Managing Older Adults With Presumed COVID-19 in the Emergency Department

A Rational Approach to Rationing

Tony Rosen, MD MPH; Lauren E. Ferrante, MD MHS; Shan W. Liu, MD SD; Emily A. Benton, MD; Mary R. Mulcare, MD; Michael E. Stern, MD; Kevin Biese, MD; Ula Hwang, MD MPH; Martine Sanon, MD


J Am Geriatr Soc. 2020;68(8):1631-1635. 

In This Article

Abstract and Introduction


The American Geriatric Society's (AGS) position paper on age-related considerations in resource allocation strategies during the COVID-19 era[1] and the expanded rationale[2] emphasizes the importance of not using age as a categorical exclusion during the allocation of scarce resources. Using age primarily may violate the ethical principle of justice as well as imply age discrimination. Older adults are heterogeneous in baseline activities and functional, cognitive, and medical status. Prior research has demonstrated that other vulnerability factors, such as frailty,[3] functional trajectory,[4] and multi-morbidity[5] are more strongly associated with death and poor outcomes than chronological age alone. Though research on COVID-19 is just beginning, we are likely to find in this disease as well, that these vulnerability factors are more predictive of poor outcomes than is chronological age. As a result, making rationing decisions informed primarily by chronological age is extremely problematic and, we believe, unethical. The AGS position paper outlined additional important considerations for the allocation of scarce resources. These include discussing goals of care, creating triage teams devoted to operationalizing rationing decision-making, and using a multi-factor strategy to assess both in-hospital mortality and conditions that would limit life regardless of the acute illness in the primary triage scoring algorithm.

We recognize that many initial decisions about allocation of ventilators, intensive care unit (ICU) beds, and hospital beds, as well as decisions about how to treat critically ill patients are occurring and will likely continue to occur in the Emergency Department (ED). Given this, we describe our current experience and reflect on how ideas from the AGS position paper may be operationalized in the ED. Much of what we discuss is also highly relevant for decision-making later during a hospitalization.