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Here is the weekly update from the Colorado Senior Lobby Legislative Committee
This week, we have information on two important issues to share with you. (The Legislature is still on recess.)
First is information on a recently requested review of certain specific criteria in the Governor’s Crisis Standards of Care. Next is, not coincidentally, information on advanced care planning. Each of these is tied to the CSL-sponsored SB20-022 Increase Medical Providers for Senior Citizens. (Please keep this in front of your legislators; the fight for passing that bill is not over yet.)
Crisis Standards of Care Review Request
Many states, including Colorado, have in place something akin to what Colorado calls Crisis Standards of Care. The idea behind these is provide guidelines for hospitals and other acute care facilities to decide which patients receive ICU beds and/or ventilators in times of overwhelming demand—a real emergency.
The use of these guidelines is limited to situations in which a state governor has declared such an emergency situation. Colorado is NOT in that situation as yet, and hopefully will never be. This is one of the key reasons for stay at home, wear a mask in public, and social distancing orders; to try to ensure that these Crisis Standards of Care are not needed.
Triage, in the military, has been around for hundreds of years. In battle, where soldiers and civilians are being severely wounded and resources to help them are very limited, it is absolutely necessary. Now, with our world in a war of sorts, it continues to make sense. At issue now are the triage standards—which we may yet need here in Colorado—and how they are applied.
Clearly, these are gut-wrenching decisions no health care provider wants to make.
Yet, in reading this CSC document closely, it brings up serious concerns for many of us in the aging advocacy arena; specifically around how AGE is used in the triage process during current and future pandemics. Under the current standards, which again are not currently in effect, AGE looms large as a determinant in the triage process.
CSL, and many other groups in Colorado, and across the country (Link to Group Sign on Letter to Office of Civil Rights – CLICK HERE), have expressed concern about this. As it stands now, anyone over the age of 50, regardless of otherwise good health, would be given “triage points” in the event that these standards were in effect. If the patient has certain underlying health conditions that person gets more points.
This is a situation where you want fewer points, not more.
Last week, after much deliberation and research, we addressed Governor Polis and asked for a review of specific language related to AGE as a criterion in the recently updated 25-page Crisis Standards of Care document. The document itself is not new; it is updated periodically, and this most recent update was done COVID-19 in mind.
The body that does this work is called the Governor’s Expert Emergency Epidemic Response Committee (GEEERC). It is composed mainly of physicians. (There was no geriatrician included.)
Since those standards are not currently in use, because we in Colorado currently have adequate acute care resources to deal with COVID-19, we have some time to deliberate those concerns; and have asked to do so.
A recent article written be a renowned geriatrician and author in the New England Journal of Medicine provides more background on our concerns:
You may also wish to read two recent articles in the Colorado Sun addressing the triage topic.
We will keep you updated on progress with our very specific CSC review request.
One last thing here: we are all well-aware of the crises in nursing homes across the country. Geriatric experts, writing about the nursing home situation, have strongly recommended integrating geriatrics and palliative care experts with the requisite skills in advanced illness care, nursing home administrators and those with experience in local coordination and data analysis, which must include information from nursing homes—as a key to confronting COVID-19 in nursing home communities across the U.S..
Please continue to be smart about your health and follow the most recent guidelines for living which are currently in effect. No one likes staying at home, wearing a mask, maintaining social distancing and the resultant economic impact and loss of jobs; it’s truly painful for many, many, people. But please also ponder, after reading all the information above, the alternative. We do NOT want any part of Colorado’s medical system to be overwhelmed as New York City’s has been.
ADVANCED CARE PLANNING
Free webinar coming up April 22: https://www.civhc.org/event/free-webinar-explore-advance-care-planning/
From the Governor’s Crisis Standards of Care (paraphrasing/summarizing):
All efforts must be made to determine a patient’s goals of care prior to being in a critical situation (in other words, NOW).
Health care providers need to know whether a given patient wants to receive aggressive critical care interventions such as ICU admission or mechanical ventilation. For a patient with decision-making capacity, the individual’s preferences to refuse hospitalization, life support like mechanical ventilation, and resuscitative efforts should always be respected.
In current circumstances, ALL hospitalized patients will be asked about Advance Directives (ADs), goals of care, and strongly encouraged to appoint a proxy decision-maker (e.g. medical durable power of attorney (MDPOA)). Patients in nursing homes, skilled nursing facilities, and other long-term care settings should also be asked about Advanced Directives and encouraged to appoint a proxy who is aware of their wishes regarding hospitalization and critical care.
These actions can help prevent the healthcare system from being overwhelmed with patients who may not want critical care interventions.
Have those family and friend conversations; collaborate and make informed decisions. While all of us need to have these conversations, it is especially important for those who are over 60 years old and are living with a chronic health conditions such as heart, lung or kidney disease or cancer. Once you are laying in an ICU bed, it’s too late; and if you are critically ill, you will likely die alone. We’ve all seen those stories; you can choose a different path, but you must act now.
The Conversation Project has the most updated COVID and Advanced Directive resources in an easy to find format; it is an excellent resource and we highly recommend it. We also list other resources below.
Please also consider taking these three steps now:
- Appoint someone as your medical decision maker (MDPOA)
- Talk about your wishes with the MDPOA,
- Talk about specifics for COVID.
Additional Advance Care Planning Resources
To access the Medical Durable Power of Attorney Document MDPOA form you need (you do not need a lawyer for completing this and if you have this document already and it’s current with your wishes, you don’t need to create a new one).
- Link to Colorado MDPOA Form – CLICK HERE
- Colorado Care Planning offers content in English & Spanish with large text option
- Colorado Care Planning ofrece contenido en inglés y español con opción de texto grande
- COVID-19 Treatment Decision Guide (one-page)
If you go to the hospital and become seriously ill, these are the questions you will likely be asked – CLICK HERE
- Remembering the Heart in Turbulent times
The greatest gift we can give another is our full and heartful presence. The elements of
presence described below have had a significant impact on grief outcomes and on how
resilient a person can be during crises – READ MORE
- More Resources, including information for caregivers:
Source: Colorado State University Extension
- Advance Planning Resources from Center for Improving Value in Healthcare – CLICK HERE
We cannot predict every choice we may have to make, but we can give those we love the guidance to confidently make decisions for us. This is the time to help the people closest to us – our friends, our spouses, our parents or grandparents – get the care that is right for them if they become seriously ill with COVID-19.
Feel free to share this information with others as all of us need to have these important conversations.
President—Colorado Senior Lobby
303 832 4535
303 862 8711
Sources of this information include:
- Colorado Care Planning
- Colorado Healthcare Ethics Resource Group
- Colorado State University Extension
- Governor’s Crisis Standards of Care
- The Conversation Project
- The Conversation Project Boulder