The UT Southwestern COVID ward last summer, when the pandemic was nearing its peak. Elizabeth Lavin

Public Health

Dallas Hospitals Did Not Agree to Triage Based on Vaccination Status

The Dallas Morning News rushed a big story that doctors say does not reflect reality at North Texas hospitals.

Yesterday afternoon, the Dallas Morning News published a story with the online headline (that has since been changed on its site) “If North Texas Runs Out of ICU Hospital Beds, Doctors Can Consider a Patient’s Vaccination Status.”

That’s a big, bold, and incorrect headline made to draw internet and TV broadcast attention, which is exactly what happened. The story, written by Dave “The Watchdog” Lieber, omitted some crucial details that would have helped the public understand what doctors are exploring. This was never a policy, according to the doctors involved, but a discussion about the ethics of instituting such a policy if the situation grew severe enough. The headline was hysterical bombast, and the story weaves between what is set in stone and what is not.

Let’s talk about something called Mass Critical Care Guidelines. The state has no set “standards of care” policy if demand at a region’s hospitals outpaces the supply of beds or equipment. That leaves it up to the individual regions to come together and design a triage plan for their service area that does not discriminate based on someone’s race, gender, economic status, disability, or other factor in case hospitals run out of ICU beds or ventilators.  

The guidelines require clinicians to employ a number of assessments to determine how patients are triaged. These include the internationally recognized SOFA score, which is an acronym for sequential organ failure assessment, and about a half dozen other assessment tools to inform decision-making. The doctors say they were considering whether to add vaccination status to these metrics. But they had not determined it to be a formal guideline.

Here is what is supposed to happen when the critical care guidelines kick in:

The overall goal is to save as many lives as possible. When a patient is so ill due to any cause that survival to hospital discharge is unlikely, it is not reasonable to allocate scarce life sustaining resources to that patient. Such patients will be triaged to supportive palliative care or hospice care, allocating the scarce life sustaining treatment to patients judged more likely to survive to discharge.

These processes are triggered when hospitals reach certain levels of staffing, bed, or equipment scarcity. As Lieber correctly notes, these guidelines are not enforceable but are generally followed by our hospitals. That is why there is broad participation from local hospital systems and community stakeholders on the organizing group that discusses these issues.

The entity responsible for developing this plan is the North Texas Mass Critical Care Guideline Task Force. It’s made up of about three dozen physicians, hospital staffers, public officials, faith leaders, and disability advocates. Developing this plan requires lots of research and discussion, and the process is meant to respond to whatever specific public health emergency or disaster is driving a run on hospital beds and equipment. Local medical societies began developing such a plan after the SARS outbreak in 2003 and 2004. They wanted to be prepared in the rare case that demand outpaced supply. We’re getting really close to that moment. The first plan was approved in 2010; it has been updated since, with guidance from the federal government. You can read the current guidelines right here.

This January, the Office for Civil Rights at the U.S. Department of Health and Human Services announced that it had worked collaboratively to revise the crisis standards of care with North Texas’ task force, as well as similar entities in southwest Texas, the state of North Carolina, and the Indian Health Service. The OCR ensured that these plans did not violate any federal anti-discrimination laws, like Title VI of the Civil Rights Act of 1964. It endorsed each plan; if North Texas changes its strategy, it could imperil that “seal of approval” if the new policy winds up discriminating against someone.

“These plans will help ensure older persons and persons with disabilities are not excluded from health care based on judgments that their lives are somehow less worthy of saving,” read a statement from OCR director Roger Severino at the time of the approval. “Everyone should be treated with equal dignity and respect, and these plans reflect these foundational principles.”

The efforts of the task force earned praise from groups like Disability Rights Texas, which declared that, without the guidelines, “persons with disabilities and older adults in Texas may continue to find themselves subject to discriminatory rationing, placing their lives at risk.” (Disability Rights Texas helped form the guidelines.)

COVID-19 has been shape-shifting since it arrived in March 2020. It would be surprising if our local task force weren’t debating whether to begin accounting for vaccination status. There are currently 22 staffed ICU beds available in Dallas County and 20 in Tarrant. The flood of patients could happen quickly. But it doesn’t appear that the idea of incorporating vaccination status was anything more than a discussion point, which is how this group creates the critical care plan. And yet the News story presented it as an imminent policy. It is worth reporting that the task force discussed vaccination status, but there is no evidence that this was ready for implementation.

“The memo referenced in recent media reports was created for internal discussion only and does not represent any decisions made to modify the guidelines in any way,” read a prepared statement from Dr. Mark Casanova, the chair of the task force. Casanova declined to chat with D Magazine, instead referring to on-camera interviews conducted Thursday night, after the News story had run, in which he clarified the matter as a discussion item before saying it would not be implemented. (The News reported that Casanova “revised his story” and characterized it as a “reversal.”)

Here is how we got here: Lieber was leaked an email, and then he interviewed “doctors involved in the decision for two hours,” including Casanova. That email included three bullet points, which read like a series of tumble-down resolutions: because the COVID-19 vaccine significantly reduces hospitalization and death, vaccination status should therefore be “part of the physician’s assessment of each individual’s likelihood of survival.” It includes carve-outs for patients who did not have proper accommodations to receive the vaccination, meaning they didn’t willfully turn down a jab. And, finally, triage decisions should prioritize individuals who are most likely to survive their ailments.

Lieber reported that Dr. Robert Fine, the task force’s co-chair, asked participants to take these recommendations to their respective organizations for consideration. Of course they would do this; the guidelines are the result of a collaborative discussion across our hospitals.

In Lieber’s defense, and in the context of the angle of the story, Fine and Casanova speak like men attempting to defend a decision. But taken within the context of the task force’s operations, it can also read like experts trying to determine the impact of incorporating vaccination status as an element for triage. Lieber’s story never settles on how firm this decision was, and the headline flat-out declares the policy as reality.

The News wouldn’t allow Lieber to comment when I contacted him. The paper has written about this task force before. In April 2020, Fine and Casanova and a few others briefed the editorial board on the critical care plan. The board nailed its purpose:

But there is also a chance that the virus spreads more quickly than all of our emergency preparations and that those who manage our health care system will be faced with the toughest choice imaginable: deciding which patients to prioritize while administering limited, if also critical, forms of care when the number of patients overwhelms our hospitals. For example, the need for ventilators — a crucial device for treating someone struggling to breathe — could end up outstripping the number of devices available.

This whole ordeal here in Dallas, with the paper running a hysterical headline, feels like our version of what happened when the Washington Post was leaked a CDC PowerPoint that included a slide that indicated the new delta variant of the coronavirus was as contagious as chickenpox. The paper reported it, and it went everywhere. Then the report later was shown to be off the mark; the CDC was using the slide as a discussion point.

The vaccination story in Dallas is also reminiscent of the news outlets that used the Provincetown, Massachusetts, study of an outbreak among vaccinated people to inform its news reporting on post-shot “breakthrough” infections. Most didn’t note that Provincetown was a total outlier, a major party that packed bars, restaurants, and homes for over a week with thousands upon thousands of men—behavior that is more of a weekend than a lifestyle.

Fine even wrote an editorial in the News last year detailing this critical care plan: “The county medical societies and hospitals in North Texas have all pledged to follow these regional guidelines. We hope and pray we will not need to activate the full guidelines, but we are worried that the time will come, and thus our desire for our entire North Texas community to understand the guidelines in advance.”

It was clear from Lieber’s story that Fine and Casanova were not prepared to present this matter to the public. But the News rushed forward, sacrificing the nuance that would help the community understand what is happening among the people charged with prioritizing our treatment.

Lieber’s claim that he spent two hours interviewing doctors involved in the task force is a clever transition device, but it also shows that this needed more time and consideration before reaching the public. This thing has spread all over, with a sensational, since-changed headline that didn’t reflect reality. It takes less than a day for misinformation to infect an untold number of people. Getting more people vaccinated should be of the utmost importance, and a story like this carries a weight that deserves deep time and consideration. Meanwhile, I can’t imagine this is going over well with the medical community, which is again strained and burned out as it seeks to care for the very people that this News story says will soon be left aside.

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