State Triage Protocols

Presently, complaints against triage protocols have been filed in multiple states, including Alabama, Kansas, and Washington, among others. ^{Reference Brownstein, Bagenstos and Mathis2} For brevity, we will examine the case of Alabama. The complaint filed by the Alabama Disabilities Advocacy Program (ADAP) in March, 2020, quotes a document titled, “Criteria for Mechanical Ventilator Triage Following Proclamation of Mass-Casualty Respiratory Emergency,” issued in 2010 under the Alabama Department of Public Health (ADPH). The complaint states that the document violates sections of the Rehabilitation Act, the Affordable Care Act (ACA), and the American Disabilities Act (ADA). ^{Reference Brownstein, Bagenstos and Mathis2} The protocol outlines a tiered approach to rationing ventilator access when resources become scarce, basing exclusion criteria on the presentation of end-stage organ failure. Appendix 2 of the plan clarifies the conditions that constitute end-stage organ failure by organ system; under the subsection, “Neurological,” it reads:

First, the statement that PWID have comparable life expectancies and can lead fulfilling lives directly opposes the following statement that clinicians should consider their social and professional lives when determining whether they are eligible for lifesaving care. Furthermore, in an emergency scenario where family members or caretakers may not be allowed to accompany patients to an exam room, or where alternative communicative devices may be unavailable, non-verbal individuals may be completely unable to communicate their needs and medical history to their physician. In this case, the quality of life of the patient is subjective to the clinician who could struggle to fully understand the patient’s own views on her or his own quality of life. Further complications arise when we consider that, when health care systems are overwhelmed, medical records may not be immediately available during triage and intake exams, so the knowledge of pre-morbidities for all patients is limited. Ultimately, it boils down to the harsh reality: If a decision is to be made between 2 patients with similar presentations of symptoms, some triage protocols direct that an abled life is more worthy than a life with a disability.

The ADPH Center for Emergency Preparedness web page claims that the referenced document is no longer in effect and has been replaced by the Alabama Crisis Standards of Care Guidelines, dated February 28, 2020. ¹⁰ The new document states the importance of equity and non-discrimination numerous times; however, it provides no guidelines or specific alterations to the mass casualty protocol that it is intended to replace. ¹¹ Under the subsection, “Stewardship of Resources,” the following statement is provided:

While conceptually sound, generalized statements such as these do not address the biases against those PWID within the health care system, wherein individuals with disabilities are presumed to be less likely to survive.

Existing Solutions

People with disabilities have been mistreated and discriminated against throughout history. ^{Reference Carlson, Smith and Wilker3} To promote social justice and prevent further mistreatment of an entire population, protections for PWID need to be integrated into the COVID-19 response. The Department of Health and Human Services has provided guidance for health professionals on best practices to avoid disability-based treatment rationing. ¹² Non-discrimination clauses and recognition of treatment bias are recommendations for state hospitals to include in their allocation of treatment and triage plans. ¹² Bias in treatment needs to be addressed to prevent discrimination in the triage process.

Despite the advancements in adaptive devices and assistive technology, the inclusion of such essential tools supporting communication and activities of daily living is lacking in emergency management planning. ^{Reference McSweeney-Feld13} The importance of supporting all persons with any access or functional assistance needs from any form of impairment or disability (eg, motor, sensory, cognitive, behavioral) with appropriate devices and technology must be a priority in public health preparedness and planning. Additionally, health care staff need training on the rights and needs of PWID to ensure unbiased and adequate treatment. ^{Reference Armitage and Nellums14} Past recommendations for addressing health care inequalities prior to COVID-19 include training health care professionals on the diverse needs of PWID; training individuals with disabilities, their families, and community support staff on best communication practices and advocacy for health care needs; improving access to quality health care at health practices and hospitals; and reducing insurance reimbursement barriers for health care providers for additional time and resources. ^{Reference Ward, Nichols and Freedman15}

Human rights-based solutions have been proposed to address the rights of children with disabilities during the COVID-19 pandemic, but this kind of approach should be applied to adults with IDs as well. Successful, inclusive community-based responses need to include PWID in the planning process to account for the unique needs of this population. ^{Reference Schiariti16} To have a plan that represents all community members, a diverse group of people should be included (ie, the Whole Community Concept). ¹⁷ All populations and stakeholders in the community need to have a seat at the table. A community-based initiative focused to include PWID in relevant preparedness planning and decision-making leads to improved engagement and overall disaster preparedness for this population. ^{Reference Adams, Eisenman and Glik18} Policy change that addresses everyone with a disability or access and functional need is important to building community resilience. ^{Reference Kruger, Hinton, Sinclair and Silverman19}

Proposed Solutions

In addition to the existing solutions, it is necessary to integrate social workers into the emergency response process. As a profession, social workers value service, social justice, dignity and worth of the person, importance of human relationships, integrity, and competence. ²⁰ Addressing discrimination, inequality, and inequities is at the core of social work practice, while also valuing and respecting the individual’s right to self-determination. PWID have a right to receive unbiased health care treatment, especially at a time when this population feels largely marginalized and overlooked. The integrated response process includes using medical social workers in hospital settings as advocates for incoming patients seeking care for COVID-19 and ensuring that PWID receive non-discriminatory treatment. Bias in health care is often unconscious and results in increasing systemic barriers. Assigning social workers as advocates will promote social justice and alleviate the burden of inequality felt by this population.

As a long-term solution, social workers need to be more integrated into the disaster management field. Including social workers in disaster protocol and planning will increase the inclusion of PWID and ensure that their needs are met and accounted for in all disaster scenarios. In health-related disasters, such as COVID-19, social disparities are highlighted and disproportionately impact certain populations over others. This is more than a response issue; it is a social justice issue that needs to be addressed at the root cause. To mitigate social disparities and alleviate the disproportionate burden on marginalized populations, social workers and emergency managers must collaborate together. Bias toward PWID must be addressed in health care and across professions.