace, MD, MPH, CMD; President, AMDA – The Society for Post-Acute and Long-Term Care Medicine, Pennsylvania

• Lori Porter, LNHA, CNA; CEO, National Association of Health Care Assistants, Missouri

• Neil Pruitt, Jr., MBA, MHA, LNHA; Chairman and CEO, PruittHealth, Inc., Georgia

• Penelope Ann Shaw, PhD; Nursing Home Resident and Advocate, Braintree Manor Healthcare, Massachusetts

• Lori O. Smetanka, JD; Executive Director, National Consumer Voice for Quality Long-Term Care, Maryland

• Janet Snipes, LNHA; Executive Director, Holly Heights Nursing Home, Colorado

• Patricia W. Stone, PhD, MPH, FAAN, RN, CIC; Professor of Health Policy in Nursing, Columbia University, New York

• Dallas Taylor, BSN, RN; Director of Nursing, Eliza Bryant Village, Ohio

Here's the info about the Commission's mission:

The Commission will conduct a comprehensive assessment of the overall response to the COVID-19 pandemic in nursing homes. Based on its assessment, the Commission will make recommendations on actions and best practices for immediate and future actions.  Three key areas of focus for the Commission include:

• Ensuring nursing home residents are protected from COVID-19 and improving the responsiveness of care delivery to maximize the quality of life for residents;

• Strengthening efforts to enable rapid and effective identification and mitigation of COVID-19 transmission (and other infectious disease) in nursing homes; and

• Enhancing strategies to improve compliance with infection control policies in response to COVID-19.

Crossing my fingers....

Topics and Speakers Announced for AALS January 2021 Program on Intersectionality, Aging and the Law

Hard to believe we are scheduling for January 2021, isn't it!  Here's the scheduled speakers and topics for the co-hosted program during the AALS Annual Meeting in San Francisco on "Intersectionality, Aging and the Law:"

• 
  Alex Boni-Saenz (Chicago-Kent), Age Diversity
• 
  Naomi Cahn (GW) & Nina Kohn (Syracuse), How Law and Sex Shape What It Means to Be Old
• 
  Veronica C. Gonzales-Zamora (UNM), The Triple Threat: Millenium Women of Color
• 
  Jessica Mantel (Houston), Allocating Scarce Medical Resources During a Pandemic: Rationing Based on Age is not the Same as Rationing Based on Disability
• 
  Katherine Pearson (PSU-Dickinson), Pandemic Protections: Where is the Line in Patient Autonomy?
• 
  Tara Sklar (U Arizona), Frailty, Vulnerability, and Big Data
• 
  Ruqaiijah Yearby (SLU), The Dark (Trinity): How Structural Discrimination, Wealth Inequalities, and Lack of Access to Health Care Cause Health Disparities for Elderly Women of Color

Washington State Bar ended Limited License Legal Technician Program

Although not specifically elder law, still an important update for us. According to a recent article in the ABA Journal, Washington Supreme Court sunsets limited license program for nonlawyers. As originally planned, the program would focus on family law and then expand into elder law.  "The court’s 7-2 vote last Thursday to prohibit anyone not already in the LLLT pipeline to pursue the license comes just eight years after the court approved the creation of the first such legal license for nonlawyers in the country. Several other states have since approved—or have considered approving—similar programs." The article notes that costs of the program and the lack of interest in the program as the reasons for the Court's decision. Those licensed will be able to continue as an LLLT but no new individuals will be licensed after July 31, 2021.

Using Advanced Age as a Factor in Rationing Health Care? Consider the Arizona COVID-19 Crisis Plan

I've recently returned from a week in Arizona with family.  I managed to arrive in Phoenix just in time for a surge in COVID-19 cases, traffic headaches connected to President Trump's campaign visits, a couple of new wildfires, and a few more degrees up the summer temperature gauge.  Probably the most newsworthy part of the trip was the announcement by Arizona authorities that the state was activating a COVID-19 crisis plan that involves triage -- or "rationing" as some  people interpreting the plan are calling it.  One component of the Arizona plan involves "protocols for scarce resource allocation."  An Arizona public statement describing the protocols attempts to reassure the public (emphasis provided with blue color):

If resources are sufficient, all patients who can potentially benefit from therapies will be offered therapies. If resources are insufficient, all patients will be individually assessed. No one will be categorically denied care based on stereotypes, assumptions about any person’s quality of life, or judgement about a person’s “worth” based on the presence or absence of disabilities.

All patients, regardless of resource availability, will be treated with respect, care, and compassion. Triage decisions will be made without regard to basis of race, ethnicity, color, national origin, religion, sex, disability, veteran status, age, genetic information, sexual orientation, gender identity, quality of life, or any other ethically irrelevant criteria.

When resources become inadequate -- implicit in the Governor's recent news conferences -- triage involves a color-coded system of triage "priority scores."  According to the statement, "All patients will be eligible to receive critical care beds and services regardless of their triage score, but available critical care resources will be allocated according to priority score, such that the availability of these services will determine how many patients will receive critical care."

The guidelines indicate health care providers must make an active assessment of the "patient's goals of care and treatment preferences.  It is imperative to know whether aggressive interventions such as hospitalization, ICU admission or mechnical ventilation are consistent with a patient's preferences.... All hospitalized patients should be asked about advance care planning documents, goals of care, and are strongly encouraged to appoint a proxy decision-maker (e.g., medical durable power of attorney... or health care agent) if not previously in place.  Patients in nursing homes, skilled nursing facilities, other long-term care settings, and outpatient care settings should also be asked about their goals of care and advanced care planning documents.... If advance clare planning documents are in place and available the healthcare provider should verify the patient's goals of care and treatment preferences remain the same....."

Will the patient's age, especially an advanced age, be relevant to a Arizona's Covid-19 crisis plan?  On the one hand, the guidelines indicate "age" is  expressly "removed ... as a specific factor for Triage Priority scores or Triage Color Groups."  On the other hand, when determining the Triage Priority Score, points assessed must reflect an evaluation of whether the patient is "expected to live more than 5 years if patient survives the acute illness [zero points added]" or whether death is "expected wtihin 5 years despite successful treatment of acute illness [2 points added]." If "death [is] expected within 1 year regardless of successful treatment of the acute illness," 4 points are added.  The patient's prioritization for critical care resources is best with a low score (1 to 3 total points), while priority is reduced to "intermediate" (4 to 5 points) or "lowest," if they are assessed with more than 6 total points.  Further, "age" is implicitly involved as the prioritization process somehow examines the specific patient's "opportunty to experience life stages (childhood, young adulthood, middle years, and older years)."

These are obviously tough calls in any health care assessment contect, but especially so in the middle of a pandemic.  Public health professionals have experience with these kinds of assessements. I suspect that many families also have engaged in a type of informal assessment when serving as a loved one's health care spokesperson or agent. 

My sister and I were thinking about last summer as I visited this summer.  Last summer, the two of us talked about similar factors when making the call on whether our mother would have hip-surgery at age 93 following a fall-related fracture.  The doctor said that without the surgery our mother was unlikely to walk again because of pain; with the surgery there was a significant chance she would be able to walk without pain.  She ended up sailing through the surgery -- and began taking steps again the same day.  Ironically, probably because of her increasing dementia, she had no fear of falling nor any memory of the surgey and thus was soon fully ambulatory (although she did sometimes substitute a walker for her occasional cane) and remained so for all but the last few days if the next six months of life.  That took her into the summer of 2019 in Arizona.

If the cornonavirus pandemic had occurred in the summer of 2019, and if safe access to hospitals and surgery were the issues, my best guess is Mom would probably have had a "high" score on any health care triage assessment -- in other words, not good news.  We are glad we never confronted decisions about respirators or ventilators.  We do know that our very elderly mother had a much better quality of life with major surgery than she would have had without it. Just one case, of course.  Again, tough calls (and yes, expensive calls for Medicare) with or without a pandemic to complicate the decision process.