Extensive surges of patients coupled with shortages of staff and resources throughout the COVID-19 pandemic have contributed to repeated crises in US hospitals and health care facilities. 1 During the recent wave of infections in mid-July through mid-November 2021, more than 1 million individuals with COVID-19 were admitted to hospitals, 156 382 of whom died of COVID-19 complications. Most of these hospital admissions and patient deaths were preventable through widely available and efficacious SARS-CoV-2 vaccines. Still, nearly 40% of vaccine-eligible people in the US are not fully immunized, 2 suggesting additional patient surges are foreseeable in 2022.Decisive actions among doctors, hospitalists, and health officials aim to allocate available treatments, resources, and personnel to avoid limiting patient access to services. Yet, in select hospitals, regions, and states, scarcities have warranted shifts to crisis standards of care (CSC). 3 Legal invocations of CSC vary. Governors in Alaska, Arizona, Idaho, New Hampshire, and New Mexico have formally invoked CSC. Declarations of emergency in Utah may automatically activate existing facility CSC plans. Kansas and Tennessee expressly allow hospitals to shift to CSC on their own initiative.Georgia, Ohio, Oregon, and other jurisdictions that lack statewide CSC plans rely on regional and/or local activations. No matter how CSC is invoked, its goal remains the same: to "extend care to as many patients as possible and save as many lives as possible." 4 Substantial Legal Challenges in CSC ImplementationAchieving this goal raises considerable legal challenges for hospitals and clinicians, including concerns with licensure, privileging, scope of practice, clinical duties, and liability. Many of these concerns are resolved through existing federal or state emergency declarations, compacts, or agreements offering a slate of legal options to facilitate CSC implementation. Among the most controversial legal issues at the core of CSC, however, is the need to make tough choices in real time when too many patients need immediate access to staff, beds, equipment, and treatment. Allocating health services in these tiebreaker situations invariably means that some patients are denied access to resources in favor of other patients.Consequences can be dire. A recent study showed that health resource availability (eg, staff and beds) was statistically correlated with heightened COVID-19 mortality rates across thousands of US hospitals in April 2020 5 -patients with COVID-19 have died waiting for access to intensive care beds.Consistent with CSC plans, hospital triage committees and clinicians responsible for tiebreaking decisions must balance medical, ethical, and practical factors while avoiding illegal criteria. Manifold considerations, including patients' race and ethnicity, skin color, and sex, are expressly forbidden from the decision-making process by law. In March 2020, the US Health and Human Services (HHS) Office for Civil Rights warned states to avoid unlawful discrimination ...
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